Please send me whatever pictures of steam line breaks/ruptures that you might have. Attach or insert as you wish. I will post the collection for the benefit of...
Hi, I know well about two at CY. Both involved feedwater heater drains, one just downstream of a # 1 FWH normal level control valve, the other just downstream...
One isolated quotation: The fallout from the Texas City refinery explosion demonstrates the high cost of ignoring routine maintenance, process safety...
This message is applicable to everybody. Just ask Bob Nelms how ignoring routine maintenance worked out with that truck of his. Certainly not on the same scale...
This message should be applicable to any facility which has been in operation over a period of time. The DOE process of integrated safety management, leaves a...
Bill, as you mention in the mail below, what is an Integrated Safety Management System ? What, How and Why is it integrated ? Thanks Arthur. _____ Van:...
These pictures capture the essence. ... For more details Google on "Integrated Safety Management System" and checkout the USDOE-related sites first. Take care,...
Bill, I looked at the USDoE pages. I can find descriptions of the parts of a safety management SYSTEM. I can't find a description of the whole system and what...
Art, Here is the classic technical report that, according to legend, started the ISMS. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and...
In doing root cause analysis rooticians run across "classic organizational phenomena." I made a table of the ones I've run into. The table is pasted below. If...
Rooticians need to lighten up and have fun too. Please let me know what should be on the following list of entertainment items for rooticians. The file is...
Bill Salot, Thanks ever so much. There are many activities in which models are routinely used, but they are so far in the background that practitioners often...
Thanks. I'm a Goldratt fan. Can you share any details or give us some references to the incidents you alluded to? Take care, Bill Corcoran Mission: Saving...
Jim and Greg, Here are two ideas that have helped me with those types of situations. ... These principles are implied by commonly required Quality rules such...
What my "Recipe" Model has going for it is the following: 1.. It has proven correct in every major problem case that I have applied it to, and 2.. In every...
Bill, In reflecting on your challenge to identify occasions when your model would not work, I could not recall a time in my years in the Navy, or working...
If you have any more on this one please pass it along to me. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful...
I can't find anything else on the web about this case. Assuming that the report is accurate, it's hard to imagine some sort of "human error" that could have...
I am currently developing a Root Cause Analysis Training Module which will be taught throughout the organization. We are part of the transportation industry,...
Matt, My reaction is the same as yours. Don't such calculations get double or triple checked??? Sadly enough, it reminds me of a story that I read in a human...
Sean, Unless you have alot of hands on case study, I can't imagine what you would teach that would take that long. We have about a dozen analysts at our...
FYI. If you have more details please post them in a reply to the group. OBTW: "Human Error" is not a cause. It is a category. Categories don't cause...
Greg and Sean, Here are some actual figures: a.. High hazard storage, maintenance, and assembly facility: forty hour course off-site, two hour management...
Gary, While I lack your qualification, I agree with you that mentoring is a critical aspect of learning the ropes, as it is with so many processes... Jack...
Jack, Here's a description of the incidents. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If...
Jack, You're probably thinking of "Set Phasers On Stun" by Steven Casey. The event described in that book is quite old but still illustrative of what can go ...
(I see the positive paradox in this....if they didn't confront me such as they did....the problem would have stayed hidden!) "Habitual Accident Abuser"...7 of...
FYI. Please pass along whatever you find out. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If...
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