Kent and all, Dee Bryan sent me a slideshow from which I extracted this week's slide of the week. If anyone has related slides please pass them along or post...
Examples of "Degree of Significance"Jim, Please note that I have redacted your message to me. Only you know which Jim it was from. Here's my answer. When we...
A good start is to call a mix-up a "mix-up." Does your organization keep track of mix-ups? Does it ask, "What are the factors that directly resulted in this...
Bill C., What good does it do to inject the term "mix-up" into the analysis of a specific event, such as a "wrong site surgery"? The term "mix-up" is not a...
Toby, I'm convinced. Thanks ever so much. Are you suggesting that we should attach video clips to RCARs and embed them in RCAR PowerPoint slideshows? Take...
Bill Rigot and all, One of the strengths of the Substitution Test flow chart is its simplicity. Einstein said: "Make everything as simple as possible, but not...
Please let me know how this can be improved. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If...
Has anyone, other than me, used a Gantt Chart as an RCA tool? What did you use it for and how did it work? Take care, Bill Corcoran Mission: Saving lives,...
Cathy, Six sigma seems to be very popular although under the pretext of improving quality, companies want to really cut costs and boost their bottom line. Sham...
In this case, can the lack of adequate periodic maintenance (i.e., lack of checking for corrosion by smart pigs), be a causal factor or the root cause? ...
FYI. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety, peace, or justice, work...
Sham, Do we have two pipelines mixed-up here? The engineer pipeline and the BP pipeline. WRT the BP pipeline. 1. The is never only one root cause. 2. What is...
Apparently the word is not getting out on mix-ups. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto:...
Bill You replied to Sham 1. There is never only one root cause. 2. What is it about the way BP does business that failed to find the pig problems before this...
Jim, Thanks ever so much for your thoughts. Should I assume that the "core problem" is out-of-date cost models? What are the factors that directly result in...
Bill wrote: Jim, Thanks ever so much for your thoughts. Should I assume that the "core problem" is out-of-date cost models? What are the factors that directly...
Did you ever think the universe prepares and educates you perfectly for your next situation? So here we sit within the mindless turmoil and sitting on the edge...
Bill Salot, I don't think that you're in over your head. But I do think that your analysis has gotten to where higher factors on the factor tree are themselves...
Jim, So far, a walkaway message from this dialogue is that a potentially fruitful line of inquiry relates to inappropriate (dysfunctional?) management of...
Bill C., You are not fooling me with your looping effects. The J. S. Carroll diagram that you copied below is made up of categories that "lie" when applied to...
Ron, Thanks. I may need to say more than what needs to be said here. You asked about the nature, the magnitude and the timing of consequences. Your event top...
Bill C., I was a little late in suggesting that you write an essay on "mix-ups". I found it in your January 2000 issue of The Firebird Forum (Vol. 3, No. 1). ...
The mix-up story goes on and on. Scroll down for the latest avoidable mix-up. I have had root cause course attendees tell me of repeated non-consequential...
More on the mix-up. It is too early to tell, but it looks like there are some important lessons to be learned for rooticians. Which lessons to be learned for...
The ABC video gives more of the picture at http://news.yahoo.com/s/ap/20060828/ap_on_re_us/kentucky_crash_92 What are your thoughts at this stage? Take care, ...
Would one of you pilots be so kind as to give us the pre-take-off protocol that is supposed to prevent runway mix-ups? Take care, Bill Corcoran Mission: Saving...
I thought you¹d be interested in this piece published on Time¹s website which suggests that the tremendous strides that aircraft / airline safety have made...
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