For rooticians who use the 5 Whys: Here is an experiment for you to try out. (What the heck, it's a new year, anyway.) The first problem you get this year try...
A simple question. Would you be so kind as to share the URL and/or contact information for your favorite few resources (other than this e-group) for...
Dr. Bill, My number one resource is inpo.org, which limited to INPO members. A second site that I have extensively used for Human Performance information as...
What are the factors that result in oversight professionals repeatedly failing to identify the limiting weaknesses? This one sounds like Davis-Besse 2002, BP,...
There is also the refinery explosion at BP (which may be the BP you note in your email). I suspect there are several root causes. In the nuclear industry, a ...
Bruce Bevard
bevardbb@...
Jan 5, 2007 12:07 am
3933
Bruce, Thanks for mentioning the BP episodes. You can join a study group by sending an e-mail to BP_Lessons_to_be_Learned-subscribe@yahoogroups.com Do you...
Bill Rigot, Thanks. I found one of Hopkins' papers on safety culture very helpful. OBTW: You were the only person to respond to my request. Take care, Bill...
Hello, This email message is a notification to let you know that a file has been uploaded to the Files area of the Root_Cause_State_of_the_Practice group. File...
Root_Cause_State_of_t...
Root_Cause_State_of_t...
Jan 7, 2007 3:03 pm
3936
HI everyone, I joined this group because I'm preparing a one-hour presentation/ mini-workshop to a women's business networking group on root cause and 5 Why's....
... easy ... the ... Annamarie, I do not disagree with your assessment of the dialogue between the PGM and the Ops representative. But I did not post it as an...
Annamarie, I have never seen an example of 5 Whys that passes the snicker test. I'm still looking. My mind is still open. However, in my actual professional...
One of the most common mistakes made by new rooticians is to fail to identify the nature, the magnitude, and the timing of all important actual, expected, and...
... to identify the nature, the magnitude, and the timing of all important actual, expected, and potential consequences. ... How about not writing a good...
Hello, This email message is a notification to let you know that a file has been uploaded to the Files area of the Root_Cause_State_of_the_Practice group. File...
Root_Cause_State_of_t...
Root_Cause_State_of_t...
Jan 11, 2007 11:26 am
3942
Hello, This email message is a notification to let you know that a file has been uploaded to the Files area of the Root_Cause_State_of_the_Practice group. File...
Root_Cause_State_of_t...
Root_Cause_State_of_t...
Jan 11, 2007 12:13 pm
3943
Randy, Thanks ever so much. What happens when that mistake is made? Is there a set of instructions for writing good problem statements? I would appreciate...
Bill, I don't know if this "failure" is what you were looking for as a mistake or not. But this "effect" came to mind quickly. Failure to gain input from all...
Bill C., I struggle with problem statements. The current reality is that an RCA team may generate an excellent problem statement, but success will be limited...
In the real world nothing every goes wrong because of one root cause. Nevertheless, otherwise competent journeyman rooticians as well as apprentice rooticians...
Good Morning: There are 2 things that come to mind for me. First, I typically hear these terms immediately following an event. Since the "real root cause" was...
Jim, Thanks. There are still procedures around that require finding one root cause. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC Corporation 21...
As long as they don't mind doing dozens of investigations for costly events, it's a sound procedure. Finding one "real root cause" is as good of a pratice as...
Barry, Thanks. I loved your message. It reminded me of a time that I was called to a certain nuclear power plant (NPP). The plant general manager (PGM) was...
Please forgive me if this posting is redundant. I just don't remember seeing the link on this list. For those who are interested, the "Baker Panel" report...
NPR radio report. Only those signed up for "all e-mails" will get the attached voice file. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC...
http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/SP/STAGING/local_assets/assets/pdfs/Baker_panel_report.pdf The Baker report is available...
IMHO, Both of these common errors are errors of perception of what they are to do. Folks commonly mix-up causes and solutions because our brains are ingrained...
Comments? Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 Voice and voice mail: 860-285-8779 ...
Another case of a rule that exists that is routinely violated and known to be violated by the management team of the airline and the FAA. Likely a factor in...
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