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...
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Apr 1, 2007 10:44 am
4044
Colleague, It is unusual for a Phoenix Approach Root Cause Analysis Report to be posted in its near entirety. There is one at the link below. ...
Does this get adequate coverage in root cause analysis? I used to regularly advise a client,"Don't just do something; stand there." Take care, Bill Corcoran W....
Bill, I find it difficult, especially with equipment related cause investigations. Management often wants to use the Ready, Fire, Aim approach to finding...
We have also seen the "ready-fire-aim" approach (less common now than in the past), although I would characterize is as the "problem" is known (X is broken) -...
The phenomenon of apparent "bad judgment" that is discussed and described in the article Bill attached to his message is mistakenly referred to by that author...
Randy, Thanks. I live about 15 miles from the Noah Webster House. I occasionally visit it the way I would visit a religious shrine. Few people know that...
http://www.asq.org/learn-about-quality/process-analysis-tools/overview/mistake-proofing.html Scroll down for the story. At your facility is "failure to...
Bill, while I agree that GENERALLY the purpose of a dictionary is to describe rather than proscribe or prescibe the ways in which words can be used (or have...
I have an electronic copy of the report. It is too big to post on a Yahoo e-group site. If you want it, please send me an e-mail request. Thanks to Dave...
It seems to me that all airports which have runways of different lengths should have the lenghts posted on the signs with the runway desigantion. Also all...
Print Story: Flight canceled after pilot's outburst on Yahoo! NewsScroll down for the story. Have you ever run into aberrant behavior in a root cause analysis?...
I always liked "Pickpockets see pockets" glen -desk-806-477-4953 -pager-806-345-9196 ... The phenomenon of apparent "bad judgment" that is discussed and ...
A study in the 90's duplicated one in the 50's on how long it took a secretary to type a business letter. They came out virtually the same. Hmmm. Upon...
Scroll down for the story. My recommended Corrective Actions: 1) Train patients in mix-up prevention, e.g, check the paper work against the issue. In this case...
Greetings! I am a member of a manufacturing company and challenged with improving our problem management process. This is not a high hazard environment so our...
Franklin, You ask a simple, but great, question that has a spectrum of answers. On one end of the spectrum is organizations that trust managers to do the right...
Thanks to my USS Tullibee (SSN 597) shipmate, Ken Loposer, for this one. Be sure to click on the links for more information. Take care, Bill Corcoran W. R....
Franklin, It seems to me that if you first described your "problem management process", the forum could make better suggestions to improve it. In other words,...
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...
Apr 17, 2007 5:31 pm
4065
Bill C., Do I understand correctly that the "tree" referenced below was generated by the Chemical Safety Board, and not by you? If so, do you see any flaws in...
Bill C., Yes, the subject CSB factor tree on the BP explosion has many good points. In addition to the ones you mentioned, * It breaks down a lot of...
HI All I am having difficulty accessing this CSB Logic Tree. I am interested seeing what you all are discussing. Is it in a format in which you could e-mail...
Ronnie, Here is a partial Missed Opportunity Matrix (MOM) for the famous Davis-Besse hole-in-the-head event. In real life the MOM is pages and pages. It is an...
Ronnie, I've made this comment before. In the Missed Opportunities Matrix (MOM), the third column is not only a list of opportunities missed in the past, but...
Bill Salot, I must agree with you. The third column of the Missed Opportunity Matrix should be used as a check on the Corrective Actions. Every Missed...
Bill C, Thanks, but this senior citizen also has frequent flashes of stupidity. You said, 'I now believe that the following tools are the minimum for a good...
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