The actual root causes were in the reward system, some unreasonable expectations, and the lack of tools to deal with the complexity of requirements. Our safety...
There has been some recent discussion about how to encourage learning from things that go wrong. The attachment was a workshop-style presentation in lieu of a...
Bruce, The attendees were: 1.. Plant Management 2.. Operators 3.. Engineering 4.. Maintenance 5.. EHS Management 6.. Me (RCA Team Advisor) Take care, Bill...
Bill Salot, The fourth fallacy is that if it can't be fixed by management it can't be a root cause. In other words the weaker the manager the fewer the things...
Asking the Best Questions The usual question asked when something goes wrong is, "Why did it go wrong?" or words to that effect. For the next week or so try...
Bill C., The fourth fallacy, as you worded it below, is indeed a fallacy for the reasons you stated. But we all know that most consultants emphasize that their...
Bill Leonard, Thanks ever so much for giving me a chance to straighten that one out. You were a key member of the best RCA Team I've ever worked with. Most...
Bill C., I have to challenge the fourth fallacy - somewhat. If you don't have some means of determining what causes can be prevented from leading to repeat...
What bothers me (a lot) at my site about "fixable" root causes is that we only capture the causes we choose to "fix" in our performance analysis database. As...
Hi All I've been receiving the group email for about a year now and this is my first time providing some active input. I consider myself a novice rootician and...
John, I think your view of the Queen of North incident is dead right. Why not write a letter to the editor (or to your government representative), As Bill C...
What's your reaction to this? Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC Corporation 21 Broadleaf Circle Windsor, CT 06095-1634 Voice and voice...
Considering the visibility and the consequences of the event, I am not surprised. I am pleased, as well, to see that the culpability of the workers who made...
Bill, Good question Bill. We anticipated this situation when we built the Cause Road Map. Each area of the Cause Road Map has a classification of "other." For...
The other option (as a user & purveyor of the dreaded & evil cause code categories...) is to include (i.e. build in) in each category a code for "Other" cause...
Bill, I am NOT a fan of "pick lists" where you select from a group of cause codes or the like. Having said that, I find it very useful to trend using cause...
doesn't an expanding cause code set create a moving target? glen -desk-806-477-4953 -pager-806-345-9196 ... Simple (I'm told). Add the new ones to the list,...
reference for the "cause roadmap," please? glen -desk-806-477-4953 -pager-806-345-9196 ... Bill, Good question Bill. We anticipated this situation when we...
We binned it as close as we could. I follow a cause code with an explanation of how it fits. I include it as the 'best fit' but note where it does not. A good...
Bill, The ABS Consulting method identifies "casaul factors"; they provide a very detailed Root Cause Map that we have used for training and real-life analysis....
Sean, Thanks. I have some follow-up questions. 1.. What is your experience with deciding on one root cause? 2.. Do your yellow stickies include chains of...
Steve, Should the cause code set permit the coder to code the truth about the factors that resulted in the consequence of interest? Take care, Bill Corcoran W....
Energy Central News I wonder what root cause analysis would come up with on this situation. ... Overtime Pay Pads MLGW Salaries -- Acting President Vows to...
A one-week old article is attached. What should psychologists, rooticians, safety culture professionals, and safety professionals glean from this article? Is...
Bill, Please see my comments below. Sean ... From: Dr. Bill Corcoran <williamcorcoran@...> To: Root_Cause_State_of_the_Practice@yahoogroups.com Sent:...
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