Scroll down for a December 8, 2006 article that just surfaced in another web venue. What are the safety culture lessons to be learned? What are the root cause...
Scroll down for a puzzling NY Times Op-Ed. Can it be true? Have you seen this phenomenon? Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC Corporation...
Yes, in an odd way, I have seen this phenomenon but fortunately, in reverse in my own family some years ago. When our son (now in his mid-thirties) was in...
Aviation mix-ups: It's been over 35 years ago, so a lot of the details are gone, but "one dark and cloudy night" I was landing in an F-8 Crusader at Point...
Bruce, Congratulations on being flexible enough to accept a starboard-to-starboard passage. One might hope that the Navy would investigate such a near miss. ...
Scroll down for the story. For elaboration go to http://en.wikipedia.org/wiki/Iran_Air_Flight_655 For more mix-ups go to the following web site, where you can...
Is this an example of failing to learn from previous experience? Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC Corporation 21 Broadleaf Circle ...
So you're tired of definitions of "root cause." So am I. Humor me this once, please. I have pasted below the section of The Rootician's Dictionary that...
Bill C., Back in 2002, when discussions of root cause definitions were becoming irksome to many, you and I continued them off-line for awhile. At that time, I...
Is this staying too close to individual error? - it is easy to state the individual did not do something correct because they have been trained or did not...
Colleague, I need a reference for the error rate experience for skill-based, rule-based, and knowledge-based performance. Please respond to this message with...
Bill, An INPO document titled "HUMAN PERFORMANCE REFERENCE MANUAL" (INPO 06-003) contains the following: SB ~ 1/10,000 - citation 47 of chaper 2 of INPO 06-003...
Ryan, Steve
SMR5@...
Jul 12, 2007 11:07 pm
4139
Sidney Dekker's "The Field Guide to Understanding Human Error" and my personal experience indicate that the next step should have been to try to determine what...
Bill: I have been doing some research on barrier and reliability analyses as they might apply to healthcare process design. This DOE publication has some data...
I would have to say "yes". Planning to take this as an example for RCA classes both for discussion on effective corrective actions and exploring extent of...
I need resources to better understand this area. We have a number of 'new information,' change management, design scope, communication between groups and basic...
Here's one you can use in a root cause class. Ask the Eight Questions. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. NSRC Corporation 21 Broadleaf...
Glen, I too have long been concerned and baffled by the causes and avoidance of engineering errors. When I was an assistant design engineer many decades ago,...
As part of a training program I am working an RCA of a severe condenser tube rupture at a BWR on a major inland river. I need some way of estimating some of...
Bill, The only things I'm aware of regarding chemistry and fuel failures are in EPRI and INPO documents (although I'm pretty sure the fuel vendors have this...
Bill and Glen, The vast proportion of engineering errors I have come across doing root cause analysis would have been surfaced earlier if the engineer's...
A colleague asked the following: I would like to understand how other organizations handle potential wrong doing events: 1. When an event occurs and a...
... (Redacted and edited slightly by Bill Corcoran to preserve anonymity) It's probably a good thing that we do not operate nuclear power plants or jet planes...
Colleague, Please take a few minutes to scroll through this e-mail and let me know: 1.. How you could use some part of the substance of this message in your...
Bill C., You have been developing this concept of "dimensions" in root cause analysis for some years now. Each update has included significant advances, and...
Bill, Which takes precedence; a no discipline clause or a Code of Federal Regulations? In trying to determine the root cause you may find a cover-up. What's...
We have actually faced this situation and handled it in a variety of different ways depending on the event/condition being investigated. If during the...
As I remember my labor relations law, you cannot have a negotiated contract that is contrary to the law of the land. It's been a while since I practiced,...
Mike and Bill, Irving Janis's work on Groupthink gives the phenomenon a richness that Wikipedia misses. If you ever find yourself in a Groupthink situation, as...
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