John, Thanks ever so much. The investigation team did a creditable job on fact gathering. The attachment is their report with my preliminary notes. If you (or...
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...
Aug 2, 2008 11:42 am
5123
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...
Aug 2, 2008 11:46 am
5124
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...
Aug 2, 2008 11:49 am
5125
What lines of inquiry does this suggest to you? http://www.nytimes.com/2008/08/03/opinion/03Judson.html? emc=tnt&tntemail1=y August 3, 2008 Guest Columnist ...
If you were asked to investigate this one, what would you include in your lines of inquiry? One of my top ones would be the cause of extent, i.e., what are the...
Hello, What I would include in my line of inquiry, were I involved, is how did CT Light & Power decide to implement an apparently inadequate new software...
Jack Stanford
jack.stanford@...
Aug 11, 2008 2:01 pm
5129
How does this apply to your operation? _________________________________________________________________ ...
"Believe your indication" is one of the top principles of Conduct of Operations. Would you be so kind as to reply to this message with one or more of: 1.....
At the INL, we have characterized a number of high profile US commercial reactor events, with a focus on the human actions that affected the course of the...
Only four specific examples come to my mind: 1. There was a huge noise out in the CY screenhouse. There was part of a tree ingested into a circ water pump....
Jack Stanford
jack.stanford@...
Aug 14, 2008 5:56 pm
5134
Sorry to sound ignorant, but does "Believe your indication" mean to trust your instruments?? Jack (John) Vanier P.Eng, CEM Energy Manager 250.246.6355 Phone ...
Well, here are examples from ORPS that show both events where people believed their indications, and others where they did not. I do not attest to the content...
Patrick, Thanks for the interesting response. The classic "Believe your indication" event is where an adverse indications appears, e.g., an alarm comes in or a...
FW: Safety Incident - logging truck - Jackson TNThanks ever so much to Bill Leonard for this one. Scroll down for the pictures or open them as attachments. The...
I will be out of the office starting 08/15/2008 and will not return until 08/18/2008. I will respond to your message when I return. If this is something that ...
Scroll down for the story. If I were investigating this one I'd want to know about the extents of the conditions, the extents of the causes, and the causes of...
A story might clear up what is meant by "Believe your indication." Scroll down for a typical, but lucky story about "Believe Your Indication." Please respond...
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...
Aug 15, 2008 12:19 pm
5142
Mike, Tks 1.0E+6 Add two more lessons to be learned: 1.. Luck is not a robust barrier. When an event is mitigated by a lucky barrier the corrective actions...
Bill C, I'm still trying to get a handle on the scope of the "believe your indication" concept. From your "Rooticians Dictionary", I concluded that it meant...
This scenario is useful to highlight the classic dichotomy between the "design bases approach" and the "PRA approach" to activites. Design bases: The landing...
Dr. Bowles, Thanks ever so much for your review article in SCIENCE (Vol 320 20 June 2008). http://www.sciencemag.org/cgi/content/full/320/5883/1605 The...
Scroll down for the details. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto: If you want safety,...
Bill Salot, Thanks ever so much. I put some responses in with your comments. THEY ARE IN CAPITALS. I am looking forward to your comments on "B." The native...
Been away for 3 weeks. My question would be: isn't this a critical enough business function to warrant running the old and the new system in parallel? Are...
A latent factor is the pollyanna effect of change that "the gain will surely outweigh the pain," and a resultant dependence on 'luck'. Mike's comment is a case...
Glen, A good tactic is, "When you realize you're in a hole stop digging." Does your place have a mechanism for a "Stop Work Order?" Take care, Â Bill Corcoran...
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