Just a couple of thoughts: If you continue operating your business with status quo, you have to recognize that you have accepted the risk of liability which...
Tedd and Bruce, Â The heart of safety is to be able to notice an anomaly and to envision the disaster of which it is a harbinger. Â It is the failure to...
Jack There are many times when cost is a legitimate factor. The recent radioisotopes plant (NRU) shutdown in Canada is a case in point. The Canadian regulator...
Dwight, Â Thanks. Â Among the deep causes of all consequential events is the failure to identify the other causal factors and/or do something about them...
Dr. Bill, I've been working within my organization to begin a discussion of what it means to be a High Reliability Organization (HRO), and I've been borrowing...
Colleagues: I have collected below all of David Harding's messages from September 12 through 19, 2008, without any intervening messages by others. I collected...
Hi, Bill, et, al., "We've always done it this way" and "That's the way we've always done it" are two of the most repulsive phrases I have encountered in my 24...
jack.stanford@...
Oct 1, 2008 9:00 pm
5279
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...
Oct 2, 2008 12:07 pm
5280
The attachment is a PDF of the RCAR by the Independent Radiation Safety Committee (IRSC) at the National Institute of Standards and Technology (NIST). The file...
Regarding to the 9/19/08 comment of David's. I don't know why the top-down approach didn't work. What is important to upper management (cost, legal compliance,...
Here's a first stab: For the listeriosis thing extent of condition: 20 people dead in Canada. Financial losses by Maple Leaf Foods and possibly resultant job...
"The most expensive employee in your QA department is your customer." Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through...
Dr. Bill et. al., I would like to offer some things I have been taught regarding the following two statements: 1. The dysfunctional reward system is probably...
Attached is the paper on how to INSTITUTIONALIZE or SUSTAIN A BEHAVIOR CHANGE. The basic steps are as follows: 1. Define standard / expectations (Find out...
Attached is the PowerPoint I presented at the HPRCT in Toronto this year related to Institutionalizing a Behavior. ... From: Fred Forck <fforck@...> To:...
Fred, One comment: In figures 1 and 4, the top of the pyramid is "Execute (People)". That seems like rather drastic action to institutionalize behavior...
Try this on one you've already done another way. Let us know how this works for you. Gantt Chart <http://www.youtube.com/watch?v=CW_wGSFavTc> Making a Gantt...
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...
Oct 3, 2008 12:11 am
5293
I think that the management at Davis-Besse believed in the "leak-before-break" scenario. They figured that - if the CRDM nozzle had a crack (as the NRC had...
Dr. Bill, I hope the main point was not missed which is to encourage rooticians to ask "What happens to them when they do that?" instead of asking "Why?". The...
Fred and all, There is more to the application of human behavioral technology to root cause analysis. Rather than continue this thread on "Root Cause in the...
This database lives on our web site at http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice_2/da\ tabase?method=reportRows&tbl=3&sortBy=2 ...
Tedd, Â The type of thinking you describe is often called making a facilitative assumption. A facilitative assumption is one that facilitates doing or...
Interesting. I have one now where one set-up (trap) factor was put into place around 2001. In 2005-2006 the trap was set by another factor. The trap was not...
Bruce, Â Tks 1.0E+6. Â I love the trapping analogies. Â They are a refreshing departure from the land mine analogies that we of the Vietnam Era have been...
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