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#5426 From: "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...>
Date: Sun Nov 2, 2008 10:41 am
Subject: GroupThink at the Top
drbillcorcoran
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How did this phenomenon apply to Challenger, Columbia, Davis-Besse (at the NRC), etc?

How does it relate to Moral Psychology, e.g., loyalty and obedience?

How does it apply to Nuclear Safety Culture, e.g., "Questioning Attitude" and "Safety Conscious Work Environment?"

 

http://www.nytimes.com/2008/11/02/business/02view.html?tntemail1=y&emc=tnt&pagewanted=all

 

November 2, 2008
Economic View

Challenging the Crowd in Whispers, Not Shouts

ALAN GREENSPAN, the former Federal Reserve chairman, acknowledged in a Congressional hearing last month that he had made an "error" in assuming that the markets would properly regulate themselves, and added that he had no idea a financial disaster was in the making. What's more, he said the Fed's own computer models and economic experts simply "did not forecast" the current financial crisis.

Mr. Greenspan's comments may have left the impression that no one in the world could have predicted the crisis. Yet it is clear that well before home prices started falling in 2006, lots of people were worried about the housing boom and its potential for creating economic disaster. It's just that the Fed did not take them very seriously.

For example, I clearly remember a taxi driver in Miami explaining to me years ago that the housing bubble there was getting crazy. With all the construction under way, which he pointed out as we drove along, he said that there would surely be a glut in the market and, eventually, a disaster.

But why weren't the experts at the Fed saying such things? And why didn't a consensus of economists at universities and other institutions warn that a crisis was on the way?

The field of social psychology provides a possible answer. In his classic 1972 book, "Groupthink," Irving L. Janis, the Yale psychologist, explained how panels of experts could make colossal mistakes. People on these panels, he said, are forever worrying about their personal relevance and effectiveness, and feel that if they deviate too far from the consensus, they will not be given a serious role. They self-censor personal doubts about the emerging group consensus if they cannot express these doubts in a formal way that conforms with apparent assumptions held by the group.

Members of the Fed staff were issuing some warnings. But Mr. Greenspan was right: the warnings were not predictions. They tended to be technical in nature, did not offer a scenario of crashing home prices and economic confidence, and tended to come late in the housing boom.

A search of the Federal Reserve Board's working paper series reveals a few papers that touch on the bubble. For example, a 2004 paper by Joshua Gallin, a Fed economist, concluded: "Indeed, one might be tempted to cite the currently low level of the rent-price ratio as a sign that we are in a house-price `bubble.'" But the paper did not endorse this view, saying that "several important caveats argue against such a strong conclusion and in favor of further research."

One of Mr. Greenspan's fellow board members, Edward M. Gramlich, urgently warned about the inadequate regulation of subprime mortgages. But judging at least from his 2007 book, "Subprime Mortgages," he did not warn about a housing bubble, let alone that its bursting would have any systemic consequences.

From my own experience on expert panels, I know firsthand the pressures that people — might I say mavericks? — may feel when questioning the group consensus.

I was connected with the Federal Reserve System as a member the economic advisory panel of the Federal Reserve Bank of New York from 1990 until 2004, when the New York bank's new president, Timothy F. Geithner, arrived. That panel advises the president of the New York bank, who, in turn, is vice chairman of the Federal Open Market Committee, which sets interest rates. In my position on the panel, I felt the need to use restraint. While I warned about the bubbles I believed were developing in the stock and housing markets, I did so very gently, and felt vulnerable expressing such quirky views. Deviating too far from consensus leaves one feeling potentially ostracized from the group, with the risk that one may be terminated.

Reading some of Mr. Geithner's speeches from around that time shows that he was concerned about systemic risks but concluded that the financial system was getting "stronger" and more "resilient." He was worried about the unsustainability of a low savings rate, government deficit and current account deficit, none of which caused our current crisis.

In 2005, in the second edition of my book "Irrational Exuberance," I stated clearly that a catastrophic collapse of the housing and stock markets could be on its way. I wrote that "significant further rises in these markets could lead, eventually, to even more significant declines," and that this might "result in a substantial increase in the rate of personal bankruptcies, which could lead to a secondary string of bankruptcies of financial institutions as well," and said that this could result in "another, possibly worldwide, recession."

I distinctly remember that, while writing this, I feared criticism for gratuitous alarmism. And indeed, such criticism came.

I gave talks in 2005 at both the Office of the Comptroller of the Currency and at the Federal Deposit Insurance Corporation, in which I argued that we were in the middle of a dangerous housing bubble. I urged these mortgage regulators to impose suitability requirements on mortgage lenders, to assure that the loans were appropriate for the people taking them.

The reaction to this suggestion was roughly this: yes, some staff members had expressed such concerns, and yes, officials knew about the possibility that there was a bubble, but they weren't taking any of us seriously.

I BASED my predictions largely on the recently developed field of behavioral economics, which posits that psychology matters for economic events. Behavioral economists are still regarded as a fringe group by many mainstream economists. Support from fellow behavioral economists was important in my daring to talk about speculative bubbles.

Speculative bubbles are caused by contagious excitement about investment prospects. I find that in casual conversation, many of my mainstream economist friends tell me that they are aware of such excitement, too. But very few will talk about it professionally.

Why do professional economists always seem to find that concerns with bubbles are overblown or unsubstantiated? I have wondered about this for years, and still do not quite have an answer. It must have something to do with the tool kit given to economists (as opposed to psychologists) and perhaps even with the self-selection of those attracted to the technical, mathematical field of economics. Economists aren't generally trained in psychology, and so want to divert the subject of discussion to things they understand well. They pride themselves on being rational. The notion that people are making huge errors in judgment is not appealing.

In addition, it seems that concerns about professional stature may blind us to the possibility that we are witnessing a market bubble. We all want to associate ourselves with dignified people and dignified ideas. Speculative bubbles, and those who study them, have been deemed undignified.

In short, Mr. Janis's insights seem right on the mark. People compete for stature, and the ideas often just tag along. Presidential campaigns are no different. Candidates cannot try interesting and controversial new ideas during a campaign whose main purpose is to establish that the candidate has the stature to be president. Unless Mr. Greenspan was exceptionally insightful about social psychology, he may not have perceived that experts around him could have been subject to the same traps.

Robert J. Shiller is professor of economics and finance at Yale and co-founder and chief economist of MacroMarkets LLC.


#5427 From: "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...>
Date: Mon Nov 3, 2008 8:52 pm
Subject: Workplace Punishment
drbillcorcoran
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http://ohmygov.com/blogs/general_news/archive/2008/10/28/alternative-discipline-underused-by-federal-employers.aspx

 

What's wrong with this picture?

 

 

Alternative discipline underused by federal employers

If the words "alternative discipline" only conjure brief memories of an outlandish HBO series, it's because the federal government does a poor job advocating for alternative punishments for workplace offenses like chronic tardiness, inappropriate behavior, lack of accountability, failure to follow instructions, and misuse of the government purchase card.

According to the United States Merit Systems Protection Board (MSPB), an "independent quasi-judicial agency established to protect merit systems," many federal agencies do not have a formal alternative discipline policy in place. MSPB's newest report released this month, Alternative Discipline: Creative Solutions for Agencies to Effectively Address Employee Misconduct, showed that out of the 46 organizations surveyed, only seven had a formal agency-wide alternative discipline policy in place.

4Traditionally, supervisors follow their agency's personnel or employment guidelines for disciplining an employee without looking into the root cause of the employee's behavior. Delving into the "why" of the action is not required or expected, since it rarely factors into the decision to discipline or terminate employment. But some federal agencies, such as the Department of Health and Human Services and the National Institutes of Standards and Technology, have taken steps to implement an alternative discipline policy as a way to change their behavior without penalizing them. The policy also helps reduce the paper jam that comes from traditional discipline such as probations, suspensions and subsequent termination.

Alternative discipline is neither a reprimand nor a suspension, but a contracted agreement between the employee and the employer requiring or mandating that the misconduct not occur again. Sometimes called "last chance agreements" in that it is the employee's last chance to shape up before more serious punishments are sought, they offer federal employees an opportunity to find their way back to what is considered acceptable behavior - the definition of which can be pretty fluid in a federal environment.

Alternative discipline can be instituted before or after traditional discipline methods are used to resolve the misconduct, and it provides managers with another option when dealing with employees who do not comply with agency employment guidelines and requirements.

For example, instead of suspending an employee, an employer may agree to have his insubordinate perform community service equal to the amount of time that they would otherwise be on suspension. This type of resolution is ideal for a manager who faces an employee with an absentee problem due to personal issues. Placing such an employee on suspension would only result in her being absent longer from work, which would simply exacerbate the problem.

Another example comes from a state police officer that was chronically late due to working a second job to supplement his income. His employers thought that suspending him without pay would only cause emotional duress and resentment, so as part of his alternative discipline agreement, he was tasked with enrolling in a financial management course.

For those outside of government, firing or even disciplining a government employee can be a very arduous process that can quickly turn into a legal battle. Such alternative punishments, which may seem a bit light for the crime, grant managers a second set of tools for working within the confines of an extremely bureaucratic system whose rules often favor the employee over the employer.  

Alternative discipline "is a great tool for supervisors to consider if they have an employee who is engaging in misconduct," said MSPB Chairman Neil McPhie. "It empowers [management] to work with the misbehaving employee in order to craft a solution that has the greatest potential to change that employee's conduct."

There are various other alternative dispute policy options for misconduct such as public apologies, shortened suspensions, participation in training programs, temporary shifts in work schedules, making financial restitution to the employer, or attending employee assistance programs.

For employees, the most important aspect of the alternative discipline agreement is that no official disciplinary action is documented which could have a deleterious effect on their employment record. That is, so long as they continue to follow the terms of the agreement. If an employee violates the alternative discipline agreement, management normally falls back on its employment guidelines and penalties for handling the misconduct.

The significant part of an alternative discipline policy is the actual contract between the employee and the manager which provides the alternative discipline details. The details are what the employee and manager have agreed to do to address the misconduct so that it does not happen again. And according to the courts, this agreement is viewed as an official contract.

Of note is the fact that these contracts must be entered into mutually by both parties. If an employee feels pressured to sign the agreement, or the employer acts in "bad faith" by not adhering to the alternative discipline contract agreement, then the contract "would not be enforced" by the MSPB or the Federal Circuit if it ever came under review.

 


© 2007 OhMyGov! by Kilimedia, LLC. All rights reserved.  www.ohmygov.com

 

 

 


#5428 From: gmitchel@...
Date: Mon Nov 3, 2008 9:18 pm
Subject: Re: The Behavioral Revolution
pxeng1
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Multiplying the effect of several cross-discipline folks in Cause Analysis Team
environment about a single or a few perceptions of an event in the past, and no
wonder we spend a majority of our time assuring that what they hear is what we
meant.
The real amazement to me is that we don't spend more.

glen
-desk-806-477-4953
-pager-806-640-0649

>>> williamcorcoran@... 10/28/08 5:09 AM >>>

This is really about self-regulation.

It started with Adam Smith (or earlier?) and it still has some good
arguments in its favor.

It got us the Reactor Oversight Program, under which we have enjoyed
high capacity factors and have gotten to wince over Davis-Besse, Palo
Verde, and the other "outliers."

Hit the reply button and let us know what rooticians should learn from
this.

http://www.nytimes.com/2008/10/28/opinion/28brooks.html?th&emc=th
<http://www.nytimes.com/2008/10/28/opinion/28brooks.html?th&emc=th>



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October 28, 2008 Op-Ed Columnist The Behavioral Revolution  By DAVID
BROOKS
<http://topics.nytimes.com/top/opinion/editorialsandoped/oped/columnists\
/davidbrooks/index.html?inline=nyt-per>
Roughly speaking, there are four steps to every decision. First, you
perceive a situation. Then you think of possible courses of action. Then
you calculate which course is in your best interest. Then you take the
action.

Over the past few centuries, public policy analysts have assumed that
step three is the most important. Economic models and entire social
science disciplines are premised on the assumption that people are
mostly engaged in rationally calculating and maximizing their
self-interest.

But during this financial crisis, that way of thinking has failed
spectacularly. As Alan Greenspan noted in his Congressional testimony
last week, he was "shocked" that markets did not work as
anticipated. "I made a mistake in presuming that the self-interests
of organizations, specifically banks and others, were such as that they
were best capable of protecting their own shareholders and their equity
in the firms."

So perhaps this will be the moment when we alter our view of
decision-making. Perhaps this will be the moment when we shift our focus
from step three, rational calculation, to step one, perception.

Perceiving a situation seems, at first glimpse, like a remarkably simple
operation. You just look and see what's around. But the operation
that seems most simple is actually the most complex, it's just that
most of the action takes place below the level of awareness. Looking at
and perceiving the world is an active process of meaning-making that
shapes and biases the rest of the decision-making chain.

Economists and psychologists have been exploring our perceptual biases
for four decades now, with the work of Amos Tversky and Daniel Kahneman,
and also with work by people like Richard Thaler, Robert Shiller, John
Bargh and Dan Ariely.

My sense is that this financial crisis is going to amount to a
coming-out party for behavioral economists and others who are bringing
sophisticated psychology to the realm of public policy. At least these
folks have plausible explanations for why so many people could have been
so gigantically wrong about the risks they were taking.

Nassim Nicholas Taleb has been deeply influenced by this stream of
research. Taleb not only has an explanation for what's happening, he
saw it coming. His popular books "Fooled by Randomness" and
"The Back Swan" were broadsides at the risk-management models
used in the financial world and beyond.

In "The Black Swan," Taleb wrote, "The government-sponsored
institution Fannie Mae, when I look at its risks, seems to be sitting on
a barrel of dynamite, vulnerable to the slightest hiccup."
Globalization, he noted, "creates interlocking fragility." He
warned that while the growth of giant banks gives the appearance of
stability, in reality, it raises the risk of a systemic collapse *
"when one fails, they all fail."

Taleb believes that our brains evolved to suit a world much simpler than
the one we now face. His writing is idiosyncratic, but he does touch on
many of the perceptual biases that distort our thinking: our tendency to
see data that confirm our prejudices more vividly than data that
contradict them; our tendency to overvalue recent events when
anticipating future possibilities; our tendency to spin concurring facts
into a single causal narrative; our tendency to applaud our own supposed
skill in circumstances when we've actually benefited from dumb luck.

And looking at the financial crisis, it is easy to see dozens of errors
of perception. Traders misperceived the possibility of rare events. They
got caught in social contagions and reinforced each other's risk
assessments. They failed to perceive how tightly linked global networks
can transform small events into big disasters.

Taleb is characteristically vituperative about the quantitative risk
models, which try to model something that defies modelization. He
subscribes to what he calls the tragic vision of humankind, which
"believes in the existence of inherent limitations and flaws in the
way we think and act and requires an acknowledgement of this fact as a
basis for any individual and collective action." If recent events
don't underline this worldview, nothing will.

If you start thinking about our faulty perceptions, the first thing you
realize is that markets are not perfectly efficient, people are not
always good guardians of their own self-interest and there might be
limited circumstances when government could usefully slant the
decision-making architecture (see "Nudge" by Thaler and Cass
Sunstein for proposals). But the second thing you realize is that
government officials are probably going to be even worse perceivers of
reality than private business types. Their information feedback
mechanism is more limited, and, being deeply politicized, they're
even more likely to filter inconvenient facts.

This meltdown is not just a financial event, but also a cultural one.
It's a big, whopping reminder that the human mind is continually
trying to perceive things that aren't true, and not perceiving them
takes enormous effort.

#5429 From: "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...>
Date: Tue Nov 4, 2008 11:06 am
Subject: Dilbert the Rootician
drbillcorcoran
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Here's how the stupidity of one root cause gets propagated.

Todays Comic


#5430 From: "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...>
Date: Wed Nov 5, 2008 9:39 pm
Subject: A Learning Experience: Different Factor Trees for Different Consequences
drbillcorcoran
Send Email Send Email
 
I was recently working with a root cause analysis team on an event
involving widgets.

The essence of the problem was that a regulatory person found a large
number of nonconforming widgets.

The widgets were of several different designs.

The nonconformances were of several types.

The root cause analysis team started by lumping all of the
nonconformances into one beg consequence.

It rapidly became clear that we could not make a factor tree for the
aggregated consequences, but had to make a factor tree for one single
consequence first.

It then became clear that the identical nonconformances had many of the
same factors.

Have you run into a case like this?

How did you handle it?

Thanks,

Bill

#5431 From: "WILLIAM L. RIGOT" <william.rigot@...>
Date: Wed Nov 5, 2008 10:27 pm
Subject: Re: A Learning Experience: Different Factor Trees for Different Consequences
wlrigot
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Dr. Bill,



I ran into this with an ongoing rash of radiological consequences
stemming from non-conformances.  What I did eventually was a Common
Cause Evaluation (CCE).  The Responsible Manager formed a team of RadCon
savvy folks who were involved in each of the events.  I had them provide
briefs in a standardized format that captured 1) What happened
(including consequences)?, 2) where did it happen? 3) who was involved?
4) what causal factors were identified? 5) what corrective actions were
identified?



By laying out all of the events side by side on a wall, the team was
able to identify aggregate issues that had never been recognized through
individual determinations.  We found that the corrective actions we'd
previously identified never worked, because we didn't see the bigger
issues.   Dr. Deming would call this "suboptimization".



I think I see a similarity in your problem with non-conformances.  What
I would do is to start with the individual consequences, then for each
consequence, figure out the causal factors.  Then I would lay them all
out horizontally to look for patterns.  While the first part of this
drill is fairly linear and structured, you'd need to put your intuitive
hat on when looking for patterns that you can aggregate into something
more meaningful.  At that point you can likely develop better corrective
actions.



BTW, this is an INPO model on CCE that I've used succesfully a few
times.



Bill Rigot
--- In Root_Cause_State_of_the_Practice@yahoogroups.com, "William R.
Corcoran, Ph.D.,P.E." <williamcorcoran@...> wrote:
>
>
> I was recently working with a root cause analysis team on an event
> involving widgets.
>
> The essence of the problem was that a regulatory person found a large
> number of nonconforming widgets.
>
> The widgets were of several different designs.
>
> The nonconformances were of several types.
>
> The root cause analysis team started by lumping all of the
> nonconformances into one beg consequence.
>
> It rapidly became clear that we could not make a factor tree for the
> aggregated consequences, but had to make a factor tree for one single
> consequence first.
>
> It then became clear that the identical nonconformances had many of
the
> same factors.
>
> Have you run into a case like this?
>
> How did you handle it?
>
> Thanks,
>
> Bill
>

#5432 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Thu Nov 6, 2008 11:04 am
Subject: Re: [rootcauseconference] Re: One cause? vs. A set of factors?
drbillcorcoran
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Debbie,
 
I do it your way.
 
A factor is something that affects an effect. (Plain English)
 
Effects can be consequences. (Plain English)
 
Effects can also be factors. (Plain English)
 
Factors can have adverse effects. ( A property of the Universe)
 
When factors have adverse effects we call them causal factors. (Plain English)
 
Factors can have beneficial effects. ( A property of the Universe) 
 
When factors have beneficial effects we call them either preventive factors, as in the case of near misses, or mitigating factors, as in the case of non-zero adverse consequences. (Plain English)
 
Causal factors can be involved in affecting the nature, the magnitude, the location, and/or the timing of an effect in one or more of three ways. They can be set-up factors. They can be triggering factors. They can be exacerbating factors that make the effect as bad as it was. ( A property of the Universe) 
 
  • A complete set of factors for an effect will explain its nature, its magnitude, its location, and its timing. ( A property of the Universe) 
 
  • A complete set of factors for an effect will always include the set-up, the triggering, the exacerbation, and the mitigation. ( A property of the Universe) 
 
You can do a no-brainer, common sense, prima facie test on a set of factors for an effect by asking:
  1. Does the set explain its nature, its magnitude, its location and its timing?
  2. Does it include what set the stage for the effect to come about, does it include the triggering, does it include what made the effect as bad as it was, and does it include what kept the effect from being more severe?.
If you don't get a YES on Question 1 you can be CERTAIN that something is missing.
If you get a YES on Question 1 and a NO on Question 2 your logic is flawed.
 
OBTW: One factor can never pass either test!!
 
OFFER: I will provide one hour of free telephone consulting (my nickel) to the first three people who find a real flaw (other than typo) in the above and provide a real life example.
 
Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
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--- On Wed, 11/5/08, daaliya@... <daaliya@...> wrote:
From: daaliya@... <daaliya@...>
Subject: Re: [rootcauseconference] Re: One cause?
To: rootcauseconference@yahoogroups.com
Date: Wednesday, November 5, 2008, 5:47 PM

In a message dated 11/5/2008 3:53:55 P.M. Eastern Standard Time, emberley.doug@ syncrude. com writes:
As you can tell, I agree with Bill C.
 
Rather than referring to "the specific cause", such as you did in the case of the specific broken window incident, it may be clearer to refer to "specific SET of circumstances" or the "specific SET of causal factors".  I would suggest not using the word "cause" to define the SET, as it apparently has different meanings to different people and causes confusion.
All, I voted.
My explanation follows:
I like to avoid certain terms due to excessive confusion. I try to avoid them is speech, once I get the project going (ie have a PO). I try even harder to avoid in print. One of these is "root cause," and another in my more specific technical work is "mechanism." Sometimes I am forced to use these words for various reasons, but I TRY to avoid words or phrases that I know cause confusion. I have probably lost work due to this, but it is hardly the only specific cause of this grouchy person losing some business. Some time ago Bill C reminded me on this forum that I "knew better" or some such when I said something had "A" cause. I agreed with him then and still do.
 
I like the term FACTORS because in MY work at the least, it is not always obvious if something IS a factor or MIGHT be a factor. So I may say something like "possible factors" or "significant factors" or "clear and obvious factors" or "potential factor."

As my sadly departed friend and fracture analysis mentor, Dr. William T. Becker used to say when describing classes and categories of physical damage, "Use adjectives." He also used to remind us that "There are no absolutes." I think that both of these are good and useful things to keep in mind.
 
 
 
Debbie Aliya
Materials Engineer

MAIL TO AND REMIT TO:
Aliya Analytical Inc.
PO Box 2407
Grand Rapids, MI 49501

www.itothen. com

PHONE: 616-475-0059

Cell: 616-292-2707

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Wyoming, MI 49548




#5433 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Thu Nov 6, 2008 3:56 pm
Subject: New file uploaded to Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
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        : /PSU Enhancing Reactor Safety.pdf
   Uploaded by : jwpholland <jholland@...>
   Description : Enhancing Reactor Safety Via Dynamic Modeling of Bubble
Transport

You can access this file at the URL:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/PSU%20Enhan\
cing%20Reactor%20Safety.pdf

To learn more about file sharing for your group, please visit:
http://help.yahoo.com/l/us/yahoo/groups/original/members/web/index.htmlfiles

Regards,

jwpholland <jholland@...>

#5434 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Thu Nov 6, 2008 10:15 pm
Subject: New file uploaded to Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
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        : /METHODS AND TOOLS/Factors/Factors in Event Investigations
   Uploaded by : drbillcorcoran <williamcorcoran@...>
   Description : Factors are what result in consequences.

You can access this file at the URL:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/METHODS%20A\
ND%20TOOLS/Factors/Factors%20in%20Event%20Investigations

To learn more about file sharing for your group, please visit:
http://help.yahoo.com/l/us/yahoo/groups/original/members/web/index.htmlfiles

Regards,

drbillcorcoran <williamcorcoran@...>

#5435 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Fri Nov 7, 2008 10:13 am
Subject: Fw: Thanks for the Magic Question to Ask
drbillcorcoran
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Debbie,
 
Thanks for the kind words.
 
You have no idea how reinforcing a little recognition can be.
 
I have attached some jpg files that might be of some use for thought material and/or templates.
 
Please let me know how asking the Magic Question worked for you.

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 


--- On Thu, 11/6/08, DaAliya@... <DaAliya@...> wrote:
From: DaAliya@... <DaAliya@...>
Subject: Thanks
To: William.R.Corcoran@...
Cc: bobnelms@..., emberley.doug@..., william.salot@...
Date: Thursday, November 6, 2008, 8:10 PM

Bill,
I think you know that I have found your approach of coming up with these lists and basic questions to cut through all the crap and get to the point over the years to be VERY IMPRESSIVE. Your brain still amazes me more than ANYONE else I have actually MET in person. But since I have never really been able to convince anyone to pay me to do what I consider real root cause analysis, I usually consider your comments to be of great interest, but they are not directly usable by me in my current practice.
 
THIS HOWEVER
 
Try asking, "What are the factors that directly resulted in the nature, the magnitude, the location, and the timing of X?"
 
struck me suddenly as being something that I may actually give a try at USING.
I have printed the following out and hung it on my wall.
 
I say suddenly because I am pretty sure that this is closer to the 100th time you have posted this than the first!
 
Thanks for your contributions.
Debbie Aliya
Materials Engineer

MAIL TO AND REMIT TO:
Aliya Analytical Inc.
PO Box 2407
Grand Rapids, MI 49501

www.itothen.com

PHONE: 616-475-0059

Cell: 616-292-2707

SHIP TO ADDRESS (NO US MAIL SERVICE HERE)
3417 Roger B. Chaffee Blvd. Suite 311
Wyoming, MI 49548




#5436 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Fri Nov 7, 2008 10:22 am
Subject: Re: [rootcauseconference] Re: Picklists, Category Trees, and Cause Codes.
drbillcorcoran
Send Email Send Email
 
Debbie,
 
Rather than helping the beginner avoid leaving important things out ,exclusive use of the Picklists, Category Trees, and Cause Codes guarantee that important thngs will be left out.
 
Event and Causal Factor Charts should be tarred with the same brush.

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 


--- On Thu, 11/6/08, daaliya@... <daaliya@...> wrote:
From: daaliya@... <daaliya@...>
Subject: Re: [rootcauseconference] Re: Picklists, Category Trees, and Cause Codes.
To: rootcauseconference@yahoogroups.com
Date: Thursday, November 6, 2008, 8:10 PM

In a message dated 11/6/2008 5:43:13 P.M. Eastern Standard Time, William.R.Corcoran@ 1959.USNA. com writes:
The use of Picklists, Category Trees, and Cause Codes in the early stages of an investigation practically guarantee that a proper set of factors will not emerge.
 
However, there is a role for Picklists, Category Trees, and Cause Codes. Perhaps we'll get to it.
And a role for recipes for doing an investigation.
They are helpful to the beginner to make sure you did not forget anything.
I prefer to consider such recipes or any other formal problem solving methodology as something in a professional toolbox that can be used as the situation requires.
 
Maybe this is different from the items you have listed above, but I see it similarly.
 
Debbie Aliya
Materials Engineer

MAIL TO AND REMIT TO:
Aliya Analytical Inc.
PO Box 2407
Grand Rapids, MI 49501

www.itothen. com

PHONE: 616-475-0059

Cell: 616-292-2707

SHIP TO ADDRESS (NO US MAIL SERVICE HERE)
3417 Roger B. Chaffee Blvd. Suite 311
Wyoming, MI 49548




#5437 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Fri Nov 7, 2008 12:00 pm
Subject: RE: [rootcauseconference] "Factors" and Diction
drbillcorcoran
Send Email Send Email
 
Bill Salot,
 
I listen to people and try to notice how they use words. This is what my hero Noah Webster did. http://en.wikipedia.org/wiki/Prescription_and_description
 
I have never heard anyone use the word "factor" restricted to active involvement the way you suggest.
 
Here is how I hear the word "factor" used: A factor is something that affects an effect.
 
But I thank you for your dialogue and value you as a colleague.
 
We can resolve our apparent inconsistency: I agree that rooticians serve their consituents better if they use the term "causal factor" instead of the term "cause."
 
I think that I have observed that it is harder to buy into "one causal factor" than it is to buy into "one cause" for a consequence.
 
If I avoid the term "cause", as I have started doing, I need not deal with what its synonyms are. I will close the poll. (I gave up using the word "root cause" except in quotations and in special cases long ago.)
 
OBTW1: The people I hear tend to use the term "causal factors" for factors that have adverse impacts on a consequence. And this is fine.
 
It gives us the terms "preventive factor" and "mitigating factor" for factors that have beneficial effects.
All potential consequences have preventive factors.
All actual consequences and expected consequences have mitigating factors.
One cannot explain the nature, the magnitude, the location, and the timing of a consequence without including beneficial factors.
 
OBTW2: A researcher named Benjamin Lee Whorf maintained that thinking is constricted by vocabulary. http://en.wikipedia.org/wiki/Benjamin_Lee_Whorf
 
There are others who have contempt for diction as being "mere symantics." These often include those who don't want to "get it" because "getting it" would force them to give up cherished misconceptions.

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 


--- On Thu, 11/6/08, Salot, William <william.salot@...> wrote:
From: Salot, William <william.salot@...>
Subject: RE: [rootcauseconference] Re: One cause?
To: rootcauseconference@yahoogroups.com
Date: Thursday, November 6, 2008, 2:06 PM

Bill C,

 

As you know, I voted “No” to indicate my belief that “causes” and “causal factors” should not be used interchangeably.

 

Let me put my reasoning another way.  We rootician’s on this forum are a small minority in the English-speaking world.  We can claim to be deep thinkers with special insights, but that is not going to bring the majority into our fold.

 

We can communicate across the divide only by using terms that both parties mutually understand.

 

My “plain English” dictionary defines the noun “cause” as “something that brings about an effect or a result”.

 

The same source defines the noun “factor” as “something that actively contributes to the production of a result”.

 

Our extensive discussions have established that a “factor”, even a “causal factor”, by itself cannot bring about anything.  Therefore “causes” and “causal factors” are fundamentally different.  Hence: my “No” vote.

 

When an authority asks for “THE cause”, patiently point out that it is a combination of many factors.

 

When an authority asks for “THE root cause”, patiently ask for direction on how to choose it from among the many factors.

 

Rooticians unite!  Explain the difference.  The customer is confused.   

 

Bill Salot

 


From: rootcauseconference @yahoogroups. com [mailto:rootcauseco nference@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
Sent: Wednesday, November 05, 2008 3:30 PM
To: rootcauseconference @yahoogroups. com
Subject: RE: [rootcauseconferenc e] Re: One cause?

 

Bill Salot,

 

I will put up a poll on this issue since it is a matter of English usage.

 

Please vote.

Take care,
 
Bill Corcoran


--- On Wed, 11/5/08, Salot, William <william.salot@ honeywell. com> wrote:

From: Salot, William <william.salot@ honeywell. com>
Subject: RE: [rootcauseconferenc e] Re: One cause?
To: rootcauseconference @yahoogroups. com
Date: Wednesday, November 5, 2008, 3:13 PM

Bill C,

 

I need some academic exercise, so-o-o . . .

 

“I beg to differ with” your below-stated professional difference of opinion with Richard.

 

In Richard’s example, you “find a problem”.  The problem you find is specific; say a specific window has been broken.

 

There are many different causes of broken windows in a generic sense.  But there is only one cause of a specific broken window.  That specific cause is a specific combination of specific factors interacting in a specific way over a specific time in a specific space.  That cause is singular and can be graphically displayed by a single specific factor tree.  The factor tree helps us understand a single cause through the logical display of its elements.    

 

I would agree if you said no problem has only one isolated causal factor.  Probably everybody would agree with that.

 

But you never hear anybody ask, “What was the causal factor?”  Instead you almost always hear people ask, “What was the cause?”

 

Let’s give them credit for understanding that the cause of a specific problem can be complex and complicated.  Challenging their desire to understand that cause, with all it entails, is like going the wrong way on a one-way street.  It impedes progress toward the real objective. 

 

Let’s answer in depth their question without narrow-mindedly questioning their perfectly legitimate phraseology.  That is what they want and expect.

 

What are your thoughts?

 

Bill Salot

 


From: rootcauseconference @yahoogroups. com [mailto:rootcauseco nference@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
Sent: Saturday, November 01, 2008 7:57 AM
To: rootcauseconference @yahoogroups. com
Subject: Re: [rootcauseconferenc e] Re: One cause?

 

I beg to differ with the statement that


"The purpose of the root cause analysis is to determine the cause of the problem..."


The above statement embeds the false assumption that the problem has one cause.

Take care,
 
Bill Corcoran



Bob:

Let say you have a house and find a problem. The purpose of the root
cause analysis is to determine the cause of the problem so as
to "perfect" the house. It does not consider the possibility of
buying a new house. Why? Because then you potentially start with a
new, and perhaps, different set of problems.

In this regard I think Einstein said it best: "No amount of genius
can overcome a preoccupation with detail".

-Richard


#5438 From: "Salot, William" <william.salot@...>
Date: Fri Nov 7, 2008 2:41 pm
Subject: RE: RE: [rootcauseconference] "Factors" and Diction
wjsalot
Send Email Send Email
 

Bill C,

 

Right on!  Avoid the ambiguities of the word “cause”.  But when the customer uses it, find a common ground early on.

 

Bill Salot

 


From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
Sent: Friday, November 07, 2008 7:01 AM
To: rootcauseconference@yahoogroups.com
Cc: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] RE: [rootcauseconference] "Factors" and Diction

 

Bill Salot,

 

I listen to people and try to notice how they use words. This is what my hero Noah Webster did. http://en.wikipedia.org/wiki/Prescription_and_description

 

I have never heard anyone use the word "factor" restricted to active involvement the way you suggest.

 

Here is how I hear the word "factor" used: A factor is something that affects an effect.

 

But I thank you for your dialogue and value you as a colleague.

 

We can resolve our apparent inconsistency: I agree that rooticians serve their consituents better if they use the term "causal factor" instead of the term "cause."

 

I think that I have observed that it is harder to buy into "one causal factor" than it is to buy into "one cause" for a consequence.

 

If I avoid the term "cause", as I have started doing, I need not deal with what its synonyms are. I will close the poll. (I gave up using the word "root cause" except in quotations and in special cases long ago.)

 

OBTW1: The people I hear tend to use the term "causal factors" for factors that have adverse impacts on a consequence. And this is fine.

 

It gives us the terms "preventive factor" and "mitigating factor" for factors that have beneficial effects.

All potential consequences have preventive factors.

All actual consequences and expected consequences have mitigating factors.

One cannot explain the nature, the magnitude, the location, and the timing of a consequence without including beneficial factors.

 

OBTW2: A researcher named Benjamin Lee Whorf maintained that thinking is constricted by vocabulary. http://en.wikipedia.org/wiki/Benjamin_Lee_Whorf

 

There are others who have contempt for diction as being "mere symantics." These often include those who don't want to "get it" because "getting it" would force them to give up cherished misconceptions.

Take care,
 
Bill Corcoran

 



--- On Thu, 11/6/08, Salot, William <william.salot@honeywell.com> wrote:

From: Salot, William <william.salot@honeywell.com>
Subject: RE: [rootcauseconference] Re: One cause?
To: rootcauseconference@yahoogroups.com
Date: Thursday, November 6, 2008, 2:06 PM

Bill C,

 

As you know, I voted “No” to indicate my belief that “causes” and “causal factors” should not be used interchangeably.

 

Let me put my reasoning another way.  We rootician’s on this forum are a small minority in the English-speaking world.  We can claim to be deep thinkers with special insights, but that is not going to bring the majority into our fold.

 

We can communicate across the divide only by using terms that both parties mutually understand.

 

My “plain English” dictionary defines the noun “cause” as “something that brings about an effect or a result”.

 

The same source defines the noun “factor” as “something that actively contributes to the production of a result”.

 

Our extensive discussions have established that a “factor”, even a “causal factor”, by itself cannot bring about anything.  Therefore “causes” and “causal factors” are fundamentally different.  Hence: my “No” vote.

 

When an authority asks for “THE cause”, patiently point out that it is a combination of many factors.

 

When an authority asks for “THE root cause”, patiently ask for direction on how to choose it from among the many factors.

 

Rooticians unite!  Explain the difference.  The customer is confused.   

 

Bill Salot

 


From: rootcauseconference @yahoogroups. com [mailto:rootcauseco nference@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
Sent: Wednesday, November 05, 2008 3:30 PM
To: rootcauseconference @yahoogroups. com
Subject: RE: [rootcauseconferenc e] Re: One cause?

 

Bill Salot,

 

I will put up a poll on this issue since it is a matter of English usage.

 

Please vote.

Take care,
 
Bill Corcoran


--- On Wed, 11/5/08, Salot, William <william.salot@ honeywell. com> wrote:

From: Salot, William <william.salot@ honeywell. com>
Subject: RE: [rootcauseconferenc e] Re: One cause?
To: rootcauseconference @yahoogroups. com
Date: Wednesday, November 5, 2008, 3:13 PM

Bill C,

 

I need some academic exercise, so-o-o . . .

 

“I beg to differ with” your below-stated professional difference of opinion with Richard.

 

In Richard’s example, you “find a problem”.  The problem you find is specific; say a specific window has been broken.

 

There are many different causes of broken windows in a generic sense.  But there is only one cause of a specific broken window.  That specific cause is a specific combination of specific factors interacting in a specific way over a specific time in a specific space.  That cause is singular and can be graphically displayed by a single specific factor tree.  The factor tree helps us understand a single cause through the logical display of its elements.    

 

I would agree if you said no problem has only one isolated causal factor.  Probably everybody would agree with that.

 

But you never hear anybody ask, “What was the causal factor?”  Instead you almost always hear people ask, “What was the cause?”

 

Let’s give them credit for understanding that the cause of a specific problem can be complex and complicated.  Challenging their desire to understand that cause, with all it entails, is like going the wrong way on a one-way street.  It impedes progress toward the real objective. 

 

Let’s answer in depth their question without narrow-mindedly questioning their perfectly legitimate phraseology.  That is what they want and expect.

 

What are your thoughts?

 

Bill Salot

 


From: rootcauseconference @yahoogroups. com [mailto:rootcauseco nference@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
Sent: Saturday, November 01, 2008 7:57 AM
To: rootcauseconference @yahoogroups. com
Subject: Re: [rootcauseconferenc e] Re: One cause?

 

I beg to differ with the statement that


"The purpose of the root cause analysis is to determine the cause of the problem..."


The above statement embeds the false assumption that the problem has one cause.

Take care,
 
Bill Corcoran



Bob:

Let say you have a house and find a problem. The purpose of the root
cause analysis is to determine the cause of the problem so as
to "perfect" the house. It does not consider the possibility of
buying a new house. Why? Because then you potentially start with a
new, and perhaps, different set of problems.

In this regard I think Einstein said it best: "No amount of genius
can overcome a preoccupation with detail".

-Richard


#5439 From: "Jerald, Jack P" <Jack.P.Jerald@...>
Date: Fri Nov 7, 2008 3:17 pm
Subject: RE: RE: [rootcauseconference] "Factors" and Diction
Jack.P.Jerald@...
Send Email Send Email
 
TO;  Bill and Bill,
 
What was the old saying:  "A distinction without a difference.", or was it:  "A difference without a distinction." ?
 
At our facility, we have further added a level of flexibility (and now confusion) with the term "contributing cause". 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Salot, William
Sent: Friday, November 07, 2008 9:42 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com; rootcauseconference@yahoogroups.com
Subject: RE: [Root_Cause_State_of_the_Practice] RE: [rootcauseconference] "Factors" and Diction

Bill C,

Right on!  Avoid the ambiguities of the word “cause”.  But when the customer uses it, find a common ground early on.

Bill Salot


From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
Sent: Friday, November 07, 2008 7:01 AM
To: rootcauseconference@yahoogroups.com
Cc: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] RE: [rootcauseconference] "Factors" and Diction

Bill Salot,

I listen to people and try to notice how they use words. This is what my hero Noah Webster did. http://en.wikipedia.org/wiki/Prescription_and_description

I have never heard anyone use the word "factor" restricted to active involvement the way you suggest.

Here is how I hear the word "factor" used: A factor is something that affects an effect.

But I thank you for your dialogue and value you as a colleague.

We can resolve our apparent inconsistency: I agree that rooticians serve their consituents better if they use the term "causal factor" instead of the term "cause."

I think that I have observed that it is harder to buy into "one causal factor" than it is to buy into "one cause" for a consequence.

If I avoid the term "cause", as I have started doing, I need not deal with what its synonyms are. I will close the poll. (I gave up using the word "root cause" except in quotations and in special cases long ago.)

OBTW1: The people I hear tend to use the term "causal factors" for factors that have adverse impacts on a consequence. And this is fine.

It gives us the terms "preventive factor" and "mitigating factor" for factors that have beneficial effects.

All potential consequences have preventive factors.

All actual consequences and expected consequences have mitigating factors.

One cannot explain the nature, the magnitude, the location, and the timing of a consequence without including beneficial factors.

OBTW2: A researcher named Benjamin Lee Whorf maintained that thinking is constricted by vocabulary. http://en.wikipedia.org/wiki/Benjamin_Lee_Whorf

There are others who have contempt for diction as being "mere symantics." These often include those who don't want to "get it" because "getting it" would force them to give up cherished misconceptions.

Take care,
 
Bill Corcoran



--- On Thu, 11/6/08, Salot, William <william.salot@honeywell.com> wrote:

From: Salot, William <william.salot@honeywell.com>
Subject: RE: [rootcauseconference] Re: One cause?
To: rootcauseconference@yahoogroups.com
Date: Thursday, November 6, 2008, 2:06 PM

Bill C,

As you know, I voted “No” to indicate my belief that “causes” and “causal factors” should not be used interchangeably.

Let me put my reasoning another way.  We rootician’s on this forum are a small minority in the English-speaking world.  We can claim to be deep thinkers with special insights, but that is not going to bring the majority into our fold.

 

We can communicate across the divide only by using terms that both parties mutually understand.

 

My “plain English” dictionary defines the noun “cause” as “something that brings about an effect or a result”.

 

The same source defines the noun “factor” as “something that actively contributes to the production of a result”.

 

Our extensive discussions have established that a “factor”, even a “causal factor”, by itself cannot bring about anything.  Therefore “causes” and “causal factors” are fundamentally different.  Hence: my “No” vote.

 

When an authority asks for “THE cause”, patiently point out that it is a combination of many factors.

 

When an authority asks for “THE root cause”, patiently ask for direction on how to choose it from among the many factors.

 

Rooticians unite!  Explain the difference.  The customer is confused.   

 

Bill Salot

 


From: rootcauseconference @yahoogroups. com [mailto:rootcauseco nference@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
Sent: Wednesday, November 05, 2008 3:30 PM
To: rootcauseconference @yahoogroups. com
Subject: RE: [rootcauseconferenc e] Re: One cause?

 

Bill Salot,

I will put up a poll on this issue since it is a matter of English usage.

Please vote.

Take care,
 
Bill Corcoran


--- On Wed, 11/5/08, Salot, William <william.salot@ honeywell. com> wrote:

From: Salot, William <william.salot@ honeywell. com>
Subject: RE: [rootcauseconferenc e] Re: One cause?
To: rootcauseconference @yahoogroups. com
Date: Wednesday, November 5, 2008, 3:13 PM

Bill C,

I need some academic exercise, so-o-o . . .

 

“I beg to differ with” your below-stated professional difference of opinion with Richard.

 

In Richard’s example, you “find a problem”.  The problem you find is specific; say a specific window has been broken.

 

There are many different causes of broken windows in a generic sense.  But there is only one cause of a specific broken window.  That specific cause is a specific combination of specific factors interacting in a specific way over a specific time in a specific space.  That cause is singular and can be graphically displayed by a single specific factor tree.  The factor tree helps us understand a single cause through the logical display of its elements.    

 

I would agree if you said no problem has only one isolated causal factor.  Probably everybody would agree with that.

 

But you never hear anybody ask, “What was the causal factor?”  Instead you almost always hear people ask, “What was the cause?”

 

Let’s give them credit for understanding that the cause of a specific problem can be complex and complicated.  Challenging their desire to understand that cause, with all it entails, is like going the wrong way on a one-way street.  It impedes progress toward the real objective. 

 

Let’s answer in depth their question without narrow-mindedly questioning their perfectly legitimate phraseology.  That is what they want and expect.

 

What are your thoughts?

 

Bill Salot

 


From: rootcauseconference @yahoogroups. com [mailto:rootcauseco nference@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
Sent: Saturday, November 01, 2008 7:57 AM
To: rootcauseconference @yahoogroups. com
Subject: Re: [rootcauseconferenc e] Re: One cause?

 

I beg to differ with the statement that


"The purpose of the root cause analysis is to determine the cause of the problem..."


The above statement embeds the false assumption that the problem has one cause.

Take care,
 
Bill Corcoran



Bob:

Let say you have a house and find a problem. The purpose of the root
cause analysis is to determine the cause of the problem so as
to "perfect" the house. It does not consider the possibility of
buying a new house. Why? Because then you potentially start with a
new, and perhaps, different set of problems.

In this regard I think Einstein said it best: "No amount of genius
can overcome a preoccupation with detail".

-Richard

>>> This e-mail and any attachments are confidential, may contain legal,
professional or other privileged information, and are intended solely for the
addressee.  If you are not the intended recipient, do not use the information
in this e-mail in any way, delete this e-mail and notify the sender. CEG-IP2

#5440 From: "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...>
Date: Sun Nov 9, 2008 10:35 am
Subject: Submarine Accident Kills 20
drbillcorcoran
Send Email Send Email
 

 

Solutions cause problems?

Change is the mother of trouble?

What is your favorite "killed by a safety device" event?

If you have more information on this event please let us know.

Thanks to LCDR Don Reynerson, USN (ret) for the headsup.

The following link expires soon:

http://online.wsj.com/article_email/SB122619710466311417-lMyQjAxMDI4MjA2ODEwOTg3Wj.html

 

Submarine Accident Kills 20 in Russia

MOSCOW -- Russian news agencies are reporting that an accident aboard a nuclear-powered submarine has killed more than 20 people.

Interfax quotes navy spokesman Capt. Igor Dygalo as saying the reactor is working normally and radiation levels are normal.

State-run RIA-Novosti cites Mr. Dygalo as saying a fire-extinguishing system went into operation in error Sunday aboard the submarine during tests in the Pacific Ocean.

Mr. Dygalo is quoted as saying the dead include sailors and shipbuilders. He says 21 others were injured and evacuated to a ship that is escorting the submarine to shore.

Russia's navy has been plagued by deadly accidents. In August 2000, the Kursk nuclear sub exploded and sank in the Barents Sea, killing its entire crew of 118.

Copyright © 2008 Associated Press


#5441 From: "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...>
Date: Sun Nov 9, 2008 10:46 am
Subject: Re: Submarine Accident Kills 20
drbillcorcoran
Send Email Send Email
 

Update:

If you were investigating this one what would be in your Lines of Inquiry?

Solutions cause problems?

Change is the mother of trouble?

Here are some hints from the article: "Russia's military is still hampered by decrepit infrastructure, aging weapons and problems with corruption and incompetence." These could be causal factors or extraneous conditions adverse to quality(ECAQ). Only your rootician can tell.

What is your favorite "killed by a safety device" event?

If you have more information on this event please let us know.

 

http://news.yahoo.com/s/ap/20081109/ap_on_re_eu/eu_russia_submarine

A Soviet-built Akula class nuclear submarine is moored at a harbor on the AP – A Soviet-built Akula class nuclear submarine is moored at a harbor on the Pacific peninsula of Kamchatka, …

Russian navy: sub accident kills at least 20

MOSCOW – A new Russian nuclear-powered submarine had a problem with its fire safety system on a test run in the Sea of Japan, sparking an accident that killed at least 20 people and injured 22 others, officials said Sunday.

It was Russia's worst naval accident since torpedo explosions sank another nuclear-powered submarine, the Kursk, in the Barents Sea in 2000, killing all 118 seamen aboard.

The submarine was not damaged in Saturday's accident and went back to its base on Russia's Pacific coast under its own power, escorted by a rescue vessel, Russian navy spokesman Capt. Igor Dygalo said Sunday. The nuclear reactor aboard the submarine was operating normally and radiation levels were normal, he said.

State-run Rossiya television said the submarine went to Bolshoi Kamen, a military shipyard and a navy base near Vladivostok.

Dygalo said the deaths and injuries were due to the "unsanctioned activation" of the firefighting system in the two sections of the submarine closest to the bow. The nuclear reactor that powers the sub was not threatened, he added.

It was unclear what activated the fire-extinguishing system. The system is designed to release Freon coolant, Russian news agencies quoted an official with Russia's top investigative agency, Sergei Markin, as saying.

Markin said in televised remarks that 14 civilians and six sailors were killed, citing preliminary information. He said 22 others were hospitalized after being evacuated to a destroyer that brought them to shore.

Earlier, Dygalo said more than 20 people were killed, including sailors and workers from the shipyard that built it, and that 21 were injured and hospitalized. He said the submarine had 208 people aboard, including 81 servicemen.

Officials did not reveal the name of the submarine, which Dygalo said was to be commissioned by the navy later this year.

Yet an unnammed official at the Amur Shipbuilding Factory said the submarine was built there and is called the Nerpa, the state-run RIA-Novosti news agency reported. Testing on the submarine began last month and it submerged for the first time last week, the agency said.

Markin said authorities have opened an investigation into violations of rules for operating military vessels, suggesting human error was likely involved.

Saturday's accident came as the Kremlin flexes its military muscle and seeks to restore Russia's naval reach, part of a drive to show off the nuclear-armed country's clout amid strained ties with the West. A naval squadron is headed to Venezuela for joint exercises this month in a show of force near U.S. waters.

Despite a major boost in military spending during Vladimir Putin's eight years as president, Russia's military is still hampered by decrepit infrastructure, aging weapons and problems with corruption and incompetence.

Construction of the Nerpa, an Akula II class attack submarine, started in 1991 but was suspended for years because of a shortage of funding, RIA-Novosti reported.

First Deputy Defense Minister Alexander Kolmakov and navy chief Adm. Vladimir Vysotsky were heading for the Pacific Coast in the wake of the accident, Dygalo said.

The Kremlin said President Dmitry Medvedev was told about the accident immediately and ordered a thorough investigation.

Putin, now prime minister, was criticized for his slow response to the Kursk disaster, which marred the first of his eight years as president.

In 2003, 11 people also died when a Russian submarine that was being taken out of service sank in the Barents Sea.

 

 


--- In Root_Cause_State_of_the_Practice@yahoogroups.com, "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...> wrote:
>
>
>
>
> Solutions cause problems?
>
> Change is the mother of trouble?
>
> What is your favorite "killed by a safety device" event?
>
> If you have more information on this event please let us know.
>
> Thanks to LCDR Don Reynerson, USN (ret) for the headsup.
>
> The following link expires soon:
>
> http://online.wsj.com/article_email/SB122619710466311417-lMyQjAxMDI4MjA2\
> ODEwOTg3Wj.html
> <http://online.wsj.com/article_email/SB122619710466311417-lMyQjAxMDI4MjA\
> 2ODEwOTg3Wj.html>
>
>
>
> * NOVEMBER 8, 2008, 9:20 P.M. ET
> Submarine Accident Kills 20 in Russia Associated Press
> MOSCOW -- Russian news agencies are reporting that an accident aboard a
> nuclear-powered submarine has killed more than 20 people.
>
> Interfax quotes navy spokesman Capt. Igor Dygalo as saying the reactor
> is working normally and radiation levels are normal.
>
> State-run RIA-Novosti cites Mr. Dygalo as saying a fire-extinguishing
> system went into operation in error Sunday aboard the submarine during
> tests in the Pacific Ocean.
>
> Mr. Dygalo is quoted as saying the dead include sailors and
> shipbuilders. He says 21 others were injured and evacuated to a ship
> that is escorting the submarine to shore.
>
> Russia's navy has been plagued by deadly accidents. In August 2000, the
> Kursk nuclear sub exploded and sank in the Barents Sea, killing its
> entire crew of 118.
>
> Copyright © 2008 Associated Press
>


#5442 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Sun Nov 9, 2008 10:52 am
Subject: Re: Re: Submarine Accident Kills 20
drbillcorcoran
Send Email Send Email
 
An MSDS (Material Safety Data Sheet) for a form of Freon is at
Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 


--- On Sun, 11/9/08, William R. Corcoran, Ph.D.,P.E. <williamcorcoran@...> wrote:
From: William R. Corcoran, Ph.D.,P.E. <williamcorcoran@...>
Subject: [Root_Cause_State_of_the_Practice] Re: Submarine Accident Kills 20
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Sunday, November 9, 2008, 5:46 AM

Update:
If you were investigating this one what would be in your Lines of Inquiry?
Solutions cause problems?

Change is the mother of trouble?
Here are some hints from the article: "Russia's military is still hampered by decrepit infrastructure, aging weapons and problems with corruption and incompetence. " These could be causal factors or extraneous conditions adverse to quality(ECAQ) . Only your rootician can tell.

What is your favorite "killed by a safety device" event?

If you have more information on this event please let us know.
 
A Soviet-built Akula class nuclear submarine is moored at a harbor on the AP – A Soviet-built Akula class nuclear submarine is moored at a harbor on the Pacific peninsula of Kamchatka, …

Russian navy: sub accident kills at least 20

MOSCOW – A new Russian nuclear-powered submarine had a problem with its fire safety system on a test run in the Sea of Japan, sparking an accident that killed at least 20 people and injured 22 others, officials said Sunday.
It was Russia's worst naval accident since torpedo explosions sank another nuclear-powered submarine, the Kursk, in the Barents Sea in 2000, killing all 118 seamen aboard.
The submarine was not damaged in Saturday's accident and went back to its base on Russia's Pacific coast under its own power, escorted by a rescue vessel, Russian navy spokesman Capt. Igor Dygalo said Sunday. The nuclear reactor aboard the submarine was operating normally and radiation levels were normal, he said.
State-run Rossiya television said the submarine went to Bolshoi Kamen, a military shipyard and a navy base near Vladivostok.
Dygalo said the deaths and injuries were due to the "unsanctioned activation" of the firefighting system in the two sections of the submarine closest to the bow. The nuclear reactor that powers the sub was not threatened, he added.
It was unclear what activated the fire-extinguishing system. The system is designed to release Freon coolant, Russian news agencies quoted an official with Russia's top investigative agency, Sergei Markin, as saying.
Markin said in televised remarks that 14 civilians and six sailors were killed, citing preliminary information. He said 22 others were hospitalized after being evacuated to a destroyer that brought them to shore.
Earlier, Dygalo said more than 20 people were killed, including sailors and workers from the shipyard that built it, and that 21 were injured and hospitalized. He said the submarine had 208 people aboard, including 81 servicemen.
Officials did not reveal the name of the submarine, which Dygalo said was to be commissioned by the navy later this year.
Yet an unnammed official at the Amur Shipbuilding Factory said the submarine was built there and is called the Nerpa, the state-run RIA-Novosti news agency reported. Testing on the submarine began last month and it submerged for the first time last week, the agency said.
Markin said authorities have opened an investigation into violations of rules for operating military vessels, suggesting human error was likely involved.
Saturday's accident came as the Kremlin flexes its military muscle and seeks to restore Russia's naval reach, part of a drive to show off the nuclear-armed country's clout amid strained ties with the West. A naval squadron is headed to Venezuela for joint exercises this month in a show of force near U.S. waters.
Despite a major boost in military spending during Vladimir Putin's eight years as president, Russia's military is still hampered by decrepit infrastructure, aging weapons and problems with corruption and incompetence.
Construction of the Nerpa, an Akula II class attack submarine, started in 1991 but was suspended for years because of a shortage of funding, RIA-Novosti reported.
First Deputy Defense Minister Alexander Kolmakov and navy chief Adm. Vladimir Vysotsky were heading for the Pacific Coast in the wake of the accident, Dygalo said.
The Kremlin said President Dmitry Medvedev was told about the accident immediately and ordered a thorough investigation.
Putin, now prime minister, was criticized for his slow response to the Kursk disaster, which marred the first of his eight years as president.
In 2003, 11 people also died when a Russian submarine that was being taken out of service sank in the Barents Sea.
 
 

--- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@ ...> wrote:
>
>
>
>
> Solutions cause problems?
>
> Change is the mother of trouble?
>
> What is your favorite "killed by a safety device" event?
>
> If you have more information on this event please let us know.
>
> Thanks to LCDR Don Reynerson, USN (ret) for the headsup.
>
> The following link expires soon:
>
> http://online. wsj.com/article_ email/SB12261971 0466311417- lMyQjAxMDI4MjA2\
> ODEwOTg3Wj.html
> <http://online. wsj.com/article_ email/SB12261971 0466311417- lMyQjAxMDI4MjA\
> 2ODEwOTg3Wj. html>
>
>
>
> * NOVEMBER 8, 2008, 9:20 P.M. ET
> Submarine Accident Kills 20 in Russia Associated Press
> MOSCOW -- Russian news agencies are reporting that an accident aboard a
> nuclear-powered submarine has killed more than 20 people.
>
> Interfax quotes navy spokesman Capt. Igor Dygalo as saying the reactor
> is working normally and radiation levels are normal.
>
> State-run RIA-Novosti cites Mr. Dygalo as saying a fire-extinguishing
> system went into operation in error Sunday aboard the submarine during
> tests in the Pacific Ocean.
>
> Mr. Dygalo is quoted as saying the dead include sailors and
> shipbuilders. He says 21 others were injured and evacuated to a ship
> that is escorting the submarine to shore.
>
> Russia's navy has been plagued by deadly accidents. In August 2000, the
> Kursk nuclear sub exploded and sank in the Barents Sea, killing its
> entire crew of 118.
>
> Copyright © 2008 Associated Press
>

#5443 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Sun Nov 9, 2008 11:06 am
Subject: Fw: [USS_Scorpion_SSN-589] Accident on K-152, AKULA Class
drbillcorcoran
Send Email Send Email
 
Exacerbating factors: Not enough emergency air breathing devices because the augmented complement, including shipyard workers, exceeded the design basis of the EAB system and this was not accommodated in the test planning?
 
Does this remind you of the BP Texas City Explosion? How?
 
Does this remind you of violations of technical safety requirements? How?

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 


--- On Sat, 11/8/08, Bruce Rule <karasjok@...> wrote:
From: Bruce Rule <karasjok@...>
Subject: [USS_Scorpion_SSN-589] Accident on K-152, AKULA Class
To: USS_Scorpion_SSN-589@yahoogroups.com
Date: Saturday, November 8, 2008, 10:23 PM

SATURDAY, NOVEMBER 8, 2008

Accident on Akula II K-152 Nerpa?

So far reports of 20 dead:

Moscow, 08 November - RIA Novosti. More than 20 people dead as a result of an incident on a nuclear submarine in the Pacific Fleet according to the Navy Public Affairs officer, K1R Igor' Dygalo. 

A malfunction of the automatic fire supression system during sea trials on one of the Pacific Fleet submarines killed more than 20 people today. Among the dead were shipyard workers and servicemen. 

The boat wasn't damaged. THe reactor compartment is normal. Background radiation on the boat is within standards. 

The Commander in Chief of the Navy has ordered a halt to testing. The decision to return the boat to its temporary base has been made. 

Comment: The commenters at Live Journal user U-96's blog seem to think that the boat was Akula II K-152 Nerpa based on the fact that it was 1) during sea trials, and 2) shipyard workers were among the dead. 

I'm sure we'll hear more about it later.

Update from U-96:

The incident which killed 20 people on board a Russian Pacific Fleet nuclear submarine occured in the bow of the boat. There is no threat to the reactor, which is located in the stern section of the boat a source in the Pacific Ocean Fleet Headquarters told RIA Novosti. 

There were 208 people on board the submarine, 81 of them military. The BPK Admiral Tributs and the salvage tug Sayany are escorting the boat. Twenty one injured have been evacuated to the Tributs in various states of health. 

U-96 comments: Two hundred and eight on board instead of the 73 normally assigned. Of course there weren't enough EBAs to go around. "In the bow section" must mean compartment one. Torpedo room.

Update 2: Novosti reports on the types of fire suppression systems found on Russian submarines:

Now there are two fire suppression systems on board nuclear submarines: air-foam and chemical. 

The air-foam system is designed to extinguish local fires and consists of two stations located at either end of the boat. The foam reserve supports six foam stations. Each station can produce one cubic meter of foam which can be applied by means of a 10 meter long hose. The stations are placed such that they can deliver foam to any corner of the compartment. 

The chemical system is designed to extinguish any type of fire in a space except for fuel and ammunition fires and consists of a fire supression station located in all compartments except the reactor compartment. The reactor compartment is covered by stations located in the 5th and 7th compartments. 

The extinguishing agent is Halon 114B2. The system can deliver three shots of extinguishing agent to each space. The system can be activated remotely from the central command post or from a local control panel as well as manually from the station in the compartment. 

(...)

2 COMMENTS:

Navalist said...
Unfortunate but not unusual. Hopefully the casualty quota for the year has been filled and there will be no more mishaps for a while.

Interesting to note that the 'boat wasn't damaged'. Did the fire suppression system just activate by itself or did something go off. Well why split hairs? Its good to know that everything is 'within normal parameters' and radiation is 'within standards'. 

Anyway, let's not get carried away everyone knows Russian submarines are one of the most lethal weapons of war every made - especially for their own crews.
Robert said...
Hope this is just a bad first report - lots of questions left to answer. It sounds like they set off halon (or the Russian equivalent) and suffocated a bunch of people - though that's postulation based on what little we know. Noticed that U-96 mentioned that this sub was ordered by the Indians. This could get complicated.

#5444 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Sun Nov 9, 2008 1:46 pm
Subject: New file uploaded to Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
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
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   File        : /Oversight/Front Line External Oversight/Advice to Facility
Representatives
   Uploaded by : drbillcorcoran <williamcorcoran@...>
   Description : If you had a good friend/ esteemed colleague who ws just
assigned to be a Facility Representative what would you advise?

You can access this file at the URL:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/Oversight/F\
ront%20Line%20External%20Oversight/Advice%20to%20Facility%20Representatives

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drbillcorcoran <williamcorcoran@...>

#5445 From: jack.stanford@...
Date: Sun Nov 9, 2008 3:06 pm
Subject: Re: Submarine Accident Kills 20
nhasme04
Send Email Send Email
 
Hello, Bill, et. al.,
 
It sounds to me that some designers in Russia are not aware that Freon is a poor choice of gas to be used as a fire retardant.  Yes, Freon puts out fires, but it puts out people too.
 
Back at Connecticut Yankee, we installed a Halon fire suppression system for the Control Room, per NFPA standards.   The gas bottles were in the turbine hall.  We found a crew willing to be on watch when the system was tested at power.  They all had oxygen masks available, but none were used.  All that happened when the Halon was triggered was some paper flying about, and a few ceiling tiles that fell (not near the control board).  The gas nozzles should have been below the ceiling tiles.  I suppose that they were installed above for appearance considerations and ease of any work on the ceiling. 
 
Most people on submarines do not usually have an oxygen mask available, especially outside the mid section (power plant).  The use of Freon is banned in many countries due to Freon's effect on the ozone layer.  It is probably also banned due to it's lethal effects.  Up to 7% exposure for 15 minutes, Halon has no effects.  Above 10%, it can cause things like dizziness.  I believe that Halon is a sister of Freon, but does not have the same effects.  The CO2 system that we had at CY had to be manually removed from service by a watchstander before anyone was allowed in the protected area.  I bet the same would have been true if we had Freon fire protection systems.
 
Jack Stanford, PE
 
 
 
-------------- Original message from "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...>: --------------

 

Solutions cause problems?

Change is the mother of trouble?

What is your favorite "killed by a safety device" event?

If you have more information on this event please let us know.

Thanks to LCDR Don Reynerson, USN (ret) for the headsup.

The following link expires soon:

http://online.wsj.com/article_email/SB122619710466311417-lMyQjAxMDI4MjA2ODEwOTg3Wj.html

 

Submarine Accident Kills 20 in Russia

MOSCOW -- Russian news agencies are reporting that an accident aboard a nuclear-powered submarine has killed more than 20 people.

Interfax quotes navy spokesman Capt. Igor Dygalo as saying the reactor is working normally and radiation levels are normal.

State-run RIA-Novosti cites Mr. Dygalo as saying a fire-extinguishing system went into operation in error Sunday aboard the submarine during tests in the Pacific Ocean.

Mr. Dygalo is quoted as saying the dead include sailors and shipbuilders. He says 21 others were injured and evacuated to a ship that is escorting the submarine to shore.

Russia's navy has been plagued by deadly accidents. In August 2000, the Kursk nuclear sub exploded and sank in the Barents Sea, killing its entire crew of 118.

Copyright © 2008 Associated Press


#5446 From: jack.stanford@...
Date: Sun Nov 9, 2008 4:03 pm
Subject: Re: Fw: [USS_Scorpion_SSN-589] Accident on K-152, AKULA Class
nhasme04
Send Email Send Email
 
Any well written test plan would have addressed EABs for the augmented crew.  I'll bet that we have NFPA code requirements that address this.
 
Jack Stanford
 
-------------- Original message from DR WILLIAM CORCORAN <williamcorcoran@...>: --------------

Exacerbating factors: Not enough emergency air breathing devices because the augmented complement, including shipyard workers, exceeded the design basis of the EAB system and this was not accommodated in the test planning?
 
Does this remind you of the BP Texas City Explosion? How?
 
Does this remind you of violations of technical safety requirements? How?

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 


--- On Sat, 11/8/08, Bruce Rule <karasjok@aol.com> wrote:
From: Bruce Rule <karasjok@aol.com>
Subject: [USS_Scorpion_SSN-589] Accident on K-152, AKULA Class
To: USS_Scorpion_SSN-589@yahoogroups.com
Date: Saturday, November 8, 2008, 10:23 PM

SATURDAY, NOVEMBER 8, 2008

Accident on Akula II K-152 Nerpa?

So far reports of 20 dead:

Moscow, 08 November - RIA Novosti. More than 20 people dead as a result of an incident on a nuclear submarine in the Pacific Fleet according to the Navy Public Affairs officer, K1R Igor' Dygalo. 

A malfunction of the automatic fire supression system during sea trials on one of the Pacific Fleet submarines killed more than 20 people today. Among the dead were shipyard workers and servicemen. 

The boat wasn't damaged. THe reactor compartment is normal. Background radiation on the boat is within standards. 

The Commander in Chief of the Navy has ordered a halt to testing. The decision to return the boat to its temporary base has been made. 

Comment: The commenters at Live Journal user U-96's blog seem to think that the boat was Akula II K-152 Nerpa based on the fact that it was 1) during sea trials, and 2) shipyard workers were among the dead. 

I'm sure we'll hear more about it later.

Update from U-96:

The incident which killed 20 people on board a Russian Pacific Fleet nuclear submarine occured in the bow of the boat. There is no threat to the reactor, which is located in the stern section of the boat a source in the Pacific Ocean Fleet Headquarters told RIA Novosti. 

There were 208 people on board the submarine, 81 of them military. The BPK Admiral Tributs and the salvage tug Sayany are escorting the boat. Twenty one injured have been evacuated to the Tributs in various states of health. 

U-96 comments: Two hundred and eight on board instead of the 73 normally assigned. Of course there weren't enough EBAs to go around. "In the bow section" must mean compartment one. Torpedo room.

Update 2: Novosti reports on the types of fire suppression systems found on Russian submarines:

Now there are two fire suppression systems on board nuclear submarines: air-foam and chemical. 

The air-foam system is designed to extinguish local fires and consists of two stations located at either end of the boat. The foam reserve supports six foam stations. Each station can produce one cubic meter of foam which can be applied by means of a 10 meter long hose. The stations are placed such that they can deliver foam to any corner of the compartment. 

The chemical system is designed to extinguish any type of fire in a space except for fuel and ammunition fires and consists of a fire supression station located in all compartments except the reactor compartment. The reactor compartment is covered by stations located in the 5th and 7th compartments. 

The extinguishing agent is Halon 114B2. The system can deliver three shots of extinguishing agent to each space. The system can be activated remotely from the central command post or from a local control panel as well as manually from the station in the compartment. 

(...)

2 COMMENTS:

Navalist said...
Unfortunate but not unusual. Hopefully the casualty quota for the year has been filled and there will be no more mishaps for a while.

Interesting to note that the 'boat wasn't damaged'. Did the fire suppression system just activate by itself or did something go off. Well why split hairs? Its good to know that everything is 'within normal parameters' and radiation is 'within standards'. 

Anyway, let's not get carried away everyone knows Russian submarines are one of the most lethal weapons of war every made - especially for their own crews.
Robert said...
Hope this is just a bad first report - lots of questions left to answer. It sounds like they set off halon (or the Russian equivalent) and suffocated a bunch of people - though that's postulation based on what little we know. Noticed that U-96 mentioned that this sub was ordered by the Indians. This could get complicated.


#5447 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Tue Nov 11, 2008 12:36 pm
Subject: New file uploaded to Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
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        : /Russian Submarine "Nerpa" 2008/Court of Inquiry Start
   Uploaded by : drbillcorcoran <williamcorcoran@...>
   Description :  Russian officials blame sub deaths on fire safety fault

You can access this file at the URL:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/Russian%20S\
ubmarine%20%22Nerpa%22%202008/Court%20of%20Inquiry%20Start

To learn more about file sharing for your group, please visit:
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Regards,

drbillcorcoran <williamcorcoran@...>

#5448 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Tue Nov 11, 2008 3:12 pm
Subject: Re: Submarine Accident Kills 20
drbillcorcoran
Send Email Send Email
 
Jack,
 
Thanks.
 
Scroll down for the Lessons to be Learned Matrix.
 
It resides at
 
For debate: Every organization that considers itself to be a Learning Organization should include a Lessons to be Learned Matrix in every root cause analysis report.

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 
Yahoo! Groups

Name:  Lessons to be Learned (LTBL) Matrix for Russian Submarine "Nerpa" 2008

Table Description:  An investigation has two bottom lines: What should be learned from it? What should be done about it? Here we list the lessons to be learned. Add yours. If you don't like one you see add a counter lesson and make some remarks. THIS TABLE MAKES AN EXCELLENT EXAMPLE AS WELL AS AN EXCELLENT TEMPLATE
Lesson to be Learned (LTBL) v Basis for the LTBL or Situation that prompted the learning. Effect on the incident and consequences of the LTBL up-front Remarks People and groups that should learn this LTBL SORT (by priority)
A more hazardous substance should not be used if a less hazardous substance is available. The use of Freon as a fire extinguishant. No loss of life. 1) HALON 1301 FIRE EXTINGUISHANT MSDS: http://www.stationreporter.net/halon.htm 2) FREON-12 MSDS: http://www.vngas.com/pdf/g143.pdf Line management, augmented crew members, regular crew members, safety oversight personnel, test management 4.0
Comment only     Strictly speaking, a Lesson to be Learned from an event does not depend on the validity of the prompt.   0.0
Contractors and other non-regular personnel should receive all of the emergency device training that the regular staff receives when the non-regulars are exposed to the same hazards. Intuition that the non-regulars were not EAB-qualified. Chances are that someone would have noticed that the training would be useless unless the right number of EABs were deployed.   Training managegment, line management, augmented crew members, regular crew members, safety oversight personnel, test management 3.0
The Job Hazard Analysis for a test plan should include the unintended actuation of every safety system. The Freon release was reported to be spurious. Fewer lives lost. (The JHA update would have required more EABs)   Line management, augmented crew members, regular crew members, safety oversight personnel, test management 5.0
The number of emergency devices should be sufficient for the actual crew, not merely for the "design" crew. There was a greatly augmented crew. Fewer lives lost.   Line managers, augmented crew members, regular crew members, safety oversight personnel, test management 1.0
The number of personnel present should not exceed that deemed acceptable in the current safety basis/ job hazard analysis. There was a greatly augmented crew. Fewer lives lost. (The JHA update would have required more EABs)   Line managers, augmented crew members, regular crew members, safety oversight personnel, test management 2.0
 



--- On Sun, 11/9/08, jack.stanford@... <jack.stanford@...> wrote:
From: jack.stanford@... <jack.stanford@...>
Subject: Re: [Root_Cause_State_of_the_Practice] Submarine Accident Kills 20
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Cc: RedlerM@...
Date: Sunday, November 9, 2008, 10:06 AM

Hello, Bill, et. al.,
 
It sounds to me that some designers in Russia are not aware that Freon is a poor choice of gas to be used as a fire retardant.  Yes, Freon puts out fires, but it puts out people too.
 
Back at Connecticut Yankee, we installed a Halon fire suppression system for the Control Room, per NFPA standards.   The gas bottles were in the turbine hall.  We found a crew willing to be on watch when the system was tested at power.  They all had oxygen masks available, but none were used.  All that happened when the Halon was triggered was some paper flying about, and a few ceiling tiles that fell (not near the control board).  The gas nozzles should have been below the ceiling tiles.  I suppose that they were installed above for appearance considerations and ease of any work on the ceiling. 
 
Most people on submarines do not usually have an oxygen mask available, especially outside the mid section (power plant).  The use of Freon is banned in many countries due to Freon's effect on the ozone layer.  It is probably also banned due to it's lethal effects.  Up to 7% exposure for 15 minutes, Halon has no effects.  Above 10%, it can cause things like dizziness.  I believe that Halon is a sister of Freon, but does not have the same effects.  The CO2 system that we had at CY had to be manually removed from service by a watchstander before anyone was allowed in the protected area.  I bet the same would have been true if we had Freon fire protection systems.
 
Jack Stanford, PE
 
 
 
-------------- Original message from "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...>: --------------

 
Solutions cause problems?
Change is the mother of trouble?
What is your favorite "killed by a safety device" event?
If you have more information on this event please let us know.
Thanks to LCDR Don Reynerson, USN (ret) for the headsup.
The following link expires soon:
 

Submarine Accident Kills 20 in Russia

MOSCOW -- Russian news agencies are reporting that an accident aboard a nuclear-powered submarine has killed more than 20 people.
Interfax quotes navy spokesman Capt. Igor Dygalo as saying the reactor is working normally and radiation levels are normal.
State-run RIA-Novosti cites Mr. Dygalo as saying a fire-extinguishing system went into operation in error Sunday aboard the submarine during tests in the Pacific Ocean.
Mr. Dygalo is quoted as saying the dead include sailors and shipbuilders. He says 21 others were injured and evacuated to a ship that is escorting the submarine to shore.
Russia's navy has been plagued by deadly accidents. In August 2000, the Kursk nuclear sub exploded and sank in the Barents Sea, killing its entire crew of 118.
Copyright © 2008 Associated Press

#5449 From: "WILLIAM L. RIGOT" <william.rigot@...>
Date: Tue Nov 11, 2008 3:49 pm
Subject: Re: Submarine Accident Kills 20
wlrigot
Send Email Send Email
 
Dr. Bill,



Interestingly, as I reflected on the LTBL matrix, I noted similarities
to the lack of adequate lifeboats for the Titanic.  Often in Safety
Analysis decisions, we convince ourselves that the short period of the
time at risk for the worst case scenario justifies not doing anything.
In this case, the short period of time for sea trials justified either
not training supplemental personnel, or providing suffficient EAB's in
the event of an atmospheric emergency.



I recently heard a presentation by John Summers, the INPO Human
Performance Manager.  The take away for me was John's admonition to
"never be one error away from a major disaster."  In this case, it
appears that the Russians systematically (and likely unknowingly)
removed defenses (EAB's, training, drills, appropriate fire fighting
agent, etc.) until they were one human error away from killing a bunch
of people.  And then the error happened.  If any one of the
aforementioned defenses been in place, this accident either wouldn't
have happened, or would have had far less consequence.  As we hear
frequently in this forum, luck is not a robust barrier.



Peace,



Bill Rigot
--- In Root_Cause_State_of_the_Practice@yahoogroups.com, DR WILLIAM
CORCORAN <williamcorcoran@...> wrote:
>
> Jack,
>
> Thanks.
>
> Scroll down for the Lessons to be Learned Matrix.
>
> It resides at
>
http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice_5/da\
tabase
>
> For debate: Every organization that considers itself to be a Learning
Organization should include a Lessons to be Learned Matrix in every root
cause analysis report.
>
>
>
> Take care,
>
> Bill Corcoran
> Mission: Saving lives, pain, assets, and careers through thoughtful
inquiry.
> Motto: If you want safety, peace, or justice, then work for
competency, integrity, and transparency.
>
> W. R. Corcoran, Ph.D., P.E.
> NSRC Corporation
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
>
>
> Subscribe to "The Firebird Forum"
TheFirebirdForum-subscribe@yahoogroups.com
> Join the group working on  on the BART Fatality Investigation
Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
>
>
>
>
>
>
>
>
>
> Name:  Lessons to be Learned (LTBL) Matrix for Russian Submarine
"Nerpa" 2008
>
> Table Description:  An investigation has two bottom lines: What should
be learned from it? What should be done about it? Here we list the
lessons to be learned. Add yours. If you don't like one you see add a
counter lesson and make some remarks. THIS TABLE MAKES AN EXCELLENT
EXAMPLE AS WELL AS AN EXCELLENT TEMPLATE
>
>
>
> Lesson to be Learned (LTBL)
> Basis for the LTBL or Situation that prompted the learning.
> Effect on the incident and consequences of the LTBL up-front
> Remarks
> People and groups that should learn this LTBL
> SORT (by priority)
>
> A more hazardous substance should not be used if a less hazardous
substance is available.
> The use of Freon as a fire extinguishant.
> No loss of life.
> 1) HALON 1301 FIRE EXTINGUISHANT MSDS:
http://www.stationreporter.net/halon.htm 2) FREON-12 MSDS:
http://www.vngas.com/pdf/g143.pdf
> Line management, augmented crew members, regular crew members, safety
oversight personnel, test management
> 4.0
>
> Comment only
>
>
> Strictly speaking, a Lesson to be Learned from an event does not
depend on the validity of the prompt.
>
> 0.0
>
> Contractors and other non-regular personnel should receive all of the
emergency device training that the regular staff receives when the
non-regulars are exposed to the same hazards.
> Intuition that the non-regulars were not EAB-qualified.
> Chances are that someone would have noticed that the training would be
useless unless the right number of EABs were deployed.
>
> Training managegment, line management, augmented crew members, regular
crew members, safety oversight personnel, test management
> 3.0
>
> The Job Hazard Analysis for a test plan should include the unintended
actuation of every safety system.
> The Freon release was reported to be spurious.
> Fewer lives lost. (The JHA update would have required more EABs)
>
> Line management, augmented crew members, regular crew members, safety
oversight personnel, test management
> 5.0
>
> The number of emergency devices should be sufficient for the actual
crew, not merely for the "design" crew.
> There was a greatly augmented crew.
> Fewer lives lost.
>
> Line managers, augmented crew members, regular crew members, safety
oversight personnel, test management
> 1.0
>
> The number of personnel present should not exceed that deemed
acceptable in the current safety basis/ job hazard analysis.
> There was a greatly augmented crew.
> Fewer lives lost. (The JHA update would have required more EABs)
>
> Line managers, augmented crew members, regular crew members, safety
oversight personnel, test management
> 2.0
>
> if(window.yzq_p==null)document.write("");
>
>
>
>
>
>
if(window.yzq_p)yzq_p('P=CGHTVELaQvDS2yiPSRB2sgA_RSUkJEkZn.sAAZ2X&T=14se\
os324%2fX%3d1226416107%2fE%3d1705713164%2fR%3dgroups%2fK%3d5%2fV%3d1.1%2\
fW%3dJ%2fY%3dYAHOO%2fF%3d1444847850%2fH%3dY2FjaGVoaW50PSJ1cy10ZWNoIg--%2\
fS%3d1%2fJ%3d5A42DA42');
> if(window.yzq_s)yzq_s();
>
>
>
>
>
>
>
> --- On Sun, 11/9/08, jack.stanford@... jack.stanford@... wrote:
>
> From: jack.stanford@... jack.stanford@...
> Subject: Re: [Root_Cause_State_of_the_Practice] Submarine Accident
Kills 20
> To: Root_Cause_State_of_the_Practice@yahoogroups.com
> Cc: RedlerM@...
> Date: Sunday, November 9, 2008, 10:06 AM
>
>
>
>
> Hello, Bill, et. al.,
>
> It sounds to me that some designers in Russia are not aware that Freon
is a poor choice of gas to be used as a fire retardant.  Yes, Freon puts
out fires, but it puts out people too.
>
> Back at Connecticut Yankee, we installed a Halon fire suppression
system for the Control Room, per NFPA standards.   The gas bottles were
in the turbine hall.  We found a crew willing to be on watch when the
system was tested at power.  They all had oxygen masks available, but
none were used.  All that happened when the Halon was triggered was some
paper flying about, and a few ceiling tiles that fell (not near the
control board).  The gas nozzles should have been below the ceiling
tiles.  I suppose that they were installed above for appearance
considerations and ease of any work on the ceiling.
>
> Most people on submarines do not usually have an oxygen mask
available, especially outside the mid section (power plant).  The use of
Freon is banned in many countries due to Freon's effect on the ozone
layer.  It is probably also banned due to it's lethal effects.  Up to 7%
exposure for 15 minutes, Halon has no effects.  Above 10%, it can cause
things like dizziness.  I believe that Halon is a sister of Freon, but
does not have the same effects.  The CO2 system that we had at CY had to
be manually removed from service by a watchstander before anyone was
allowed in the protected area.  I bet the same would have been true if
we had Freon fire protection systems.
>
> Jack Stanford, PE
>
>
>
> -------------- Original message from "William R. Corcoran, Ph.D.,P.E."
williamcorcoran@...: --------------
>
>
>
>
>
> Solutions cause problems?
> Change is the mother of trouble?
> What is your favorite "killed by a safety device" event?
> If you have more information on this event please let us know.
> Thanks to LCDR Don Reynerson, USN (ret) for the headsup.
> The following link expires soon:
> http://online. wsj.com/article_ email/SB12261971 0466311417-
lMyQjAxMDI4MjA2O DEwOTg3Wj. html
>
>
> NOVEMBER 8, 2008, 9:20 P.M. ET
> Submarine Accident Kills 20 in Russia
> Associated Press
>
>
>
>
>
> MOSCOW -- Russian news agencies are reporting that an accident aboard
a nuclear-powered submarine has killed more than 20 people.
> Interfax quotes navy spokesman Capt. Igor Dygalo as saying the reactor
is working normally and radiation levels are normal.
> State-run RIA-Novosti cites Mr. Dygalo as saying a fire-extinguishing
system went into operation in error Sunday aboard the submarine during
tests in the Pacific Ocean.
> Mr. Dygalo is quoted as saying the dead include sailors and
shipbuilders. He says 21 others were injured and evacuated to a ship
that is escorting the submarine to shore.
> Russia's navy has been plagued by deadly accidents. In August 2000,
the Kursk nuclear sub exploded and sank in the Barents Sea, killing its
entire crew of 118.
> Copyright © 2008 Associated Press
>

#5450 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Tue Nov 11, 2008 4:10 pm
Subject: Re: Re: Submarine Accident Kills 20
drbillcorcoran
Send Email Send Email
 
Bill Rigot,
 
Thanks.
 
The updated LTBL Matrix is pasted below.
 
Does you organization require an LTBL Matrix in every event investigation report?
 
If not, is it ignoring a crucial LTBL?

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 
Yahoo! Groups

Name:  Lessons to be Learned (LTBL) Matrix for Russian Submarine "Nerpa" 2008

Table Description:  An investigation has two bottom lines: What should be learned from it? What should be done about it? Here we list the lessons to be learned. Add yours. If you don't like one you see add a counter lesson and make some remarks. THIS TABLE MAKES AN EXCELLENT EXAMPLE AS WELL AS AN EXCELLENT TEMPLATE
Lesson to be Learned (LTBL) Basis for the LTBL or Situation that prompted the learning. Effect on the incident and consequences of the LTBL up-front Remarks People and groups that should learn this LTBL SORT (by priority) v
Comment only     Strictly speaking, a Lesson to be Learned from an event does not depend on the validity of the prompt.   0.0
Every organization that calls itself a Learning Organization should have a matrix like this one as part of every event investigation report. This organization apparently has not been learning from experience. It may have reduced the loss of life. It is hard to imagine that the Russian Navy is not aware of events whose LTBL would have reduced the consequences of this event.   Operating Experience Program management, line mangement, oversight management... 0.1
The number of emergency devices should be sufficient for the actual exposed population. Not enough Emergency Air Breathing devices for the actual complement. Fewer lives lost. This LTBL could have been learned from the loss of life in the RMS Titanic disaster, or even in the story of Noah's Arc! Operating Experience Program management, line mangement, oversight management... 0.9
The number of emergency devices should be sufficient for the actual crew, not merely for the "design" crew. There was a greatly augmented crew. Fewer lives lost.   Line managers, augmented crew members, regular crew members, safety oversight personnel, test management 1.0
The number of personnel present should not exceed that deemed acceptable in the current safety basis/ job hazard analysis. There was a greatly augmented crew. Fewer lives lost. (The JHA update would have required more EABs)   Line managers, augmented crew members, regular crew members, safety oversight personnel, test management 2.0
Contractors and other non-regular personnel should receive all of the emergency device training that the regular staff receives when the non-regulars are exposed to the same hazards. Intuition that the non-regulars were not EAB-qualified. Chances are that someone would have noticed that the training would be useless unless the right number of EABs were deployed.   Training managegment, line management, augmented crew members, regular crew members, safety oversight personnel, test management 3.0
A more hazardous substance should not be used if a less hazardous substance is available. The use of Freon as a fire extinguishant. No loss of life. 1) HALON 1301 FIRE EXTINGUISHANT MSDS: http://www.stationreporter.net/halon.htm 2) FREON-12 MSDS: http://www.vngas.com/pdf/g143.pdf Line management, augmented crew members, regular crew members, safety oversight personnel, test management 4.0
The Job Hazard Analysis for a test plan should include the unintended actuation of every safety system. The Freon release was reported to be spurious. Fewer lives lost. (The JHA update would have required more EABs)   Line management, augmented crew members, regular crew members, safety oversight personnel, test management 5.0


--- On Tue, 11/11/08, WILLIAM L. RIGOT <william.rigot@...> wrote:
From: WILLIAM L. RIGOT <william.rigot@...>
Subject: [Root_Cause_State_of_the_Practice] Re: Submarine Accident Kills 20
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Tuesday, November 11, 2008, 10:49 AM


Dr. Bill,

Interestingly, as I reflected on the LTBL matrix, I noted similarities
to the lack of adequate lifeboats for the Titanic. Often in Safety
Analysis decisions, we convince ourselves that the short period of the
time at risk for the worst case scenario justifies not doing anything.
In this case, the short period of time for sea trials justified either
not training supplemental personnel, or providing suffficient EAB's in
the event of an atmospheric emergency.

I recently heard a presentation by John Summers, the INPO Human
Performance Manager. The take away for me was John's admonition to
"never be one error away from a major disaster." In this case, it
appears that the Russians systematically (and likely unknowingly)
removed defenses (EAB's, training, drills, appropriate fire fighting
agent, etc.) until they were one human error away from killing a bunch
of people. And then the error happened. If any one of the
aforementioned defenses been in place, this accident either wouldn't
have happened, or would have had far less consequence. As we hear
frequently in this forum, luck is not a robust barrier.

Peace,

Bill Rigot
--- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM
CORCORAN <williamcorcoran@ ...> wrote:
>
> Jack,
>
> Thanks.
>
> Scroll down for the Lessons to be Learned Matrix.
>
> It resides at
>
http://tech. groups.yahoo. com/group/ Root_Cause_ State_of_ the_Practice_ 5/da\
tabase

>
> For debate: Every organization that considers itself to be a Learning
Organization should include a Lessons to be Learned Matrix in every root
cause analysis report.
>
>
>
> Take care,
>
> Bill Corcoran
> Mission: Saving lives, pain, assets, and careers through thoughtful
inquiry.
> Motto: If you want safety, peace, or justice, then work for
competency, integrity, and transparency.
>
> W. R. Corcoran, Ph.D., P.E.
> NSRC Corporation
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
>
>
> Subscribe to "The Firebird Forum"
TheFirebirdForum- subscribe@ yahoogroups. com
> Join the group working on on the BART Fatality Investigation
Root_Cause_State_ of_the_Practice_ 7-subscribe@ yahoogroups. com
>
>
>
>
>
>
>
>
>
> Name: Lessons to be Learned (LTBL) Matrix for Russian Submarine
"Nerpa" 2008
>
> Table Description: An investigation has two bottom lines: What should
be learned from it? What should be done about it? Here we list the
lessons to be learned. Add yours. If you don't like one you see add a
counter lesson and make some remarks. THIS TABLE MAKES AN EXCELLENT
EXAMPLE AS WELL AS AN EXCELLENT TEMPLATE
>
>
>
> Lesson to be Learned (LTBL)
> Basis for the LTBL or Situation that prompted the learning.
> Effect on the incident and consequences of the LTBL up-front
> Remarks
> People and groups that should learn this LTBL
> SORT (by priority)
>
> A more hazardous substance should not be used if a less hazardous
substance is available.
> The use of Freon as a fire extinguishant.
> No loss of life.
> 1) HALON 1301 FIRE EXTINGUISHANT MSDS:
http://www.stationr eporter.net/ halon.htm 2) FREON-12 MSDS:
http://www.vngas. com/pdf/g143. pdf
> Line management, augmented crew members, regular crew members, safety
oversight personnel, test management
> 4.0
>
> Comment only
>
>
> Strictly speaking, a Lesson to be Learned from an event does not
depend on the validity of the prompt.
>
> 0.0
>
> Contractors and other non-regular personnel should receive all of the
emergency device training that the regular staff receives when the
non-regulars are exposed to the same hazards.
> Intuition that the non-regulars were not EAB-qualified.
> Chances are that someone would have noticed that the training would be
useless unless the right number of EABs were deployed.
>
> Training managegment, line management, augmented crew members, regular
crew members, safety oversight personnel, test management
> 3.0
>
> The Job Hazard Analysis for a test plan should include the unintended
actuation of every safety system.
> The Freon release was reported to be spurious.
> Fewer lives lost. (The JHA update would have required more EABs)
>
> Line management, augmented crew members, regular crew members, safety
oversight personnel, test management
> 5.0
>
> The number of emergency devices should be sufficient for the actual
crew, not merely for the "design" crew.
> There was a greatly augmented crew.
> Fewer lives lost.
>
> Line managers, augmented crew members, regular crew members, safety
oversight personnel, test management
> 1.0
>
> The number of personnel present should not exceed that deemed
acceptable in the current safety basis/ job hazard analysis.
> There was a greatly augmented crew.
> Fewer lives lost. (The JHA update would have required more EABs)
>
> Line managers, augmented crew members, regular crew members, safety
oversight personnel, test management
> 2.0
>
> if(window.yzq_ p==null)document .write("" );
>
>
>
>
>
>
if(window.yzq_ p)yzq_p(' P=CGHTVELaQvDS2y iPSRB2sgA_ RSUkJEkZn. sAAZ2X&T= 14se\
os324%2fX%3d1226416 107%2fE%3d170571 3164%2fR% 3dgroups% 2fK%3d5%2fV% 3d1.1%2\
fW%3dJ%2fY%3dYAHOO% 2fF%3d1444847850 %2fH%3dY2FjaGVoa W50PSJ1cy10ZWNoI g--%2\
fS%3d1%2fJ%3d5A42DA 42');
> if(window.yzq_ s)yzq_s() ;
>
>
>
>
>
>
>
> --- On Sun, 11/9/08, jack.stanford@ ... jack.stanford@ ... wrote:
>
> From: jack.stanford@ ... jack.stanford@ ...
> Subject: Re: [Root_Cause_ State_of_ the_Practice] Submarine Accident
Kills 20
> To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
> Cc: RedlerM@...
> Date: Sunday, November 9, 2008, 10:06 AM
>
>
>
>
> Hello, Bill, et. al.,
>
> It sounds to me that some designers in Russia are not aware that Freon
is a poor choice of gas to be used as a fire retardant. Yes, Freon puts
out fires, but it puts out people too.
>
> Back at Connecticut Yankee, we installed a Halon fire suppression
system for the Control Room, per NFPA standards. The gas bottles were
in the turbine hall. We found a crew willing to be on watch when the
system was tested at power. They all had oxygen masks available, but
none were used. All that happened when the Halon was triggered was some
paper flying about, and a few ceiling tiles that fell (not near the
control board). The gas nozzles should have been below the ceiling
tiles. I suppose that they were installed above for appearance
considerations and ease of any work on the ceiling.
>
> Most people on submarines do not usually have an oxygen mask
available, especially outside the mid section (power plant). The use of
Freon is banned in many countries due to Freon's effect on the ozone
layer. It is probably also banned due to it's lethal effects. Up to 7%
exposure for 15 minutes, Halon has no effects. Above 10%, it can cause
things like dizziness. I believe that Halon is a sister of Freon, but
does not have the same effects. The CO2 system that we had at CY had to
be manually removed from service by a watchstander before anyone was
allowed in the protected area. I bet the same would have been true if
we had Freon fire protection systems.
>
> Jack Stanford, PE
>
>
>
> ------------ -- Original message from "William R. Corcoran, Ph.D.,P.E."
williamcorcoran@ ...: ------------ --
>
>
>
>
>
> Solutions cause problems?
> Change is the mother of trouble?
> What is your favorite "killed by a safety device" event?
> If you have more information on this event please let us know.
> Thanks to LCDR Don Reynerson, USN (ret) for the headsup.
> The following link expires soon:
> http://online. wsj.com/article_ email/SB12261971 0466311417-
lMyQjAxMDI4MjA2O DEwOTg3Wj. html
>
>
> NOVEMBER 8, 2008, 9:20 P.M. ET
> Submarine Accident Kills 20 in Russia
> Associated Press
>
>
>
>
>
> MOSCOW -- Russian news agencies are reporting that an accident aboard
a nuclear-powered submarine has killed more than 20 people.
> Interfax quotes navy spokesman Capt. Igor Dygalo as saying the reactor
is working normally and radiation levels are normal.
> State-run RIA-Novosti cites Mr. Dygalo as saying a fire-extinguishing
system went into operation in error Sunday aboard the submarine during
tests in the Pacific Ocean.
> Mr. Dygalo is quoted as saying the dead include sailors and
shipbuilders. He says 21 others were injured and evacuated to a ship
that is escorting the submarine to shore.
> Russia's navy has been plagued by deadly accidents. In August 2000,
the Kursk nuclear sub exploded and sank in the Barents Sea, killing its
entire crew of 118.
> Copyright © 2008 Associated Press
>


#5451 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Wed Nov 12, 2008 12:19 pm
Subject: New file uploaded to Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
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        : /Russian Submarine "Nerpa" 2008/Nuclear sub victims mourned
   Uploaded by : drbillcorcoran <williamcorcoran@...>
   Description : More event information 11/11/08

You can access this file at the URL:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/Russian%20S\
ubmarine%20%22Nerpa%22%202008/Nuclear%20sub%20victims%20mourned

To learn more about file sharing for your group, please visit:
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Regards,

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#5452 From: "William R. Corcoran, Ph.D.,P.E." <williamcorcoran@...>
Date: Wed Nov 12, 2008 12:32 pm
Subject: Nuclear sub victims mourned
drbillcorcoran
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This story is at

http://www.russiatoday.com/news/news/33032

 

For the Lessons to be Learned Matrix go to

http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice_5/database

 

November 11, 2008, 6:22

Nuclear sub victims mourned

On Tuesday the Far Eastern Primorsky region will mourn the 20 people who lost their lives as a result of a tragic accident on board a Russian nuclear-powered submarine. A preliminary investigation into Saturday's accident, which left another 21 injured, says a malfunction in the submarine's fire extinguishing system is the most likely cause.

It remains unclear why the fire extinguishing system was mistakenly activated and whether there were enough gas masks for the contractors who were poisoned.

The accident on board the Nerpa submarine happened in waters off Russia's Pacific coast during training exercises.

The 20 who perished -17 people from the shipyard delivery team and three sailors - were killed by the release of a poisonous gas used to put out fires - known as Freon - which was triggered when the fire extinguishing system was accidentally turned on. 

However, it is still unclear why everybody on the craft was unable to use safety equipment.

A high-ranking source at the Pacific Fleet's headquarters told RIA Novosti news agency: "Perhaps the submariners did not notice the gas being released and when they realised it was already too late."

The chairman of the St Petersburg club for submariners Igor Kurdin has his own explanation of what happened. He thinks that it was a lack of special training for civilian victims that brought about their death.

He says an alarm is activated every time the fire extinguishing system is turned on. If that happens, sailors are obliged to use the safety equipment.

"If we talk about professional submariners, they know how to do this quickly and safely for themselves. But there were civilians on board and it was them who suffered most," he said.

One of the factors that may also have contributed to the disaster was overcrowding. The submarine had 208 people aboard, including 81 seamen, according to Russian navy spokesman Igor Dygalo. Yet Russian news agencies said a sub of this type normally carries only 73.

The Investigative Committee under the Prosecutor General's office has launched a probe, which is focusing on what activated the firefighting system and possible violations of submarine operating rules.

A Russian Pacific Fleet spokesman said the vessel's reactor is intact and there was no radiation leak. Japan's Defence Ministry also confirmed radiation levels were normal. The submarine has returned to port.

Hundreds of people gathered in Vladivostok to mourn the country's biggest naval tragedy since the Kursk disaster eight years ago.Church services were held to commemorate those who died and to pray that the injured make a full recovery.

The vessel was not yet part of the country's fleet but was due to be commissioned by the end of the year. Navy officials stress it's too early to say whether Sunday's incident would change those plans. 

Ïîäïèñü K-152 Nerpa, a nuclear-powered Project 971 Shchuka-B type, or Akula-class by NATO classification, AFP PHOTO / NTV
Construction of the Akula II (Shark) class Nerpa nuclear attack submarine began in 1991. However, because of a lack of funding, work was suspended for more than 10 years. The Akula II class vessels are considered the quietest and deadliest of Russia's nuclear-powered attack submarines. The Nerpa started sea trials on October 27.

Son rescues father and dies

A father and son, Aleksandr and Vladimir Nezhura – both ventilation-system technicians - were on board the Nerpa when the accident happened. Twenty-five-year-old Aleksandr saved his father who had fainted when the gas started leaking. Komsomolskaya Pravda reports that he then came back to the poisoned section of the sub to help others, but died.

Vladimir is in an intensive care unit. He doesn't know yet that his heroic son perished, as doctors worry that the news would kill him.  

Aleksandr had always admired his father and was happy to follow n his footsteps. They'd been on the Nerpa since September. For Vladimir it was to be the last trip before retirement.

Aleksandr's mother said her son was nicknamed "9-11" because he always trying to rescue others.

Nezhura junior had a wife and a child.

Previous accidents

The deadliest Russian submarine accident occurred on August 12, 2000, in the Barents Sea when the Kursk sank at a depth of 107 metres, killing 118 people. The nuclear sub was lifted from the seabed in June 2002.


#5453 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Wed Nov 12, 2008 4:35 pm
Subject: Event and Causal Factors Chart Template
drbillcorcoran
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Do you have a template for doing Event and Causal Factors Charts in a common software such as VISIO, PowerPoint, or Excel?
 
If so would you be so kind as to send me the link to it?
 
One of my next projects is to demonstrate how to do a form of E&CF that makes sense.

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 

#5454 From: "Hobbs, Andrew F." <hobbsaf@...>
Date: Wed Nov 12, 2008 8:42 pm
Subject: RE: Event and Causal Factors Chart Template
hobbsaf@...
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An example chart is attached in Visio format.

 

Andy Hobbs

UT-BATTELLE

Oak Ridge National Laboratory

Quality Systems & Services / Quality Programs

Issues Management / ACTS Administrator

865-574-0812

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
Sent: Wednesday, November 12, 2008 11:35 AM
To: root_cause_state_of_the_practice@yahoogroups.com; Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Event and Causal Factors Chart Template

 

Do you have a template for doing Event and Causal Factors Charts in a common software such as VISIO, PowerPoint, or Excel?

 

If so would you be so kind as to send me the link to it?

 

One of my next projects is to demonstrate how to do a form of E&CF that makes sense.

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779

 

Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com

Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com

 


#5455 From: DR WILLIAM CORCORAN <williamcorcoran@...>
Date: Wed Nov 12, 2008 8:47 pm
Subject: RE: Event and Causal Factors Chart Template
drbillcorcoran
Send Email Send Email
 
Thanks 1.0E+6
 
I'll try it out.

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
 
Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
Join the group working on  on the BART Fatality Investigation  Root_Cause_State_of_the_Practice_7-subscribe@yahoogroups.com
 


--- On Wed, 11/12/08, Hobbs, Andrew F. <hobbsaf@...> wrote:
From: Hobbs, Andrew F. <hobbsaf@...>
Subject: RE: [Root_Cause_State_of_the_Practice] Event and Causal Factors Chart Template
To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
Date: Wednesday, November 12, 2008, 3:42 PM

An example chart is attached in Visio format.

 

Andy Hobbs

UT-BATTELLE

Oak Ridge National Laboratory

Quality Systems & Services / Quality Programs

Issues Management / ACTS Administrator

865-574-0812

 

From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of DR WILLIAM CORCORAN
Sent: Wednesday, November 12, 2008 11:35 AM
To: root_cause_state_ of_the_practice@ yahoogroups. com; Root_Cause_State_ of_the_Practice@ yahoogroups. com
Subject: [Root_Cause_ State_of_ the_Practice] Event and Causal Factors Chart Template

 

Do you have a template for doing Event and Causal Factors Charts in a common software such as VISIO, PowerPoint, or Excel?

 

If so would you be so kind as to send me the link to it?

 

One of my next projects is to demonstrate how to do a form of E&CF that makes sense.

Take care,
 
Bill Corcoran
Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
 
W. R. Corcoran, Ph.D., P.E.
NSRC Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779

 

Subscribe to "The Firebird Forum"  TheFirebirdForum- subscribe@ yahoogroups. com

Join the group working on  on the BART Fatality Investigation  Root_Cause_State_ of_the_Practice_ 7-subscribe@ yahoogroups. com

 


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