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Jan 1, 2009 9:34 am
5786
Bruce, Bills, et al, Â The plain English basic is that a factor is something that affected an effect. To be a factor it must be a fact. But all facts are not...
The previous posting is replaced with this one.  Factors: Back to the Basics  The plain English basic is that a factor is something that affected an...
See "Back to the Basics" at  http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/Dictionary%20and%20Babel/  I intend to keep that...
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Root_Cause_State_of_t...
Jan 1, 2009 10:47 am
5791
Concering DWY, I believe that DWY is a causal factor. There are many studies that show that it equates to driving while drunk. It is a negative - lack of...
The attached picture got my attention-big time. It prompted me to consider how important it is to have gripping, but valid, pictures in investigation reports. ...
After reading about the huge sludge event, I let my imagination run wild. Imagination does not have a place in RCA reports/assessments. Anyone who spends...
Jack, You said: "Imagination does not have a place in RCA reports/assessments." I agree that what is in an investigation report has to be based on fact, not...
I would say that the failure of many investigations/causal analyses is the lack of imagination. Too often investigators and rooticians have pre-conceived...
Hobbs, Andrew F.
hobbsaf@...
Jan 2, 2009 1:49 pm
5796
Dr. Bill, One place where I can see imagination being used is in "near hit" investigations. At the end of the investigation someone goes "Holy Crap, here's...
Bill C, Let's not get carried away. "Imagination" can be good or bad. Like "luck", it is not robust. Good "imagination" is driven by sound "logic". Bad...
Bill C, Hooray! Yes! Let's do it! It's only logical! Bill Salot ________________________________ From: Root_Cause_State_of_the_Practice@yahoogroups.com ...
Bill Rigot, In order to have one of those near miss/ near hit / fragile precursor insights one must have a cognitive model of the system including the...
Bill C, You have done a lot of development work since you adopted use of the term, "factor". I particularly like your reference to a factor" as a "training...
I think that questioning is a better approach than using one's imagination. Perhaps imagination is a good tool that leads to better questions, i.e. what would...
Back when I started riding motorcycles in the early 1970s, there was no motorcycle helmet law in CT. My father was an MD, but he never told me that I had to...
We had an event where corroded safety-related piping sprung a leak as we were cleaning it to take wall thickness measurements. The resulting shutdown took...
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Jan 3, 2009 1:54 pm
5810
This is another good example of why I decided not to become a lawyer (or an MD). A lot of times, I don't see lawyers doing good. Jack Stanford ... Mike...
Dr. Bill, The place you're describing is where I work. I see some evidence of change, because that kind of thinking invariably leads to the same wrong ...
Bill Rigot, Thanks for mentioning the Factors-Consequences Matrix. Here's a basic one for the BART Fatality. [Yahoo! Groups] Name: Factors-Consequences...
Dr. Bill & Barry, If this is the incident I'm thinking of, it was briefed extensively at the 2008 Engineering Human Performance conference at Davis Besse by...
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