Have a safe and thoughtful New Year. Scroll down for today's update. Best Regards, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts 21...
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Jan 2, 2003 9:51 am
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Jan 5, 2003 5:03 pm
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Larry, Thanks for your insights. FYI, I have been researching procedure use, non use, misuse, abuse, excuse, and refuse for about twenty years, more or less. ...
Please scroll down for an article from today's NY Times. Best Regards, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts 21 Broadleaf...
Does anyone know why it went to $30 million? What were the exacerbating factors? Best Regards, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review...
Colleague, The last issue of "The Firebird Forum" advanced the 360 Degree Approach to Generic Implications. It prompted several on-line and off-line...
I thought you'd like these gems: ____________________________________________________ 2. AIRPORT DETECTOR FINDS FOUR-MONTH-OLD SURGICAL TOOL IN WOMAN'S STOMACH...
Greg, From the point of view of the regulations it is a near miss. From the point of view of a positive control of radiation dose it is a hit. You have...
Rich, What you say makes perfect sense. When you have limited resources how do you choose between situations that meet one of your four criteria? Best Regards,...
Greg, When you do your barrier analysis I would suggest that you consider not only which barriers failed (all but a few), but also how they failed, e.g.,...
Vicki, Any set of statistics that indicates that less than about 95% of incidents are caused by human performance issues is incredible. And those human...
Please scroll down for today's update. Best Regards, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review Concepts 21 Broadleaf Circle Windsor, CT...
... situations that meet one of your four criteria? ... We don't choose. If it meets the criteria, we do the root cause analysis. Current management thinking...
Colleague, So far the root cause community has not looked at intelligence (or more properly, lack thereof) as a legitimate causal factor of adverse events. ...
Bill, Thanks for weighing in so clearly. Without defining what it is that is measured by an IQ test, let's just talk about how "intelligence" might affect...
In some instances, a high degree of intelligence (or alcohol) impairs the thought process. More intelligence (or alcohol) tends to make people think "Naw, they...
Jim, Good point. Do you have any examples from your experience? Thanks ever so much. Best Regards, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety...
Clark, Thanks for the comment on red flagging. Some organizations "basis capture" specific provisions in procedures that are the result of: 1) commitments to...
Bill Some organizations "basis capture" specific provisions in procedures that are the result of: 1) commitments to regulators, and 2) (less frequently)...
Some organizations "basis capture" specific provisions in procedures that are the result of: 1) commitments to regulators, and 2) (less frequently) serious...
It is noteworthy that you have changed the definition from that posed in your article. The article defines intelligence as "an ability to manipulate...
Does the surgical experience with foreign material management (FMM) sound consistent with the experience in your industry? Does emergent work generally result...
My good idea is: For all patient safety events that are investigated answer the following eight questions: 1. What were the consequences for the patient, the...
Jack, Here is a report I found today. It sounds like TVA doesn't understand root cause analysis. Or, perhaps, they don't want to broadcast what set them up for...
Please scroll down for today's update. It sounds like D-B still has not achieved positive control of the schedule. Note the PBS TV program scheduled for...
It was a large cross-channel ferry that sunk on the way out of Zeebrugge with great loss of life because they left the door open. Try searching on it in...
Bill, A complete (and a great example of) root cause analysis is available: mv Herald of Free Enterprise Report of the Court No. 8074, Department of Transport,...
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Jan 23, 2003 11:44 am
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http://groups.yahoo.com/group/DBRVH_LTBL/files/Nuclear%20Safety%20Culture/Challenger%20Launch%20Decision The above link is to a file in our Files Section. If...
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