Vee, You have impressive company when you say that management is about managing risk. Peter Drucker said that the function of management is to convert risk to...
Graham, Thanks for the very meaty posting. All failures of protective devices are latent unless they are challenged by a process failure. This leads to the...
Bill W., I think that it is a great idea. I'm looking forward to your results. OBTW: Have you tried Jerry Porras's Stream Analysis to do the same thing? I'm...
How should Root cause investigators progress thier analysis when the information provided by the interviewee is not supported by the evidence?, i.e. the...
You need to ask, "Why does a worker feel compelled to make statements that are less than completely truthful?" Is the climate in the company, regardless of...
Before condemning the individual, you might want to find out how he used the error prevention tools and why he selected the wrong device. The problem could be...
Mike You said ". . . if he had truely used the tools he could not have made the error." I submit that this statement reflects a serious underestimation of the ...
Thank-you Mike. I like your analogy to the prosecutor. The indivdual has a history in our organization, in fact a week before this event the individual...
Malcolm, Thanks for the thread title edit, "contradictions" is much more politically correct. If you refer to my response to a previous post in this thread...
I'm rarely accused of political correctness. How refreshing. ... politically correct. If you refer to my response to a previous post in this thread you will...
Other Mike, Mike Salazar on this end. I don't have fast enough fingers to type this one all out. If you would like to discuss this off line, I may be able to...
Please make sure you are not biased as the investigator. I had an evaluation in which the operator used all the needed self-checking tools at the time prior to...
FirstEnergy says Davis-Besse replacement power getting expensive By John Seewer, Associated Press, 3/11/2003 21:32 PORT CLINTON, Ohio (AP) The cost of keeping...
Colleague, The forwarded message below came from a colleague who is involved in "Safety-conscious Work Environment" activities. I stripped off identification...
Bill W., You can check out HPRCT at http://www.hprct.org/ I hope to see you there. Best Regards, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety...
Dear Bill, I am slow, but I have been thinking about the Occurrence Pyramid (The Firebird Forum, Volume 3, Number 6). I believe that we are looking at the...
I have worked with other people who interpreted the Occurrence Pyramid as you do. You concluded that "[t]he model implies a deterministic way of looking at the...
Rich, You are absolutely right. This is why it is so important to stamp out the "green infractions". The green infractions are the culture that produces the...
Simple reply and then I am off running. Managing performance shapers in the worker's environment and task structure will "optimize" the conditions for task...
Bernie, The policy of requiring a fix for every cause is quite interesting. It prompts me to wonder if it has any significant unintended side effects. Does it...
Bernie, As long as you have that definition you can only have one root cause. "Rootness" has to do with the property of being fundamental,deep, basic. ...
Paul and Mark, Thanks for your dialogue. What is judgment? Is it the result of the Observe, Analyze, Decide sequence? Does it require the use of cognitive...
Bill - I like the concept of "observe, analyze, decide". Yes - basically that is what we do. Another concept I use - borrowed from Russell Ackoff is that of...
Hello fellow group members, A question was posed to me. And I came to ask those who are more knowledgable than me. If one was to do a HazOp or ISM on a...
Denise, Any action that is physically possible is credible. The two most abundant things in the universe are hydrogen and stupidity. Best Regards, Bill...
Denise, I don't think Bill C. was implying that you are stupid. I think he was equating human error to stupidity, and concluding, based on the abundance of...
Bill Salot, You are certainly correct. A human, even a Ph.D., being in front of a valve may do anything. People seem to have attacks of stupidity at the worst...
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