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#10322 From: "BILL" <wlrigot@...>
Date: Wed May 23, 2012 4:56 pm
Subject: Re: Performance Discipline
wlrigot
Send Email Send Email
 

Gerry,

 

If you go to the Files section of this group, you'll find a file I wrote a few years ago called "Fixes that Fail".  You'll see a systems thinking view of the Blame Cycle and all the bad things that ensue from it.  I use this in my training interventions and consulting to illustrate to managers who blame, rather than inquire, when bad things happen.  This eventually leads to managers seeing that what I illustrate on the graphic is exactly what they are seeing in their world.  When I begin to get them to start thinking about the changes necessary to get them out of that cycle, I usually here from them "that's not how we do things around here."  When I hear that, I tell them "If you always do what you've always done, you're always going to get what you have right now....and how's that working out for you?"  This usually leads to the cognitive tension needed for them to actually change, and stop blaming the person who touched it last.

 

Bill Rigot


--- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Arsenault, Gerry" <arsenaultg@...> wrote:
>
> UNRESTRICTED | ILLIMITÉ
>
>
>
> Amen Capt Bill!
>
>
>
> How would you address the culture of blaming the person who touched it last?
>
>
>
> G.
>
>
>
> From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of BILL
> Sent: Wednesday, May 23, 2012 10:00 AM
> To: Root_Cause_State_of_the_Practice@yahoogroups.com
> Subject: [Root_Cause_State_of_the_Practice] Re: Performance Discipline
>
>
>
>
>
> Dr. Bill,
>
>
>
> Having been a Weapons Officer early in my career, I read this article and shook my head. First of all, the writer, and presumably the investigation report, sis a good job at describing what did not happen:
>
> * fatally injured sailor did not obey the danger circle posting
> * the fire control techs didn't do the SOT on time and were rushed
> * the fire control tech did not sound the alarm (it had been inoprerable for months)
> * the fire control tech did not follow his procedure
> * no tag out ws in place per procedure
> * the right person did not approve the SOT to be performed
> * the problem with the launcher in erratic movements was not diagnosed
>
> I can't say for certain that my sailors in the Weapons Department wouldn't have done what I read in the article, but I'm pretty sure they didn't. the reason I can say that is because I, my division officers, the Chief's and the LPO's spent a lot of time in th spaces watching what was going on. In a FRAM 1 destroyer, it's pretty easy. But the size of the ship should not be an excuse.
>
>
>
> I would much prefer an investigation to highlight what did happen, and why it made sense at the time. The fact that the leadership team on the ship and with the flag staff only considers discipline when there are bad consequences tells me that they are tolerant of at risk behaviors, as long as the job gets done. The very best experiences I've had in my career were when we were disciplined in how we approached our business. We followed procedures. But if we couldn't, we figured out how to make the procedures correct o that our sailors could follow them all the time. whe I was Chief Engineer of a nuclear aircraft carrier, I had a sign over my desk that read "Make the system work for you. don't be driven by the system". I didn't expect my officers, chiefs and other leaders to blindly follow rules. I wanted them to understand the underlying principles of operation so they could understand how it was supposed to work.
>
>
>
> This article does a pretty good job of explaining some of the underlying organizational complexity, but still subconsciously blames the PC1 for being in the Danger Circle making a phone call, and the Fire Control tech for commencing the SOT without making sure the area was clear. Any time I see complacency in a headline ir a Root Cause, I know that we are still blaming the "person who touched it last".
>
>
>
> Bill Rigot
>
>
> --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Dr. Bill Corcoran" William.R.Corcoran@ wrote:
> >
> > Please scroll down for the link and the story.
> > (Thanks to Bryan Lethcoe for the heads up.)
> >
> > +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
> >
> > Performance discipline is consistently and systematically performing in accordance with known good practice.
> >
> > +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
> >
> > What are the other lessons to be learned from this one?
> >
> > Â
> > Take care,
> > Â
> > Bill Corcoran
> >
> > Â
> > William R. Corcoran, Ph.D., P.E.
> > Nuclear Safety Review Concepts Corporation
> > 21 Broadleaf Circle
> > Windsor, CT 06095-1634
> > 860-285-8779
> > William.R.Corcoran@
> > http://www.linkedin.com/in/williamcorcoranphdpe
> >
> >
> > 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.
> >
> > Method: Mastering Investigative Technology
> >
> > Mindset: A good business issue investigation makes the despicable explicable.
> >
> > Memory: The harmful factors of every adverse event to date have included insufficient transparency.
> >
> > Mantra: Fix the nonconformities that resulted in the enormities.
> >
> >
> > Â
> > ****Internet Email Confidentiality Footer****
> > Â
> > Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
> > +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
> >
> > http://www.navytimes.com/mobile/index.php?storyUrl=http%3A%2F%2Fwww.navytimes.com%2Fnews%2F2012%2F05%2Fnavy-essex-regan-young-crew-mistakes-lead-to-sailor-death-052212w%2F
> > ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
> >
> >
> > Wednesday, May 23, 2012
> > 6:08 AM
> > Benefits | Money | Careers & Education
> > Forums | The Scoop Deck | NEW! Video
> > < < Back to Home
> > A crew’s mistakes lead to a sailor’s death
> > BY SAM FELLMAN - STAFF WRITER |
> > POSTED : TUESDAY MAY 22, 2012 17:31:01 EDT
> > Not long after morning colors, Personnel Specialist 1st Class (SW/AW) Regan Young ventured onto the aft missile deck to make some phone calls before the amphibious assault ship Essex weighed anchor after a
> > three-day port visit to Bali, Indonesia. The aft missile deck was a
> > popular â€" but unauthorized â€" place to use cellphones. Young sat down
> > beneath the missile launcher and placed a call.
> >
> > It was a hectic morning Nov. 23 as the crew prepared for sea â€" and
> > one division was way behind schedule. At 8 a.m. â€" only an hour before
> > the ship set the sea and anchor detail â€" combat fire control division
> > discovered that the pre-underway missile launcher test hadn’t been
> > completed, an involved process that requires five personnel, including a safety observer, and an equipment tag-out to ensure the boxy,
> > eight-cell launcher is operational.
> >
> > The work center supervisor, a fire controlman who was likely a petty
> > officer, dispatched three FCs to hurriedly complete the check. One of
> > them entered the aft launcher room about 8:15 a.m. Thinking he knew the
> > steps by heart, he didn’t bother to break out the procedures, per the
> > regulations. He didn’t establish communications with the other stations, didn’t follow the start-up steps, didn’t post a safety observer â€" and
> > didn’t check that the aft missile deck was clear. And before he switched the NATO Sea Sparrow launcher to remote control, he didn’t sound the
> > alarm: The bell had been broken for nearly a year.
> >
> > At the turn of the switch, the launcher’s stow locks disengaged and
> > its servo motors energized. And then, unexpectedly, the massive launcher moved. It spun clockwise nearly a full turn as its cells rose skyward, a dynamic and random motion that can be triggered when the system is
> > improperly initialized.
> > Tell us
> > If you’ve seen complacency or a lack of following procedures aboard your ship, write to us: navylet@
> > It struck Young, a 37-year-old father of two who was three weeks from transferring, its lower edge pinning him down as it dragged him across
> > the nonskid deck.
> >
> > Alarmed to hear the mount spin, the fire controlman rushed topside.
> > He saw Young stagger into the ship, blood running down his face. Young
> > collapsed. At 8:22 a.m., a medical emergency was called away. One of the missile cell covers had shattered and Young’s cellphone, multitool,
> > watch and sunglasses were strewn inside the red painted circle around
> > the launcher, which warned in white block letters: â€"DANGER AREA.”
> > Young was pronounced dead at 10:07 a.m. of â€"severe blunt force trauma to his body” from the launcher’s impact, concluded a subsequent command investigation, which was obtained by Navy Times via Freedom of
> > Information Act request. It found complacency and lax oversight among
> > the factors that led to Young’s death, the fleet’s first
> > maintenance-related death in 1½ years and a preventable tragedy that has raised renewed questions about whether the surface Navy is getting
> > safety right.
> >
> > Indeed, the busted alarm bell â€" a $1,352.56 part â€" and the unusual,
> > violent motion of the launcher seemed to be nothing out of the ordinary
> > to the fire controlmen entrusted to safely operate the system.
> >
> > â€"Sometimes when you turn on the launcher it will move on its own,”
> > the 28-year-old FC, who had flipped the launcher into remote, told a
> > master-at-arms in a statement signed four minutes after Young was
> > pronounced dead. â€"This is not something that happens all the time, but
> > there is a danger circle around the launcher for a reason.” He added
> > that he was going to act as the safety observer after he had powered up
> > the launcher.
> > The final report, which provided the timeline of events that led up
> > to the tragedy, made clear that Essex’s maintenance problems went all
> > the way to the top.
> >
> > â€"Essex leadership did not effectively foster a culture of procedural
> > compliance and accountability,” Rear Adm. Scott Jones, commander of
> > Expeditionary Strike Group 7, wrote in his Feb. 23 letter closing the
> > investigation. â€"I specifically approve the opinion that the death of PS1 Young occurred in the line of duty, not due to his own misconduct.”
> >
> > Five enlisted crew members â€" whose names and titles are redacted from the report â€" were issued letters of instruction and one was issued a
> > nonpunitive letter of caution. In addition, three sailors received
> > nonjudicial punishment and one was detached for cause and removed from
> > Essex, a 7th Fleet spokesman said. Jones administratively counseled the
> > commanding officer, Capt. Dave Fluker, a helicopter pilot who in April
> > took command of the Wasp-class sister ship Bonhomme Richard as part of a crew swap.
> >
> > Meanwhile, the 20-year-old Essex is headed for a much-needed major
> > overhaul in the U.S. after a recent history of maintenance problems.
> > Outside of Fluker’s counseling, no officers or chiefs have been
> > disciplined in any way and none have been relieved of their duties.
> > â€"That’s not much of a punishment for killing somebody or allowing it
> > to happen in the environment that you fostered,” said one former
> > Wasp-class commanding officer after reviewing the report. â€"The whole
> > chain of command failed,” he said, adding: â€"Why have a chain of command
> > if they’re not going to be the ones that enforce the standards?”
> >
> > Nonetheless, the Navy â€" which has fired 10 COs this year for reasons as diverse as personal misconduct, loss of confidence in
> > their abilities and poor command climate â€" maintained that the right
> > actions had been taken in this case.
> >
> > â€"Rear Adm. Jones reviewed what was a very thorough investigation, and based upon the facts of that investigation, he determined what were the appropriate actions,” said Cmdr. Ron Steiner, 7th Fleet spokesman.
> > â€"It’s the commander that makes those decisions.”
> > Steiner noted that Essex held a safety standdown and completed a
> > comprehensive review of the combat system department’s manning and
> > training. Also, Naval Sea Systems Command now plans to automate all Sea
> > Sparrow launcher alarms.
> > ‘Free reign’
> > Aircraft carriers and amphibious assault ships carry NATO Sea Sparrow launchers to intercept incoming missiles and strike enemy aircraft and
> > ships. These short-range missiles, adapted from the air-to-air Sparrow
> > missile, were introduced to the fleet in 1976, according the Navy’s
> > official website. The most significant tragedy involving the Sea Sparrow occurred in 1992, when the aircraft carrier Saratoga accidentally fired two missiles at the Turkish destroyer Mauvenet, killing five, including the CO, and injuring 14.
> >
> > The system has also seen maintenance-related accidents. In the early
> > 1990s, the aircraft carrier Kitty Hawk had a Sea Sparrow incident when
> > civilian technicians inadvertently placed the launcher in remote while
> > missiles were being loaded, which caused the mount to move, the report
> > says. In the past decade, there have been two incidents when techs were
> > shocked while performing maintenance; one of them was on Essex in 2006,
> > according to Naval Safety Center records.
> >
> > But these accidents were far from the minds of Essex crew members,
> > who, like Young, frequented the aft missile deck to make phone calls or
> > see the sights â€" astern and aft of the flight deck, this area provided
> > them an unfettered view of the ship’s wake.
> >
> > â€"Aft NSSMS is always littered with people wanting to use their cell
> > phones or see the country we are pulling in or out of,” the work center
> > supervisor told a Naval Criminal Investigative Service agent later,
> > using the acronym for the NATO Sea Sparrow missile system. In addition,
> > the supervisor said boatswain mates often flaked out mooring lines
> > inside the danger circle.
> >
> > On Nov. 23, Essex was two months into a Western Pacific patrol. The
> > ship had left its home port of Sasebo, Japan, with the 31st Marine
> > Expeditionary Unit embarked.
> >
> > That morning, Young had been looking for a place to make some phone
> > calls. He had been turned away from the smoke pit and made his way aft.
> > The day before in Bali, he bought a teddy bear for his daughter and a
> > jersey for his son. Young, who didn’t drink alcohol that day, returned
> > to the ship at 1:30 a.m. on a liberty boat, his liberty buddy told
> > investigators.
> >
> > Young had just hit his 18-year mark in the Navy and was thinking
> > about what to do after he retired, his friend said. He talked about
> > moving his family to Las Vegas and getting a job with Military Sealift
> > Command. That would take him to places like Thailand and the
> > Philippines, where he was born. His friend said that during the Bali
> > port call, Young was often on the phone, speaking in Tagalog.
> >
> > On the aft missile deck Nov. 23, Young placed one call at 8:06 a.m.
> > and another 13 minutes later. The report doesn’t say who Young called.
> > At about 8 a.m., after quarters and cleaning stations, the launcher
> > work center supervisor suddenly learned that the pre-underway check of
> > the missile launcher hadn’t been performed. Known as a system
> > operability test, or SOT, it is a check performed weekly on both
> > launchers; because it is so routine, the supervisor said he had given
> > â€"the techs free reign” to complete it.
> >
> > While routine, the check is hardly simple. The instructions call for
> > five qualified FCs, including one to act as a safety observer on the
> > missile deck. The procedures also require an equipment tag-out. In
> > addition, there was some confusion on Essex about who could approve it.
> > Moving guns and launchers requires the captain’s permission on Essex,
> > but since this check isn’t supposed to cause any movement, the work
> > center supervisor felt he didn’t need to inform the chain of command,
> > according to the report.
> >
> > In port, the combat systems officer of the watch approves this
> > maintenance, the report says. But Essex that day was anchored. Despite
> > this confusion, the work center supervisor decided to go ahead, without
> > seeking permission from CSOOW or any other watchstander or leader. No
> > tags were hung.
> >
> > The three FCs had less than an hour to complete what’s supposed to be a 15-minute check. The technicians were in three compartments
> > throughout the ship and didn’t use a net to stay in constant
> > communication. One of them was in NATO Director Room 2, high up on the
> > island, to start and load the computer that controls the launcher’s
> > movement. The boot-up normally takes one to three minutes.
> >
> > But the FC in the aft launcher room didn’t call to verify that the
> > software had loaded, as the instructions call for. In fact, he wasn’t
> > using a checklist or the instructions â€" as required â€" and hadn’t
> > reviewed them beforehand. He was going from memory, the report says.
> > Prior to placing the launcher in remote â€" a step that can
> > inadvertently cause it to move â€" the operator is required to push and
> > hold the alarm button for 10 seconds, which sounds the bell around the
> > launcher for that duration. The operator skipped that.
> > He then turned the aft launcher to remote. This triggered a known â€" and dangerous â€" glitch.
> >
> > Once turned on and ready, the computer operational program provides
> > valid commands to position the launcher when it is remote. â€"When the
> > [NATO Sea Sparrow computer operational program] is not properly loaded,
> > no valid position commands are provided to the [guided missile launcher] causing the GML to move to an unordered position,” Naval Surface
> > Warfare Center Port Hueneme, Calif., engineers concluded in a report on
> > the incident. That, in some cases, causes erratic and undirected
> > launcher movement, they wrote.
> >
> > The experts demonstrated this hazardous fault in two dynamic
> > recreations, one at Port Hueneme and one on the ship. In the Essex test, when they initiated the aft launcher the same way â€" computer off, power on, control in remote â€" the launcher rotated 344 degrees clockwise and
> > rose 85 degrees where it hit the upper stops, a nearly identical motion
> > to the one that killed Young.
> >
> > â€"It was advised by the team not to retest the event as the extreme
> > movement may potential[ly] damage the [gun missile launcher system] or
> > the missiles,” the engineers wrote.
> > ‘We thought we knew what we were doing’
> > The warning alarms had been a long-standing problem. The work center
> > supervisor said he’d personally fixed the forward and aft alarms over
> > the six months he’d been aboard Essex, telling an NCIS agent: â€"They
> > continue to fail.”
> >
> > However, he did not enter any maintenance jobs into the ship’s
> > maintenance database or the combat systems trouble log. And division
> > leaders above him swore they hadn’t known about these problems; one told the agent that â€"he believed that his division sailors followed required checklists 100 percent of the time,” the report says.
> >
> > But these problems were well-known to the Sea Sparrow techs who performed this check every week.
> >
> > â€"Normally, I would have sounded the alarm, but it is broken and has
> > been for over a year,” the 28-year-old fire controlman who had placed
> > the launcher in remote told the NCIS agent in a sworn statement four
> > days later. He said his job on Nov. 23 had been to power up the
> > launcher, then go to the aft missile deck to act as a safety observer.
> > He also admitted he and others in his work center didn’t normally use
> > combat system operational sequencing system instructions, references
> > that are required for maintenance.
> >
> > â€"When did the CSOSS stop being used?” the NCIS agent asked.
> >
> > â€"When we thought we knew what we were doing,” he said. â€"Initializing equipment, it is not hard. I’ve done it so many times.”
> > â€"Is your supervisor aware you are not using the correct amount of
> > people as required by the [maintenance requirement card] to do the
> > work?”
> > â€"Yes, I believe he is aware.”
> >
> > Asked if he wanted to add anything, the FC said: â€"I apologize for all this happening and I feel so responsible.”
> >
> > His boss, however, was unapologetic. A 29-year-old fire controlman
> > from New Hampshire, the work center supervisor tried to deflect
> > responsibility for the accident. In his sworn statement six days after
> > the incident, he said he was told he didn’t need permission for the
> > check Nov. 23; he claimed that CSOSS instructions were faulty and said
> > he’d found a discrepancy that, if followed to the letter, would have
> > prevented the system from being energized; he blamed his technician for
> > not checking that the aft missile deck was clear; and he questioned why
> > Young was sitting there in the first place.
> >
> > â€"I do not know what PS1 Young was doing on the weather deck, much
> > less under a missile launcher with a red circle encompassing it reading
> > ‘DANGER AREA,’” he said. â€"I do, however, believe that he might have been on his cell phone.”
> >
> > In addition to acknowledging alarm bell problems and saying the
> > launcher’s Nov. 23 spasm â€"is not a rarity,” he admitted that he knew his technicians frequently ignored the maintenance instructions. The agent
> > asked him if there had been any repercussions when he caught his techs
> > doing this.
> >
> > â€"I personally have not given any repercussions.”
> > â€"Why not?” she pressed.
> > â€"I don’t know,” he said. â€"I did not feel they were warranted.”
> > ‘How far has the rot spread?’
> > After a monthlong investigation, the investigating officer singled
> > out the work center supervisor for blame. This fire controlman had a
> > â€"laissez-faire management style” that â€"produced complacency and
> > over-confidence” in his subordinates, the report concluded. And when he
> > had conflicting instructions about whether he needed permission for the
> > check, he chose not to seek guidance from his chain of command.
> > â€"He failed to provide effective leadership,” the investigator
> > concluded, finding that the rest of the chain of command â€" from the
> > division’s leading petty officer, chief and division officer, through
> > the department head and senior enlisted, to the executive officer and CO â€" had â€"fostered a culture of procedural compliance and accountability.”
> >
> > â€"The work center supervisor was the one exception to this rule,” the report concluded.
> >
> > Jones, the one-star ESG commander, disagreed. He struck down this
> > opinion and noted: â€"The combat system department leadership failed to
> > establish and foster an atmosphere of compliance with established
> > maintenance and safety standards.” He counseled the CO, Fluker, and
> > ordered the ship to make monthly reports on the progress of fixing
> > issues arising from the investigation. A SH-60B pilot and 1987 Naval
> > Academy grad, Fluker became XO onboard Essex in September 2009 and took
> > command of the ship in January 2011, according to his official bio.
> >
> > A second former Wasp-class commanding officer said it’s hard to
> > ascertain from the report whether the complacency and insufficient
> > oversight extended beyond the department to Essex as a whole, gator big
> > decks generally or the wider fleet.
> >
> > The proper procedures exist and weren’t followed in this case, noted
> > the retired officer, who asked to remain anonymous to avoid fraying ties with uniformed peers. The key question now from the CO’s perspective,
> > he continued, is â€"how far has the rot spread?”
> >
> > But the first former skipper said he saw evidence of wider problems
> > on Essex. He pointed to the work center supervisor’s statement that crew members often congregated on the aft missile deck to make phone calls,
> > an activity officially off-limits. That suggests the rules weren’t
> > enforced, he said.
> >
> > â€"It’s hard to point the finger at the individual sailor if nobody is
> > enforcing the rules,” said this retired officer, who also asked for
> > anonymity. â€"That kid wasn’t where he was supposed to be but, on the
> > other hand, it doesn’t seem like they had an environment where anybody
> > really worried about things like that.”
> >
> > â€"The fact that you have written standing orders and you have written
> > guidance and ship’s instructions doesn’t mean squat if nobody’s
> > enforcing it.”
> >
> > Same goes for the alarms, he continued. It is standard for the CO to
> > be notified when any alarm is broken or bypassed, and yet in this case
> > no one notified the CO, fixed the bell or logged that it wasn’t working. Nor did any chief or officer notice that the aft launcher alarm,
> > required to be sounded for 10 seconds before each check that may or will move the launcher, hadn’t rang for a year.
> >
> >
> > â€"With a looming hull swap, how much of an attitude that
> > this-won’t-be-my-problem-much-longer existed amongst the crew?” he
> > asked.
> >
>


#10323 From: "Noga, Scott T" <scott_t_noga@...>
Date: Wed May 23, 2012 6:06 pm
Subject: RE: Re: Performance Discipline
rebus3
Send Email Send Email
 

This fatality accident occurring on the USS Essex late last year happens to be the same ship that collided with the USNS Yukon tanker a few days ago, damaging both pretty heavily.

In addition to the endemic poor conduct of operations, the fatality accident included a longstanding broken alarm that was part of numerous unlogged and unreported maintenance issues.  The news account of the fatality accident investigation reports the cause was placed primarily on the FC supervisor lack of supervision but exonerated all superiors and did not seem to scrutinize the cultural issues very much. The collision accident news account reported poor and deferred maintenance of the ship, leading to a “steering malfunction”.  No mention is made of any operational deficiencies.

I wouldn’t be surprised if the incidents have some common causes, in combination with latent causes left by the prior crew.  There was a crew swap between incidents, which may include a loss of “tribal knowledge” applicable to the Essex poorly documented maintenance status at the time of the second event.

 

Scott Noga

Risk Management Program

WRPS - Hanford, USDOE contractor

ph. 509/373-1484

 

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of BILL
Sent: Wednesday, May 23, 2012 9:47 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Re: Performance Discipline

 

 

Mike,

 

I retired from the Navy 20 years ago, but have been doing some consulting work with some of the shipyardsin the past year.  Before I retired, I would say that Just Culture existed in a couple of areas, specifically Navy Nuclear and Naval Aviation.  But especially in the Surface Warfare arena, it was pretty brutal, and we tended to eat our young (and some not so young!).  Today, I continue to see a tendency to blame the "person who touched it last".  I read that in the accident reports I'm reading where the "root" causes identified are:

  • failed to follow procedures
  • failed to do a pre job brief
  • lost situational awareness
  • was complacent
  • failed to follow training

When I see those things, as I did in this article, I know that they're still in the blame game.  This makes leaders sleep better at night, but doesn't really address the fundamental leadership issues that led to the event in the first place.  So I think that the navy still has a ways to go in the area of Just Culture.

 

Bill Rigot


--- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Berkenbile, Michael J" <Michael_Berkenbile@...> wrote:
>
> This was an interesting read. Where the article lacks context it certainly made up for it with inflammatory content and bias. Who is at the helm at Navy Times and what is happening in the US Navy that would cause sailors to feel compelled to communicate issues outside the US Navy, i.e., directly to the periodical?
> I am not a Navy man. My point of reference and military experience is from Coast Guard Aviation. In that culture, I recall many were willing to come forward in the interests of safety. While no one expected a blame-free system, many understood that there is a balance. Competent people will develop unhealthy norms and competent people make mistakes. I’ll confess that during my career I was not cognizant of the term “Just Culture”, but I was aware that the organization understood the need to motivate adoption of what we refer to as a just culture, to learn from mistakes, to assign accountability, and the need to take disciplinary action when necessary, especially in instances of reckless behavior. I cannot recall one instance in 20-years where I felt any reservation to fully communicate my mistakes or my role in errors. And believe me- I made some mistakes.
> A question for our Navy vet rooticians: What is the past/current state of Just Culture in the Navy?
> r/Mike
> From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dr. Bill Corcoran
> Sent: Wednesday, May 23, 2012 3:26 AM
> To: RCSOTP1
> Subject: [Root_Cause_State_of_the_Practice] Performance Discipline
>
>
> Please scroll down for the link and the story.
> (Thanks to Bryan Lethcoe for the heads up.)
>
> +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
>
> Performance discipline is consistently and systematically performing in accordance with known good practice.
>
> +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
>
> What are the other lessons to be learned from this one?
>
> Take care,
>
> Bill Corcoran
>
>
> William R. Corcoran, Ph.D., P.E.
> Nuclear Safety Review Concepts Corporation
> 21 Broadleaf Circle
> Windsor, CT 06095-1634
> 860-285-8779
> William.R.Corcoran@...
> http://www.linkedin.com/in/williamcorcoranphdpe
>
>
> 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.
>
> Method: Mastering Investigative Technology
>
> Mindset: A good business issue investigation makes the despicable explicable.
>
> Memory: The harmful factors of every adverse event to date have included insufficient transparency.
>
> Mantra: Fix the nonconformities that resulted in the enormities.
>
> ****Internet Email Confidentiality Footer****
>
> Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
> +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
>
> http://www.navytimes.com/mobile/index.php?storyUrl=http%3A%2F%2Fwww.navytimes.com%2Fnews%2F2012%2F05%2Fnavy-essex-regan-young-crew-mistakes-lead-to-sailor-death-052212w%2F
> ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
> [cid:~WRD000.jpg]<http://www.navytimes.com/mobile/index.php>
> Wednesday, May 23, 2012
> 6:08 AM
> Benefits<http://www.navytimes.com/mobile/index.php?pageUrl=http%3A%2F%2Fwww.militarytimes.com%2Frss_mobile.php%3Fchannel%3Dbenefits&pageName=Benefits> | Money<http://www.navytimes.com/mobile/index.php?pageUrl=http%3A%2F%2Fwww.militarytimes.com%2Frss_mobile.php%3Fchannel%3Dmoney&pageName=Money> | Careers & Education<http://www.navytimes.com/mobile/index.php?pageUrl=http%3A%2F%2Fwww.militarytimes.com%2Frss_mobile.php%3Fchannel%3Dcareers&pageName=Careers+%26+Education>
> Forums<http://www.militarytimes.com/forum/forumdisplay.php?25-Navy> | The Scoop Deck<http://www.militarytimes.com/mobile/scoopdeck/> | NEW! Video<http://www.navytimes.com/mobile/video.php>
> < < Back to Home<http://www.navytimes.com/mobile/index.php>
> A crew’s mistakes lead to a sailor’s death
> BY SAM FELLMAN<MAILTO:SFELLMAN@...?SUBJECT=QUESTION%20FROM%20NAVYTIMES.COM%20READER> - STAFF WRITER | POSTED : TUESDAY MAY 22, 2012 17:31:01 EDT
> Not long after morning colors, Personnel Specialist 1st Class (SW/AW) Regan Young ventured onto the aft missile deck to make some phone calls before the amphibious assault ship Essex weighed anchor after a three-day port visit to Bali, Indonesia. The aft missile deck was a popular â€" but unauthorized â€" place to use cellphones. Young sat down beneath the missile launcher and placed a call.
>
> It was a hectic morning Nov. 23 as the crew prepared for sea â€" and one division was way behind schedule. At 8 a.m. â€" only an hour before the ship set the sea and anchor detail â€" combat fire control division discovered that the pre-underway missile launcher test hadn’t been completed, an involved process that requires five personnel, including a safety observer, and an equipment tag-out to ensure the boxy, eight-cell launcher is operational.
>
> The work center supervisor, a fire controlman who was likely a petty officer, dispatched three FCs to hurriedly complete the check. One of them entered the aft launcher room about 8:15 a.m. Thinking he knew the steps by heart, he didn’t bother to break out the procedures, per the regulations. He didn’t establish communications with the other stations, didn’t follow the start-up steps, didn’t post a safety observer â€" and didn’t check that the aft missile deck was clear. And before he switched the NATO Sea Sparrow launcher to remote control, he didn’t sound the alarm: The bell had been broken for nearly a year.
>
> At the turn of the switch, the launcher’s stow locks disengaged and its servo motors energized. And then, unexpectedly, the massive launcher moved. It spun clockwise nearly a full turn as its cells rose skyward, a dynamic and random motion that can be triggered when the system is improperly initialized.
> Tell us
> If you’ve seen complacency or a lack of following procedures aboard your ship, write to us: navylet@...<http://www.navytimes.com/mobile/index.php?storyUrl=mailto%3Anavylet%40navytimes.com%3Fsubject%3DTell%2520us%3A%2520Have%2520you%2520seen%2520complacency%2520or%2520a%2520lack%2520of%2520following%2520procedures%2520aboard%2520your%2520ship%3F>.
> It struck Young, a 37-year-old father of two who was three weeks from transferring, its lower edge pinning him down as it dragged him across the nonskid deck.
>
> Alarmed to hear the mount spin, the fire controlman rushed topside. He saw Young stagger into the ship, blood running down his face. Young collapsed. At 8:22 a.m., a medical emergency was called away. One of the missile cell covers had shattered and Young’s cellphone, multitool, watch and sunglasses were strewn inside the red painted circle around the launcher, which warned in white block letters: “DANGER AREA.”
> Young was pronounced dead at 10:07 a.m. of “severe blunt force trauma to his body” from the launcher’s impact, concluded a subsequent command investigation, which was obtained by Navy Times via Freedom of Information Act request. It found complacency and lax oversight among the factors that led to Young’s death, the fleet’s first maintenance-related death in 1½ years and a preventable tragedy that has raised renewed questions about whether the surface Navy is getting safety right.
>
> Indeed, the busted alarm bell â€" a $1,352.56 part â€" and the unusual, violent motion of the launcher seemed to be nothing out of the ordinary to the fire controlmen entrusted to safely operate the system.
>
> “Sometimes when you turn on the launcher it will move on its own,” the 28-year-old FC, who had flipped the launcher into remote, told a master-at-arms in a statement signed four minutes after Young was pronounced dead. “This is not something that happens all the time, but there is a danger circle around the launcher for a reason.” He added that he was going to act as the safety observer after he had powered up the launcher.
> The final report, which provided the timeline of events that led up to the tragedy, made clear that Essex’s maintenance problems went all the way to the top.
>
> “Essex leadership did not effectively foster a culture of procedural compliance and accountability,” Rear Adm. Scott Jones, commander of Expeditionary Strike Group 7, wrote in his Feb. 23 letter closing the investigation. “I specifically approve the opinion that the death of PS1 Young occurred in the line of duty, not due to his own misconduct.”
>
> Five enlisted crew members â€" whose names and titles are redacted from the report â€" were issued letters of instruction and one was issued a nonpunitive letter of caution. In addition, three sailors received nonjudicial punishment and one was detached for cause and removed from Essex, a 7th Fleet spokesman said. Jones administratively counseled the commanding officer, Capt. Dave Fluker, a helicopter pilot who in April took command of the Wasp-class sister ship Bonhomme Richard as part of a crew swap<http://www.navytimes.com/news/2012/02/navy-gator-crews-prep-for-hull-swap-japan-essex-bonhomme-richard-021312w/>.
>
> Meanwhile, the 20-year-old Essex is headed for a much-needed major overhaul in the U.S. after a recent history of maintenance problems.
> Outside of Fluker’s counseling, no officers or chiefs have been disciplined in any way and none have been relieved of their duties.
> “That’s not much of a punishment for killing somebody or allowing it to happen in the environment that you fostered,” said one former Wasp-class commanding officer after reviewing the report. “The whole chain of command failed,” he said, adding: “Why have a chain of command if they’re not going to be the ones that enforce the standards?”
>
> Nonetheless, the Navy â€" which has fired 10 COs this year<http://www.navytimes.com/co_firings/> for reasons as diverse as personal misconduct, loss of confidence in their abilities and poor command climate â€" maintained that the right actions had been taken in this case.
>
> “Rear Adm. Jones reviewed what was a very thorough investigation, and based upon the facts of that investigation, he determined what were the appropriate actions,” said Cmdr. Ron Steiner, 7th Fleet spokesman. “It’s the commander that makes those decisions.”
> Steiner noted that Essex held a safety standdown and completed a comprehensive review of the combat system department’s manning and training. Also, Naval Sea Systems Command now plans to automate all Sea Sparrow launcher alarms.
> ‘Free reign’
> Aircraft carriers and amphibious assault ships carry NATO Sea Sparrow launchers to intercept incoming missiles and strike enemy aircraft and ships. These short-range missiles, adapted from the air-to-air Sparrow missile, were introduced to the fleet in 1976, according the Navy’s official website. The most significant tragedy involving the Sea Sparrow occurred in 1992, when the aircraft carrier Saratoga accidentally fired two missiles at the Turkish destroyer Mauvenet, killing five, including the CO, and injuring 14.
>
> The system has also seen maintenance-related accidents. In the early 1990s, the aircraft carrier Kitty Hawk had a Sea Sparrow incident when civilian technicians inadvertently placed the launcher in remote while missiles were being loaded, which caused the mount to move, the report says. In the past decade, there have been two incidents when techs were shocked while performing maintenance; one of them was on Essex in 2006, according to Naval Safety Center records.
>
> But these accidents were far from the minds of Essex crew members, who, like Young, frequented the aft missile deck to make phone calls or see the sights â€" astern and aft of the flight deck, this area provided them an unfettered view of the ship’s wake.
>
> “Aft NSSMS is always littered with people wanting to use their cell phones or see the country we are pulling in or out of,” the work center supervisor told a Naval Criminal Investigative Service agent later, using the acronym for the NATO Sea Sparrow missile system. In addition, the supervisor said boatswain mates often flaked out mooring lines inside the danger circle.
>
> On Nov. 23, Essex was two months into a Western Pacific patrol. The ship had left its home port of Sasebo, Japan, with the 31st Marine Expeditionary Unit embarked.
>
> That morning, Young had been looking for a place to make some phone calls. He had been turned away from the smoke pit and made his way aft. The day before in Bali, he bought a teddy bear for his daughter and a jersey for his son. Young, who didn’t drink alcohol that day, returned to the ship at 1:30 a.m. on a liberty boat, his liberty buddy told investigators.
>
> Young had just hit his 18-year mark in the Navy and was thinking about what to do after he retired, his friend said. He talked about moving his family to Las Vegas and getting a job with Military Sealift Command. That would take him to places like Thailand and the Philippines, where he was born. His friend said that during the Bali port call, Young was often on the phone, speaking in Tagalog.
>
> On the aft missile deck Nov. 23, Young placed one call at 8:06 a.m. and another 13 minutes later. The report doesn’t say who Young called.
> At about 8 a.m., after quarters and cleaning stations, the launcher work center supervisor suddenly learned that the pre-underway check of the missile launcher hadn’t been performed. Known as a system operability test, or SOT, it is a check performed weekly on both launchers; because it is so routine, the supervisor said he had given “the techs free reign” to complete it.
>
> While routine, the check is hardly simple. The instructions call for five qualified FCs, including one to act as a safety observer on the missile deck. The procedures also require an equipment tag-out. In addition, there was some confusion on Essex about who could approve it. Moving guns and launchers requires the captain’s permission on Essex, but since this check isn’t supposed to cause any movement, the work center supervisor felt he didn’t need to inform the chain of command, according to the report.
>
> In port, the combat systems officer of the watch approves this maintenance, the report says. But Essex that day was anchored. Despite this confusion, the work center supervisor decided to go ahead, without seeking permission from CSOOW or any other watchstander or leader. No tags were hung.
>
> The three FCs had less than an hour to complete what’s supposed to be a 15-minute check. The technicians were in three compartments throughout the ship and didn’t use a net to stay in constant communication. One of them was in NATO Director Room 2, high up on the island, to start and load the computer that controls the launcher’s movement. The boot-up normally takes one to three minutes.
>
> But the FC in the aft launcher room didn’t call to verify that the software had loaded, as the instructions call for. In fact, he wasn’t using a checklist or the instructions â€" as required â€" and hadn’t reviewed them beforehand. He was going from memory, the report says.
> Prior to placing the launcher in remote â€" a step that can inadvertently cause it to move â€" the operator is required to push and hold the alarm button for 10 seconds, which sounds the bell around the launcher for that duration. The operator skipped that.
> He then turned the aft launcher to remote. This triggered a known â€" and dangerous â€" glitch.
>
> Once turned on and ready, the computer operational program provides valid commands to position the launcher when it is remote. “When the [NATO Sea Sparrow computer operational program] is not properly loaded, no valid position commands are provided to the [guided missile launcher] causing the GML to move to an unordered position,” Naval Surface Warfare Center Port Hueneme, Calif., engineers concluded in a report on the incident. That, in some cases, causes erratic and undirected launcher movement, they wrote.
>
> The experts demonstrated this hazardous fault in two dynamic recreations, one at Port Hueneme and one on the ship. In the Essex test, when they initiated the aft launcher the same way â€" computer off, power on, control in remote â€" the launcher rotated 344 degrees clockwise and rose 85 degrees where it hit the upper stops, a nearly identical motion to the one that killed Young.
>
> “It was advised by the team not to retest the event as the extreme movement may potential[ly] damage the [gun missile launcher system] or the missiles,” the engineers wrote.
> ‘We thought we knew what we were doing’
> The warning alarms had been a long-standing problem. The work center supervisor said he’d personally fixed the forward and aft alarms over the six months he’d been aboard Essex, telling an NCIS agent: “They continue to fail.”
>
> However, he did not enter any maintenance jobs into the ship’s maintenance database or the combat systems trouble log. And division leaders above him swore they hadn’t known about these problems; one told the agent that “he believed that his division sailors followed required checklists 100 percent of the time,” the report says.
>
> But these problems were well-known to the Sea Sparrow techs who performed this check every week.
>
> “Normally, I would have sounded the alarm, but it is broken and has been for over a year,” the 28-year-old fire controlman who had placed the launcher in remote told the NCIS agent in a sworn statement four days later. He said his job on Nov. 23 had been to power up the launcher, then go to the aft missile deck to act as a safety observer. He also admitted he and others in his work center didn’t normally use combat system operational sequencing system instructions, references that are required for maintenance.
>
> “When did the CSOSS stop being used?” the NCIS agent asked.
>
> “When we thought we knew what we were doing,” he said. “Initializing equipment, it is not hard. I’ve done it so many times.”
> “Is your supervisor aware you are not using the correct amount of people as required by the [maintenance requirement card] to do the work?”
> “Yes, I believe he is aware.”
>
> Asked if he wanted to add anything, the FC said: “I apologize for all this happening and I feel so responsible.”
>
> His boss, however, was unapologetic. A 29-year-old fire controlman from New Hampshire, the work center supervisor tried to deflect responsibility for the accident. In his sworn statement six days after the incident, he said he was told he didn’t need permission for the check Nov. 23; he claimed that CSOSS instructions were faulty and said he’d found a discrepancy that, if followed to the letter, would have prevented the system from being energized; he blamed his technician for not checking that the aft missile deck was clear; and he questioned why Young was sitting there in the first place.
>
> “I do not know what PS1 Young was doing on the weather deck, much less under a missile launcher with a red circle encompassing it reading ‘DANGER AREA,’” he said. “I do, however, believe that he might have been on his cell phone.”
>
> In addition to acknowledging alarm bell problems and saying the launcher’s Nov. 23 spasm “is not a rarity,” he admitted that he knew his technicians frequently ignored the maintenance instructions. The agent asked him if there had been any repercussions when he caught his techs doing this.
>
> “I personally have not given any repercussions.”
> “Why not?” she pressed.
> “I don’t know,” he said. “I did not feel they were warranted.”
> ‘How far has the rot spread?’
> After a monthlong investigation, the investigating officer singled out the work center supervisor for blame. This fire controlman had a “laissez-faire management style” that “produced complacency and over-confidence” in his subordinates, the report concluded. And when he had conflicting instructions about whether he needed permission for the check, he chose not to seek guidance from his chain of command.
> “He failed to provide effective leadership,” the investigator concluded, finding that the rest of the chain of command â€" from the division’s leading petty officer, chief and division officer, through the department head and senior enlisted, to the executive officer and CO â€" had “fostered a culture of procedural compliance and accountability.”
>
> “The work center supervisor was the one exception to this rule,” the report concluded.
>
> Jones, the one-star ESG commander, disagreed. He struck down this opinion and noted: “The combat system department leadership failed to establish and foster an atmosphere of compliance with established maintenance and safety standards.” He counseled the CO, Fluker, and ordered the ship to make monthly reports on the progress of fixing issues arising from the investigation. A SH-60B pilot and 1987 Naval Academy grad, Fluker became XO onboard Essex in September 2009 and took command of the ship in January 2011, according to his official bio.
>
> A second former Wasp-class commanding officer said it’s hard to ascertain from the report whether the complacency and insufficient oversight extended beyond the department to Essex as a whole, gator big decks generally or the wider fleet.
>
> The proper procedures exist and weren’t followed in this case, noted the retired officer, who asked to remain anonymous to avoid fraying ties with uniformed peers. The key question now from the CO’s perspective, he continued, is “how far has the rot spread?”
>
> But the first former skipper said he saw evidence of wider problems on Essex. He pointed to the work center supervisor’s statement that crew members often congregated on the aft missile deck to make phone calls, an activity officially off-limits. That suggests the rules weren’t enforced, he said.
>
> “It’s hard to point the finger at the individual sailor if nobody is enforcing the rules,” said this retired officer, who also asked for anonymity. “That kid wasn’t where he was supposed to be but, on the other hand, it doesn’t seem like they had an environment where anybody really worried about things like that.”
>
> “The fact that you have written standing orders and you have written guidance and ship’s instructions doesn’t mean squat if nobody’s enforcing it.”
>
> Same goes for the alarms, he continued. It is standard for the CO to be notified when any alarm is broken or bypassed, and yet in this case no one notified the CO, fixed the bell or logged that it wasn’t working. Nor did any chief or officer notice that the aft launcher alarm, required to be sounded for 10 seconds before each check that may or will move the launcher, hadn’t rang for a year.
>
>
> “With a looming hull swap, how much of an attitude that this-won’t-be-my-problem-much-longer existed amongst the crew?” he asked.
>


#10324 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Fri May 25, 2012 10:15 am
Subject: One Page Quality Manual
drbillcorcoran
Send Email Send Email
 
Here it is in less than one page:

Quality is the ability to perform satisfactorily in service.
Quality is being suitable for the intended purposes.

Say what you do.
Do what you say.
Prove it.
Improve it.

Have acceptance criteria for all conditions, actions, and products at all stages.

Investigate all quality problems.
Fix the problems.
Fix the processes that created the problems.
Fix the processes that should have detected the problems earlier.
Fix the processes that should have detected the process problems.
Fix the harmful factors of the above.

Apply the fixes everywhere they apply.
Quantify rework.
Track the resolution and effectiveness of all investigation results.
When you have a repeat problem fix the investigation process.

When you know about a quality problem tell all of the potentially affected customers right away.
 ________________________________________________________

What else is needed?

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

#10325 From: "Salot, William" <william.salot@...>
Date: Fri May 25, 2012 7:44 pm
Subject: RE: One Page Quality Manual
wjsalot
Send Email Send Email
 

Bill C,

 

Your “Manual” shows well why “5 Whys” and “Rapid Problem Solving” only scratch the surface.

 

We don’t do enough of what is in your “Manual”.

 

I will send it to my Plant Manager.

 

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, May 25, 2012 6:16 AM
To: RCSOTP1
Subject: [Root_Cause_State_of_the_Practice] One Page Quality Manual

 

 

Here it is in less than one page:

 

Quality is the ability to perform satisfactorily in service.
Quality is being suitable for the intended purposes.

Say what you do.
Do what you say.
Prove it.
Improve it.

Have acceptance criteria for all conditions, actions, and products at all stages.

Investigate all quality problems.

Fix the problems.

Fix the processes that created the problems.

Fix the processes that should have detected the problems earlier.

Fix the processes that should have detected the process problems.

Fix the underlying harmful factors that led to each of the above problems.

 

Apply the fixes everywhere they apply.

Quantify rework.

Track the implementation and effectiveness of corrective actions and improvements.
Track the resolution and effectiveness of all investigation
recommendations.
When you have a repeat problem fix the investigation process.

 

When you know about a quality problem tell all of the potentially affected customers right away.

When you can’t resolve it, escalate it to those who can.

 ________________________________________________________

What else is needed?

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


#10326 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Sat May 26, 2012 9:46 am
Subject: Re: One Page Quality Manual Rev 1
drbillcorcoran
Send Email Send Email
 
Thanks, Bill.

Here's Rev 1
____________________________________________________________________________________________

One Page Quality Manual R1 2012.05.25

Quality is the ability to perform satisfactorily in service.
Quality is being suitable for the intended purposes.

Say what you do.
Do what you say.
Prove it.
Improve it.

Have acceptance criteria for all conditions, actions, and products at all stages.

Record all quality problems. Be specific, timely, accurate, reliable. (STAR)
Investigate all quality problems.
Fix the problems.
Fix the processes that created the problems.
Fix the processes that should have detected the problems earlier.
Fix the processes that should have detected the process problems.
Fix the harmful factors of the above.

Apply the fixes everywhere they apply.
Quantify rework.
Track the resolution and effectiveness of all investigation results.
When you have a repeat problem fix the investigation process.

When you know about a quality problem tell all of the potentially affected customers right away.

When you can't resolve a problem escalate it in writing to someone who should be able to.
____________________________________________________________________________________________
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


From: "Salot, William" <william.salot@...>
To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
Sent: Friday, May 25, 2012 3:44 PM
Subject: RE: [Root_Cause_State_of_the_Practice] One Page Quality Manual

 
Bill C,
 
Your “Manual” shows well why “5 Whys” and “Rapid Problem Solving” only scratch the surface.
 
We don’t do enough of what is in your “Manual”.
 
I will send it to my Plant Manager.
 
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, May 25, 2012 6:16 AM
To: RCSOTP1
Subject: [Root_Cause_State_of_the_Practice] One Page Quality Manual
 
 
Here it is in less than one page:
 
Quality is the ability to perform satisfactorily in service.
Quality is being suitable for the intended purposes.

Say what you do.
Do what you say.
Prove it.
Improve it.

Have acceptance criteria for all conditions, actions, and products at all stages.

Investigate all quality problems.
Fix the problems.
Fix the processes that created the problems.
Fix the processes that should have detected the problems earlier.
Fix the processes that should have detected the process problems.
Fix the underlying harmful factors that led to each of the above problems.
 
Apply the fixes everywhere they apply.
Quantify rework.
Track the implementation and effectiveness of corrective actions and improvements.
Track the resolution and effectiveness of all investigation
recommendations.
When you have a repeat problem fix the investigation process.
 
When you know about a quality problem tell all of the potentially affected customers right away.
When you can’t resolve it, escalate it to those who can.
 ________________________________________________________

What else is needed?
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe

 
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#10327 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Sat May 26, 2012 10:02 am
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        : /Quality/One Page Quality Manual R2 2012.05.25.0601
   Uploaded by : drbillcorcoran <William.R.Corcoran@...>
   Description :  Quality is the ability to perform satisfactorily in service.

You can access this file at the URL:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/Quality/One\
%20Page%20Quality%20Manual%20R2%202012.05.25.0601

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

drbillcorcoran <William.R.Corcoran@...>

#10328 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Sat May 26, 2012 10:30 am
Subject: Re: New file uploaded to Root_Cause_State_of_the_Practice
drbillcorcoran
Send Email Send Email
 
The file is at
http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/Quality/
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


From: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Saturday, May 26, 2012 6:02 AM
Subject: [Root_Cause_State_of_the_Practice] New file uploaded to Root_Cause_State_of_the_Practice

 

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 : /Quality/One Page Quality Manual R2 2012.05.25.0601
Uploaded by : drbillcorcoran <William.R.Corcoran@...>
Description : Quality is the ability to perform satisfactorily in service.

You can access this file at the URL:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/Quality/One%20Page%20Quality%20Manual%20R2%202012.05.25.0601

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

drbillcorcoran <William.R.Corcoran@...>





#10329 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Tue May 29, 2012 3:16 pm
Subject: Re: One Page Quality Manual
drbillcorcoran
Send Email Send Email
 
Bill Salot,

I've gotten some comments from other sources.

I don't think it's one page anymore.:( sad

Here's the update:
________________________________________________________________________________
One Page Quality Manual R8 2012.05.29.0551

The native version of this file is at
http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/Quality/

PURPOSE

The quality manual governs the quality management system.
The quality management system is how business is done.

SCOPE

Say what the quality manual applies to.
Make the quality manual apply to what the organization cares about.

MANDATE

The quality manual is an order from the highest level person who cares about quality to that person's subordinates.
Adherence to the quality manual is a condition of employment.
Deviation from the quality manual is treated as insubordination.

DEFINITIONS

Quality is the ability to perform satisfactorily in service.
Quality is being suitable for the intended purposes.

Define the terms in plain English.
Make plain English the language of the quality management system.

OVERVIEW

Say what you do.
Do what you say.
Prove it.
Improve it.

ACCEPTANCE CRITERIA

Have acceptance criteria for all conditions, actions, and products at all stages.
Flow requirements down to the workers.
Make the flowdown traceable in both directions.

INSTRUCTIONS

Perform activities affecting quality in accordance with written instructions appropriate to the circumstances.
Make the instructions require consistent and systematic behavior in accordance with known good practice.

PROBLEM MANAGEMENT

Assure that personnel are set-up for success in what they do. Provide the right instructions, supervision, and training.

Establish measures to assure that all quality problems are promptly identified and corrected.
Record all quality problems. Be specific, timely, accurate, reliable. (STAR)
Investigate all quality problems.
Fix the problems.
Fix the processes that created the problems.
Fix the processes that should have detected the problems earlier.
Fix the processes that should have detected the process problems.
Fix the harmful factors of the above.

Apply the fixes everywhere they apply.
Apply the fixes to everyone to whom they apply.

Pre-select all activities to be debriefed. Record the debrief: the good, the improveable, the improvements. Treat the improveables as quality problems.

Quantify rework in dollars. Tell those who are involved in budgeting.

Track the resolution and effectiveness of all investigation results.

When you have a repeat problem fix the investigation process.

When you know about a quality problem tell all of the potentially affected customers right away.

When you can't resolve a problem escalate it in writing to someone who should be able to.

PURCHASING

Establish measures to assure that purchasing activities are governed by this manual to the extent that the purchased item is important to quality.

DOCUMENTS

Maintain a controlled document system is support of the quality management system.

RECORDS

Keep sufficient records to provide evidence of the above.

AUDITS

Audit every sentence above. Treat the deviations as quality problems.

For details see the other files at
http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice/files/Quality/



________________________________________________________________________________

Comments? Suggestions?
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


From: "Salot, William" <william.salot@...>
To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
Sent: Friday, May 25, 2012 3:44 PM
Subject: RE: [Root_Cause_State_of_the_Practice] One Page Quality Manual

 
Bill C,
 
Your “Manual” shows well why “5 Whys” and “Rapid Problem Solving” only scratch the surface.
 
We don’t do enough of what is in your “Manual”.
 
I will send it to my Plant Manager.
 
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, May 25, 2012 6:16 AM
To: RCSOTP1
Subject: [Root_Cause_State_of_the_Practice] One Page Quality Manual
 
 
Here it is in less than one page:
 
Quality is the ability to perform satisfactorily in service.
Quality is being suitable for the intended purposes.

Say what you do.
Do what you say.
Prove it.
Improve it.

Have acceptance criteria for all conditions, actions, and products at all stages.

Investigate all quality problems.
Fix the problems.
Fix the processes that created the problems.
Fix the processes that should have detected the problems earlier.
Fix the processes that should have detected the process problems.
Fix the underlying harmful factors that led to each of the above problems.
 
Apply the fixes everywhere they apply.
Quantify rework.
Track the implementation and effectiveness of corrective actions and improvements.
Track the resolution and effectiveness of all investigation
recommendations.
When you have a repeat problem fix the investigation process.
 
When you know about a quality problem tell all of the potentially affected customers right away.
When you can’t resolve it, escalate it to those who can.
 ________________________________________________________

What else is needed?
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



#10330 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Tue Jun 5, 2012 11:48 am
Subject: New poll for Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
Enter your vote today!  A new poll has been created for the
Root_Cause_State_of_the_Practice group:

Ineffective change management was a harmful factor of every consequential event
I have personally investigated and/or known about.

   o Strongly agree
   o Agree
   o Neither agree nor disagree
   o Disagree
   o Strongly disagree


To vote, please visit the following web page:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/surveys?id=131407\
26

Note: Please do not reply to this message. Poll votes are
not collected via email. To vote, you must go to the Yahoo! Groups
web site listed above.

Thanks!

#10331 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Tue Jun 5, 2012 1:22 pm
Subject: Ineffective Change Management as a Harmful Factot
drbillcorcoran
Send Email Send Email
 
Please scroll down to the link to the poll and cast your vote.

Also there is more on change management in
The Rootician's Dictionary 2012.06.02
How to talk like a rootician. Definitions of Words Rooticians use and abuse. If you don't like a definition send your favorite to firebird.one@alum.MIT.edu. Please say what's wrong with the existing one and what's better about yours.
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


From: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Tuesday, June 5, 2012 7:48 AM
Subject: [Root_Cause_State_of_the_Practice] New poll for Root_Cause_State_of_the_Practice

 

Enter your vote today! A new poll has been created for the
Root_Cause_State_of_the_Practice group:

Ineffective change management was a harmful factor of every consequential event I have personally investigated and/or known about.

o Strongly agree
o Agree
o Neither agree nor disagree
o Disagree
o Strongly disagree

To vote, please visit the following web page:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/surveys?id=13140726

Note: Please do not reply to this message. Poll votes are
not collected via email. To vote, you must go to the Yahoo! Groups
web site listed above.

Thanks!




#10332 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Tue Jun 5, 2012 1:54 pm
Subject: Re: Ineffective Change Management as a Harmful Factot
drbillcorcoran
Send Email Send Email
 
Some events involving ineffective change management:
BP Texas City
Apollo XIII
USS Forrestal (CVA 59) fire

Which ones should be added to the list?
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
Sent: Tuesday, June 5, 2012 9:22 AM
Subject: [Root_Cause_State_of_the_Practice] Ineffective Change Management as a Harmful Factot

 
Please scroll down to the link to the poll and cast your vote.

Also there is more on change management in
The Rootician's Dictionary 2012.06.02
How to talk like a rootician. Definitions of Words Rooticians use and abuse. If you don't like a definition send your favorite to firebird.one@ alum.MIT. edu. Please say what's wrong with the existing one and what's better about yours.
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


From: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@...! om
Sent: Tuesday, June 5, 2012 7:48 AM
Subject: [Root_Cause_State_of_the_Practice] New poll for Root_Cause_State_of_the_Practice

 

Enter your vote today! A new poll has been created for the
Root_Cause_State_of_the_Practice group:

Ineffective change management was a harmful factor of every consequential event I have personally investigated and/or known about.

o Strongly agree
o Agree
o Neither agree nor disagree
o Disagree
o Strongly disagree

To vote, please visit the following web page:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/surveys?id=13140726

Note: Please do not reply to this message. Poll votes are
not collected via email. To vote, you must go to the Yahoo! Groups
web site listed above.

Thanks!






#10333 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Tue Jun 5, 2012 5:51 pm
Subject: Poll results for Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
The following Root_Cause_State_of_the_Practice poll is now closed.  Here are the
final results:


POLL QUESTION: A top attribute of a good safety culture is that the people call
things by their right names.

CHOICES AND RESULTS
- Strongly agree, 8 votes, 61.54%
- Agree, 3 votes, 23.08%
- Neither agree nor disagree, 1 votes, 7.69%
- Disagree, 0 votes, 0.00%
- Strongly disagree, 1 votes, 7.69%

INDIVIDUAL VOTES
- Strongly agree
      - william.rigot@...
      - dcrowther@...
      - thomas.j.harrington@...
      - arsenaultg@...
      - teixeira.cds@...
      - William.R.Corcoran@...
      - patrick.mccabe@...
      - emridgell@...
- Agree
      - romylio@...
      - andy.hobbs@...
      - blethcoe@...
- Neither agree nor disagree
      - rdboroughs@...
- Disagree
- Strongly disagree
      - paul.oortman.gerlings@...


For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html

#10334 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Wed Jun 6, 2012 11:59 am
Subject: Poll results for Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
The following Root_Cause_State_of_the_Practice poll is now closed.  Here are the
final results:


POLL QUESTION: Shared mental content (beliefs, values, morals, ethics, "truths",
rules of thumb, problem solving approaches, etc.) is the part of culture that is
not visible to the eye.

CHOICES AND RESULTS
- Strongly agree, 10 votes, 58.82%
- Agree, 4 votes, 23.53%
- Neither agree nor disagree, 0 votes, 0.00%
- Disagree, 3 votes, 17.65%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
      - rtsoule198214@...
      - mcagrad06@...
      - rdboroughs@...
      - jackinbc@...
      - william.rigot@...
      - William.R.Corcoran@...
      - paul.oortman.gerlings@...
      - thomas.j.harrington@...
      - steamshovel2002@...
      - patrick.mccabe@...
- Agree
      - grahamiwa@...
      - scott_t_noga@...
      - smwana2003@...
      - romylio@...
- Neither agree nor disagree
- Disagree
      - fjreedy2@...
      - richard.cole@...
      - john.a.thomas@...
- Strongly disagree


For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html

#10335 From: "Dr. Bill Corcoran" <William.R.Corcoran@...>
Date: Wed Jun 6, 2012 12:37 pm
Subject: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
drbillcorcoran
Send Email Send Email
 
I would greatly appreciate hearing from those who voted "disagree."

How did you come to that conclusion.
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


From: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Wednesday, June 6, 2012 7:59 AM
Subject: [Root_Cause_State_of_the_Practice] Poll results for Root_Cause_State_of_the_Practice

 

The following Root_Cause_State_of_the_Practice poll is now closed. Here are the
final results:

POLL QUESTION: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

CHOICES AND RESULTS
- Strongly agree, 10 votes, 58.82%
- Agree, 4 votes, 23.53%
- Neither agree nor disagree, 0 votes, 0.00%
- Disagree, 3 votes, 17.65%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
- rtsoule198214@...
- mcagrad06@...
- rdboroughs@...
- jackinbc@...
- william.rigot@...
- William.R.Corcoran@...
- paul.oortman.gerlings@...
- thomas.j.harrington@...
- steamshovel2002@...
- patrick.mccabe@...
- Agree
- grahamiwa@...
- scott_t_noga@...
- smwana2003@...
- romylio@...
- Neither agree nor disagree
- Disagree
- fjreedy2@...
- richard.cole@...
- john.a.thomas@...
- Strongly disagree

For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

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#10336 From: "Salot, William" <william.salot@...>
Date: Wed Jun 6, 2012 3:50 pm
Subject: RE: Ineffective Change Management as a Harmful Factot
wjsalot
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Bill C,

 

That list could become very long because there may be few, if any, consequential events that do not involve ineffective change management.

 

Does every consequential event involve a change?  Don’t some consequential events involve failure to make a needed change (bad habit, established inadequate procedure, poor practice, etc.)?   

 

Changes and absence of change both have effects, and the effects cannot all be controlled.   Some changes can neither be made nor prevented (flow of time, vagaries of weather, day and night, etc.). 

 

Does change management sometimes require accepting the risk or inevitability of making or not making changes; buying insurance against unforeseen changes or in lieu of making unjustifiable changes; contingency planning for the consequences of making or not making changes, etc?

 

Doesn’t the effectiveness of change management hang on the acceptability of the consequences of making or not making changes?

 

Would change management be more accurately termed consequence management?   (Most managers would not like the weak, pessimistic, negative sound of that.)   

 

If you define change management that way, then it is involved in every consequential event.

 

But if you limit the scope of change management to managing discrete changes proposed to meet a specific objective (as many management of change systems do), then there are consequential events that do not involve it.

 

Do you agree?

 

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: Tuesday, June 05, 2012 9:55 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: Re: [Root_Cause_State_of_the_Practice] Ineffective Change Management as a Harmful Factot

 

 

Some events involving ineffective change management:

BP Texas City

Apollo XIII

USS Forrestal (CVA 59) fire

 

Which ones should be added to the list?

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 


#10337 From: "Brown, Robert L" <robert_l_brown@...>
Date: Tue Jun 12, 2012 12:01 am
Subject: RE: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
kionadad
Send Email Send Email
 

I would have voted with the disagree, had I voted so I’ll comment.

 

I don’t argue the presence of the points.  I would argue that such things ARE visible to the eye, if looked for.  An analyst or Rootician that parachutes in the for the analysis might readily miss them if he or she does not look, but I would think that by now, looking for these type of things is fundamental.

 

Bob Brown

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dr. Bill Corcoran
Sent: Wednesday, June 06, 2012 5:37 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I would greatly appreciate hearing from those who voted "disagree."

 

How did you come to that conclusion.

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

 


From: "Root_Cause_St! ate_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Wednesday, June 6, 2012 7:59 AM
Subject: [Root_Cause_State_of_the_Practice] Poll results for Root_Cause_State_of_the_Practice

 

 


The following Root_Cause_State_of_the_Practice poll is now closed. Here are the
final results:

POLL QUESTION: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

CHOICES AND RESULTS
- Strongly agree, 10 votes, 58.82%
- Agree, 4 votes, 23.53%
- Neither agree nor disagree, 0 votes, 0.00%
- Disagree, 3 votes, 17.65%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
- rtsoule198214@...
- mcagrad06@...
- rdboroughs@...
- jackinbc@...
- william.rigot@...
- William.R.Corcoran@...
- paul.oortman.gerlings@...
- thomas.j.harrington@...
- steamshovel2002@...
- patrick.mccabe@...
- Agree
- grahamiwa@...
- scott_t_noga@...
- smwana2003@...
- romylio@...
- Neither agree nor disagree
- Disagree
- fjreedy2@...
- richard.cole@...
- john.a.thomas@...
- Strongly disagree

For more information about this group, please visit
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#10338 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Tue Jun 12, 2012 10:07 am
Subject: Re: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
drbillcorcoran
Send Email Send Email
 
Bob,

Thanks. That's helpful.

The proposition was:

POLL QUESTION: "Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye."

How would your vote change if I changed the proposition to the following?:


POLL QUESTION: "Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not directly visible to the eye."

I have never been aware of the ability to directly see mental content, but I have imagined that I had the ability to infer mental content from visible entities such as behaviors and conditions.
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


From: "Brown, Robert L" <robert_l_brown@...>
To: "'Root_Cause_State_of_the_Practice@yahoogroups.com'" <Root_Cause_State_of_the_Practice@yahoogroups.com>
Sent: Monday, June 11, 2012 8:01 PM
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 
I would have voted with the disagree, had I voted so I’ll comment.
 
I don’t argue the presence of the points.  I would argue that such things ARE visible to the eye, if looked for.  An analyst or Rootician that parachutes in the for the analysis might readily miss them if he or she does not look, but I would think that by now, looking for these type of things is fundamental.
 
Bob Brown
 
From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dr. Bill Corcoran
Sent: Wednesday, June 06, 2012 5:37 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
 
 
I would greatly appreciate hearing from those who voted "disagree."
 
How did you come to that conclusion.
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.
 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
 

From: "Root_Cause_St! ate_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Wednesday, June 6, 2012 7:59 AM
Subject: [Root_Cause_State_of_the_Practice] Poll results for Root_Cause_State_of_the_Practice
 
 

The following Root_Cause_State_of_the_Practice poll is now closed. Here are the
final results:

POLL QUESTION: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

CHOICES AND RESULTS
- Strongly agree, 10 votes, 58.82%
- Agree, 4 votes, 23.53%
- Neither agree nor disagree, 0 votes, 0.00%
- Disagree, 3 votes, 17.65%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
- rtsoule198214@...
- mcagrad06@...
- rdboroughs@...
- jackinbc@...
- william.rigot@...
- William.R.Corcoran@...
- paul.oortman.gerlings@...
- thomas.j.harrington@...
- steamshovel2002@...
- patrick.mccabe@...
- Agree
- grahamiwa@...
- scott_t_noga@...
- smwana2003@...
- romylio@...
- Neither agree nor disagree
- Disagree
- fjreedy2@...
- richard.cole@...
- john.a.thomas@...
- Strongly disagree

For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html
 



#10339 From: "Noga, Scott T" <scott_t_noga@...>
Date: Tue Jun 12, 2012 2:22 pm
Subject: RE: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
rebus3
Send Email Send Email
 

Except that you can’t actually “see” those things.  All you can see is circumstantial evidence.  It’s like saying you can “see” the air by observing leaves moving on the trees.  Is that actually observable proof of the existence of air, or could it be misleading/misinterpreted evidence?  One has to build a case centered around the weight of all the available evidence, but rarely is anything self-evident and unassailable - -except perhaps to those with preconceived biases or motivation.  There is a danger in jumping to conclusions when observing mere indicators.

 

Scott Noga

Risk Management Program

WRPS - Hanford, USDOE contractor

ph. 509/373-1484

 

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Brown, Robert L
Sent: Monday, June 11, 2012 5:01 PM
To: 'Root_Cause_State_of_the_Practice@yahoogroups.com'
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I would have voted with the disagree, had I voted so I’ll comment.

 

I don’t argue the presence of the points.  I would argue that such things ARE visible to the eye, if looked for.  An analyst or Rootician that parachutes in the for the analysis might readily miss them if he or she does not look, but I would think that by now, looking for these type of things is fundamental.

 

Bob Brown

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dr. Bill Corcoran
Sent: Wednesday, June 06, 2012 5:37 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I would greatly appreciate hearing from those who voted "disagree."

 

How did you come to that conclusion.

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

 


From: "Root_Cause_St! ate_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Wednesday, June 6, 2012 7:59 AM
Subject: [Root_Cause_State_of_the_Practice] Poll results for Root_Cause_State_of_the_Practice

 

 


The following Root_Cause_State_of_the_Practice poll is now closed. Here are the
final results:

POLL QUESTION: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

CHOICES AND RESULTS
- Strongly agree, 10 votes, 58.82%
- Agree, 4 votes, 23.53%
- Neither agree nor disagree, 0 votes, 0.00%
- Disagree, 3 votes, 17.65%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
- rtsoule198214@...
- mcagrad06@...
- rdboroughs@...
- jackinbc@...
- william.rigot@...
- William.R.Corcoran@...
- paul.oortman.gerlings@...
- thomas.j.harrington@...
- steamshovel2002@...
- patrick.mccabe@...
- Agree
- grahamiwa@...
- scott_t_noga@...
- smwana2003@...
- romylio@...
- Neither agree nor disagree
- Disagree
- fjreedy2@...
- richard.cole@...
- john.a.thomas@...
- Strongly disagree

For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html

 


#10340 From: "Brown, Robert L" <robert_l_brown@...>
Date: Tue Jun 12, 2012 2:43 pm
Subject: RE: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
kionadad
Send Email Send Email
 

I would refer you to the Allegory of the Cave to understand the whole concept.

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
Sent: Tuesday, June 12, 2012 7:22 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

Except that you can’t actually “see” those things.  All you can see is circumstantial evidence.  It’s like saying you can “see” the air by observing leaves moving on the trees.  Is that actually observable proof of the existence of air, or could it be misleading/misinterpreted evidence?  One has to build a case centered around the weight of all the available evidence, but rarely is anything self-evident and unassailable - -except perhaps to those with preconceived biases or motivation.  There is a danger in jumping to conclusions when observing mere indicators.

 

Scott Noga

Risk Management Program

WRPS - Hanford, USDOE contractor

ph. 509/373-1484

 

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Brown, Robert L
Sent: Monday, June 11, 2012 5:01 PM
To: 'Root_Cause_State_of_the_Practice@yahoogroups.com'
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I would have voted with the disagree, had I voted so I’ll comment.

 

I don’t argue the presence of the points.  I would argue that such things ARE visible to the eye, if looked for.  An analyst or Rootician that parachutes in the for the analysis might readily miss them if he or she does not look, but I would think that by now, looking for these type of things is fundamental.

 

Bob Brown

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dr. Bill Corcoran
Sent: Wednesday, June 06, 2012 5:37 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I would greatly appreciate hearing from those who voted "disagree."

 

How did you come to that conclusion.

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

 


From: "Root_Cause_St! ate_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Wednesday, June 6, 2012 7:59 AM
Subject: [Root_Cause_State_of_the_Practice] Poll results for Root_Cause_State_of_the_Practice

 

 


The following Root_Cause_State_of_the_Practice poll is now closed. Here are the
final results:

POLL QUESTION: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

CHOICES AND RESULTS
- Strongly agree, 10 votes, 58.82%
- Agree, 4 votes, 23.53%
- Neither agree nor disagree, 0 votes, 0.00%
- Disagree, 3 votes, 17.65%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
- rtsoule198214@...
- mcagrad06@...
- rdboroughs@...
- jackinbc@...
- william.rigot@...
- William.R.Corcoran@...
- paul.oortman.gerlings@...
- thomas.j.harrington@...
- steamshovel2002@...
- patrick.mccabe@...
- Agree
- grahamiwa@...
- scott_t_noga@...
- smwana2003@...
- romylio@...
- Neither agree nor disagree
- Disagree
- fjreedy2@...
- richard.cole@...
- john.a.thomas@...
- Strongly disagree

For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html

 


#10341 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Tue Jun 12, 2012 3:43 pm
Subject: New poll for Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
Enter your vote today!  A new poll has been created for the
Root_Cause_State_of_the_Practice group:

Shared mental content (beliefs, values, morals, ethics, "truths", rules of
thumb, problem solving approaches, etc.) is the part of culture that is not
DIRECTLY visible to the eye.



   o Strongly agree
   o Agree
   o Neither agree nor disagree
   o Disagree
   o strongly disagree


To vote, please visit the following web page:
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/surveys?id=131416\
55

Note: Please do not reply to this message. Poll votes are
not collected via email. To vote, you must go to the Yahoo! Groups
web site listed above.

Thanks!

#10342 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Tue Jun 12, 2012 3:46 pm
Subject: Re: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
drbillcorcoran
Send Email Send Email
 
I recreated the poll:

Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not directly visible to the eye.

Please vote at

http://tech.groups.yahoo.com/group/Root_Cause_State_of_the_Practice/polls

While you're there please vote in the other open polls.

 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
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From: "Noga, Scott T" <scott_t_noga@...>
To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
Sent: Tuesday, June 12, 2012 10:22 AM
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 
Except that you can’t actually “see” those things.  All you can see is circumstantial evidence.  It’s like saying you can “see” the air by observing leaves moving on the trees.  Is that actually observable proof of the existence of air, or could it be misleading/misinterpreted evidence?  One has to build a case centered around the weight of all the available evidence, but rarely is anything self-evident and unassailable - -except perhaps to those with preconceived biases or motivation.  There is a danger in jumping to conclusions when observing mere indicators.
 
Scott Noga
Risk Management Program
WRPS - Hanford, USDOE contractor
ph. 509/373-1484
 
 
From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Brown, Robert L
Sent: Monday, June 11, 2012 5:01 PM
To: 'Root_Cause_State_of_the_Practice@yahoogroups.com'
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
 
 
I would have voted with the disagree, had I voted so I’ll comment.
 
I don’t argue the presence of the points.  I would argue that such things ARE visible to the eye, if looked for.  An analyst or Rootician that parachutes in the for the analysis might readily miss them if he or she does not look, but I would think that by now, looking for these type of things is fundamental.
 
Bob Brown
 
From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dr. Bill Corcoran
Sent: Wednesday, June 06, 2012 5:37 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
 
 
I would greatly appreciate hearing from those who voted "disagree."
 
How did you come to that conclusion.
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.
 
****Internet Email Confidentiality Footer****
 
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From: "Root_Cause_St! ate_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Wednesday, June 6, 2012 7:59 AM
Subject: [Root_Cause_State_of_the_Practice] Poll results for Root_Cause_State_of_the_Practice
 
 

The following Root_Cause_State_of_the_Practice poll is now closed. Here are the
final results:

POLL QUESTION: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

CHOICES AND RESULTS
- Strongly agree, 10 votes, 58.82%
- Agree, 4 votes, 23.53%
- Neither agree nor disagree, 0 votes, 0.00%
- Disagree, 3 votes, 17.65%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
- rtsoule198214@...
- mcagrad06@...
- rdboroughs@...
- jackinbc@...
- william.rigot@...
- William.R.Corcoran@...
- paul.oortman.gerlings@...
- thomas.j.harrington@...
- steamshovel2002@...
- patrick.mccabe@...
- Agree
- grahamiwa@...
- scott_t_noga@...
- smwana2003@...
- romylio@...
- Neither agree nor disagree
- Disagree
- fjreedy2@...
- richard.cole@...
- john.a.thomas@...
- Strongly disagree

For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

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http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html
 



#10343 From: "Mitchell, Glen" <gmitchel@...>
Date: Tue Jun 12, 2012 5:34 pm
Subject: RE: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
pxeng1
Send Email Send Email
 

I am wondering about the application of this idiom.

The only one I see is that, due to resource limitations,  we have to select among actions, including attempting to change culture.

If we knew the indicators of a particular “Shared mental content” we could better target our culture change efforts… and sell it to the purse strings. J

 

Glen

x4953

 

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: Tuesday, June 12, 2012 10:46 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: Re: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I recreated the poll:

 

Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not directly visible to the eye.

 

Please vote at

 

 

While you're there please vote in the other open polls.

 

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

 


From: "Noga, Scott T" <scott_t_noga@...>
To: "
Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
Sent: Tuesday, June 12, 2012 10:22 AM
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

Except that you can’t actually “see” those things.  All you can see is circumstantial evidence.  It’s like saying you can “see” the air by observing leaves moving on the trees.  Is that actually observable proof of the existence of air, or could it be misleading/misinterpreted evidence?  One has to build a case centered around the weight of all the available evidence, but rarely is anything self-evident and unassailable - -except perhaps to those with preconceived biases or motivation.  There is a danger in jumping to conclusions when observing mere indicators.

 

Scott Noga

Risk Management Program

WRPS - Hanford, USDOE contractor

ph. 509/373-1484

 

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Brown, Robert L
Sent: Monday, June 11, 2012 5:01 PM
To: 'Root_Cause_State_of_the_Practice@yahoogroups.com'
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I would have voted with the disagree, had I voted so I’ll comment.

 

I don’t argue the presence of the points.  I would argue that such things ARE visible to the eye, if looked for.  An analyst or Rootician that parachutes in the for the analysis might readily miss them if he or she does not look, but I would think that by now, looking for these type of things is fundamental.

 

Bob Brown

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dr. Bill Corcoran
Sent: Wednesday, June 06, 2012 5:37 AM
To:
Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I would greatly appreciate hearing from those who voted "disagree."

 

How did you come to that conclusion.

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

 


From: "Root_Cause_St! ate_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Wednesday, June 6, 2012 7:59 AM
Subject: [Root_Cause_State_of_the_Practice] Poll results for Root_Cause_State_of_the_Practice

 

 


The following Root_Cause_State_of_the_Practice poll is now closed. Here are the
final results:

POLL QUESTION: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

CHOICES AND RESULTS
- Strongly agree, 10 votes, 58.82%
- Agree, 4 votes, 23.53%
- Neither agree nor disagree, 0 votes, 0.00%
- Disagree, 3 votes, 17.65%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
- rtsoule198214@...
- mcagrad06@...
- rdboroughs@...
- jackinbc@...
- william.rigot@...
- William.R.Corcoran@...
- paul.oortman.gerlings@...
- thomas.j.harrington@...
- steamshovel2002@...
- patrick.mccabe@...
- Agree
- grahamiwa@...
- scott_t_noga@...
- smwana2003@...
- romylio@...
- Neither agree nor disagree
- Disagree
- fjreedy2@...
- richard.cole@...
- john.a.thomas@...
- Strongly disagree

For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html

 

 


#10344 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Tue Jun 12, 2012 5:44 pm
Subject: RE: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
drbillcorcoran
Send Email Send Email
 
Glen,

Thanks.

It could be a challenge.

The mental content is part of the culture, but one cannot see it directly.

How can we tell that it has changed for the better?

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


--- On Tue, 6/12/12, Mitchell, Glen <gmitchel@...> wrote:

From: Mitchell, Glen <gmitchel@...>
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.
To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
Date: Tuesday, June 12, 2012, 1:34 PM

 

I am wondering about the application of this idiom.

The only one I see is that, due to resource limitations,  we have to select among actions, including attempting to change culture.

If we knew the indicators of a particular “Shared mental content” we could better target our culture change efforts… and sell it to the purse strings. J

 

Glen

x4953

 

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: Tuesday, June 12, 2012 10:46 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: Re: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I recreated the poll:

 

Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not directly visible to the eye.

 

Please vote at

 

 

While you're there please vote in the other open polls.

 

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

 


From: "Noga, Scott T" <scott_t_noga@...>
To: "
Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
Sent: Tuesday, June 12, 2012 10:22 AM
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

Except that you can’t actually “see” those things.  All you can see is circumstantial evidence.  It’s like saying you can “see” the air by observing leaves moving on the trees.  Is that actually observable proof of the existence of air, or could it be misleading/misinterpreted evidence?  One has to build a case centered around the weight of all the available evidence, but rarely is anything self-evident and unassailable - -except perhaps to those with preconceived biases or motivation.  There is a danger in jumping to conclusions when observing mere indicators.

 

Scott Noga

Risk Management Program

WRPS - Hanford, USDOE contractor

ph. 509/373-1484

 

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Brown, Robert L
Sent: Monday, June 11, 2012 5:01 PM
To: 'Root_Cause_State_of_the_Practice@yahoogroups.com'
Subject: RE: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I would have voted with the disagree, had I voted so I’ll comment.

 

I don’t argue the presence of the points.  I would argue that such things ARE visible to the eye, if looked for.  An analyst or Rootician that parachutes in the for the analysis might readily miss them if he or she does not look, but I would think that by now, looking for these type of things is fundamental.

 

Bob Brown

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dr. Bill Corcoran
Sent: Wednesday, June 06, 2012 5:37 AM
To:
Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: [Root_Cause_State_of_the_Practice] Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

 

 

I would greatly appreciate hearing from those who voted "disagree."

 

How did you come to that conclusion.

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

 


From: "Root_Cause_St! ate_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Sent: Wednesday, June 6, 2012 7:59 AM
Subject: [Root_Cause_State_of_the_Practice] Poll results for Root_Cause_State_of_the_Practice

 

 


The following Root_Cause_State_of_the_Practice poll is now closed. Here are the
final results:

POLL QUESTION: Shared mental content (beliefs, values, morals, ethics, "truths", rules of thumb, problem solving approaches, etc.) is the part of culture that is not visible to the eye.

CHOICES AND RESULTS
- Strongly agree, 10 votes, 58.82%
- Agree, 4 votes, 23.53%
- Neither agree nor disagree, 0 votes, 0.00%
- Disagree, 3 votes, 17.65%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
- rtsoule198214@...
- mcagrad06@...
- rdboroughs@...
- jackinbc@...
- william.rigot@...
- William.R.Corcoran@...
- paul.oortman.gerlings@...
- thomas.j.harrington@...
- steamshovel2002@...
- patrick.mccabe@...
- Agree
- grahamiwa@...
- scott_t_noga@...
- smwana2003@...
- romylio@...
- Neither agree nor disagree
- Disagree
- fjreedy2@...
- richard.cole@...
- john.a.thomas@...
- Strongly disagree

For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html

 

 


#10345 From: Arnie Gundersen <sailchamplain@...>
Date: Tue Jun 12, 2012 5:58 pm
Subject: an interesting 40 y/o problem!
sailchamplain@...
Send Email Send Email
 
'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR).

Power ReactorEvent Number: 48011
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: RICH ROGALSKI
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/11/2012
Notification Time: 10:03 [ET]
Event Date: 05/04/2011
Event Time: 13:25 [EDT]
Last Update Date: 06/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section: 
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization): 
MALCOLM WIDMANN (R2DO)

UnitSCRAM CodeRX CRITInitial PWRInitial RX ModeCurrent PWRCurrent RX Mode
2NY100Power Operation100Power Operation
Event Text
REFUELING WATER STORAGE TANK CONNECTED TO NON-SEISMICALLY QUALIFIED SYSTEM 

"On May 4, 2011, at approximately 1325 Eastern Daylight Time (EDT), with H. B. Robinson Steam Electric Plant (HBRSEP), Unit No. 2, in Mode 1 at 100% power, it was determined that over the last 40 years, HBRSEP, Unit No. 2 periodically performed cleanup of the Refueling Water Storage Tank (RWST) by aligning the non-seismically qualified refueling water purification system to the safety related and seismically qualified RWST without recognizing that the action rendered the RWST inoperable. As a result, on multiple occasions, the RWST was inoperable for a period longer than allowed by Technical Specification (TS) Limiting Condition for Operation 3.5.4, Emergency Core Cooling Systems Refueling Water Storage Tank. 

'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR). 

"A clearance order has been placed in effect to ensure restrictions for piping that could affect the operability of the RWST remain in place. 

"This event was described in Licensee Event Report 2011-001-00 and was initially reported in accordance with 10 CFR 50.73(a)(2)(i)(B), any operation or condition which was prohibited by the plant's Technical Specifications. However, further reviews determined at 0800 on June 11, 2012, that the event is also reportable under 10 CFR 50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a safety function. 

"During the three year period prior to May 4, 2011, it is estimated that the purification loop was in service aligned to the RWST while on-line nine times, totaling 297 days." 

The licensee has notified the NRC Resident Inspector.


#10346 From: "Salot, William" <william.salot@...>
Date: Tue Jun 12, 2012 6:27 pm
Subject: RE: an interesting 40 y/o problem!
wjsalot
Send Email Send Email
 

Congratulations!  After 40 years, “Nukes” have finally identified a problem with but a single cause, and such a simple cause it is!  I am impressed!

Bill Salot

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Arnie Gundersen
Sent: Tuesday, June 12, 2012 1:58 PM
To: Root_Cause_State_of_the_Practice@yahoogroups.com; DR WILLIAM CORCORAN
Subject: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!

 

 

'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR).

 

Power Reactor

Event Number: 48011

Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: RICH ROGALSKI
HQ OPS Officer: DONG HWA PARK

Notification Date: 06/11/2012
Notification Time: 10:03 [ET]
Event Date: 05/04/2011
Event Time: 13:25 [EDT]
Last Update Date: 06/11/2012

Emergency Class: NON EMERGENCY
10 CFR Section: 
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION

Person (Organization): 
MALCOLM WIDMANN (R2DO)

 

Unit

SCRAM Code

RX CRIT

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

2

N

Y

100

Power Operation

100

Power Operation

Event Text

REFUELING WATER STORAGE TANK CONNECTED TO NON-SEISMICALLY QUALIFIED SYSTEM 

"On May 4, 2011, at approximately 1325 Eastern Daylight Time (EDT), with H. B. Robinson Steam Electric Plant (HBRSEP), Unit No. 2, in Mode 1 at 100% power, it was determined that over the last 40 years, HBRSEP, Unit No. 2 periodically performed cleanup of the Refueling Water Storage Tank (RWST) by aligning the non-seismically qualified refueling water purification system to the safety related and seismically qualified RWST without recognizing that the action rendered the RWST inoperable. As a result, on multiple occasions, the RWST was inoperable for a period longer than allowed by Technical Specification (TS) Limiting Condition for Operation 3.5.4, Emergency Core Cooling Systems Refueling Water Storage Tank. 

'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR). 

"A clearance order has been placed in effect to ensure restrictions for piping that could affect the operability of the RWST remain in place. 

"This event was described in Licensee Event Report 2011-001-00 and was initially reported in accordance with 10 CFR 50.73(a)(2)(i)(B), any operation or condition which was prohibited by the plant's Technical Specifications. However, further reviews determined at 0800 on June 11, 2012, that the event is also reportable under 10 CFR 50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a safety function. 

"During the three year period prior to May 4, 2011, it is estimated that the purification loop was in service aligned to the RWST while on-line nine times, totaling 297 days." 

The licensee has notified the NRC Resident Inspector.

 


#10347 From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
Date: Wed Jun 13, 2012 12:27 pm
Subject: Re: an interesting 40 y/o problem!
drbillcorcoran
Send Email Send Email
 
What were the factors that resulted in "the cause" existing for forty years?

What were the earlier, cheaper, safer, more responsible, more compliant ways that the problem and the factors that resulted in it could have been found?

How many more instances of "the cause" exist in this plant and others?
 
Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 
****Internet Email Confidentiality Footer****
 
Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


From: "Salot, William" <william.salot@...>
To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>; DR WILLIAM CORCORAN <William.R.Corcoran@...>
Sent: Tuesday, June 12, 2012 2:27 PM
Subject: RE: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!

 
Congratulations!  After 40 years, “Nukes” have finally identified a problem with but a single cause, and such a simple cause it is!  I am impressed!
Bill Salot
 
From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Arnie Gundersen
Sent: Tuesday, June 12, 2012 1:58 PM
To: Root_Cause_State_of_the_Practice@yahoogroups.com; DR WILLIAM CORCORAN
Subject: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!
 
 
'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR).
 
Power Reactor
Event Number: 48011
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: RICH ROGALSKI
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/11/2012
Notification Time: 10:03 [ET]
Event Date: 05/04/2011
Event Time: 13:25 [EDT]
Last Update Date: 06/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section: 
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization): 
MALCOLM WIDMANN (R2DO)
 
Unit
SCRAM Code
RX CRIT
Initial PWR
Initial RX Mode
Current PWR
Current RX Mode
2
N
Y
100
Power Operation
100
Power Operation
Event Text
REFUELING WATER STORAGE TANK CONNECTED TO NON-SEISMICALLY QUALIFIED SYSTEM 

"On May 4, 2011, at approximately 1325 Eastern Daylight Time (EDT), with H. B. Robinson Steam Electric Plant (HBRSEP), Unit No. 2, in Mode 1 at 100% power, it was determined that over the last 40 years, HBRSEP, Unit No. 2 periodically performed cleanup of the Refueling Water Storage Tank (RWST) by aligning the non-seismically qualified refueling water purification system to the safety related and seismically qualified RWST without recognizing that the action rendered the RWST inoperable. As a result, on multiple occasions, the RWST was inoperable for a period longer than allowed by Technical Specification (TS) Limiting Condition for Operation 3.5.4, Emergency Core Cooling Systems Refueling Water Storage Tank. 

'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR). 

"A clearance order has been placed in effect to ensure restrictions for piping that could affect the operability of the RWST remain in place. 

"This event was described in Licensee Event Report 2011-001-00 and was initially reported in accordance with 10 CFR 50.73(a)(2)(i)(B), any operation or condition which was prohibited by the plant's Technical Specifications. However, further reviews determined at 0800 on June 11, 2012, that the event is also reportable under 10 CFR 50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a safety function. 

"During the three year period prior to May 4, 2011, it is estimated that the purification loop was in service aligned to the RWST while on-line nine times, totaling 297 days." 

The licensee has notified the NRC Resident Inspector.
 



#10348 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Wed Jun 13, 2012 12:30 pm
Subject: Poll results for Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
The following Root_Cause_State_of_the_Practice poll is now closed.  Here are the
final results:


POLL QUESTION: Process safety culture is a proper subset of safety culture for
an organization that has processes..

CHOICES AND RESULTS
- Strongly agree, 4 votes, 50.00%
- Agree, 2 votes, 25.00%
- Neither agree nor disagree, 1 votes, 12.50%
- Disagree, 1 votes, 12.50%
- Strongly disagree, 0 votes, 0.00%

INDIVIDUAL VOTES
- Strongly agree
      - djclarke@...
      - william.rigot@...
      - arsenaultg@...
      - William.R.Corcoran@...
- Agree
      - thomas.j.harrington@...
      - romylio@...
- Neither agree nor disagree
      - paul.oortman.gerlings@...
- Disagree
      - blethcoe@...
- Strongly disagree


For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html

#10349 From: Root_Cause_State_of_the_Practice@yahoogroups.com
Date: Wed Jun 13, 2012 12:30 pm
Subject: Poll results for Root_Cause_State_of_the_Practice
Root_Cause_State_of_the_Practice@yahoogroups.com
Send Email Send Email
 
The following Root_Cause_State_of_the_Practice poll is now closed.  Here are the
final results:


POLL QUESTION: The set of physical objects that characterize an organization are
part of its culture.

CHOICES AND RESULTS
- Strongly agree, 3 votes, 27.27%
- Agree, 5 votes, 45.45%
- Neither agree nor disagree, 1 votes, 9.09%
- Disagree, 1 votes, 9.09%
- Strongly disagree, 1 votes, 9.09%

INDIVIDUAL VOTES
- Strongly agree
      - romylio@...
      - arsenaultg@...
      - William.R.Corcoran@...
- Agree
      - dan_assefa@...
      - thomas.j.harrington@...
      - dcrowther@...
      - william.rigot@...
      - fjreedy2@...
- Neither agree nor disagree
      - patrick.mccabe@...
- Disagree
      - emridgell@...
- Strongly disagree
      - paul.oortman.gerlings@...


For more information about this group, please visit
http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice

For help with Yahoo! Groups, please visit
http://help.yahoo.com/l/us/yahoo/groups/original/members/forms/general.html

#10350 From: "Arsenault, Gerry" <arsenaultg@...>
Date: Wed Jun 13, 2012 1:19 pm
Subject: RE: an interesting 40 y/o problem!
aarsenau1g
Send Email Send Email
 

AECL - OFFICIAL USE ONLY | À USAGE EXCLUSIF - EACL

 

How was the “cause” determined in this case?

Apply the same methodology in an extent of cause assessment to other systems that have seismic requirements.

 

The cockroach principle tells you if there is one on the floor there are fifty under the fridge.

It is quite likely  additional examples of non-compliance to seismic requirements in other systems are  lying in wait to be found.

 

G.

 

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, June 13, 2012 8:27 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: Re: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!

 

What were the factors that resulted in "the cause" existing for forty years?

 

What were the earlier, cheaper, safer, more responsible, more compliant ways that the problem and the factors that resulted in it could have been found?

 

How many more instances of "the cause" exist in this plant and others?

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

 


From: "Salot, William" <william.salot@...>
To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>; DR WILLIAM CORCORAN <William.R.Corcoran@...>
Sent: Tuesday, June 12, 2012 2:27 PM
Subject: RE: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!

 

 

Congratulations!  After 40 years, “Nukes” have finally identified a problem with but a single cause, and such a simple cause it is!  I am impressed!

Bill Salot

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Arnie Gundersen
Sent: Tuesday, June 12, 2012 1:58 PM
To: Root_Cause_State_of_the_Practice@yahoogroups.com; DR WILLIAM CORCORAN
Subject: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!

 

 

'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR).

 

Power Reactor

Event Number: 48011

Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: RICH ROGALSKI
HQ OPS Officer: DONG HWA PARK

Notification Date: 06/11/2012
Notification Time: 10:03 [ET]
Event Date: 05/04/2011
Event Time: 13:25 [EDT]
Last Update Date: 06/11/2012

Emergency Class: NON EMERGENCY
10 CFR Section: 
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION

Person (Organization): 
MALCOLM WIDMANN (R2DO)

 

Unit

SCRAM Code

RX CRIT

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

2

N

Y

100

Power Operation

100

Power Operation

Event Text

REFUELING WATER STORAGE TANK CONNECTED TO NON-SEISMICALLY QUALIFIED SYSTEM 

"On May 4, 2011, at approximately 1325 Eastern Daylight Time (EDT), with H. B. Robinson Steam Electric Plant (HBRSEP), Unit No. 2, in Mode 1 at 100% power, it was determined that over the last 40 years, HBRSEP, Unit No. 2 periodically performed cleanup of the Refueling Water Storage Tank (RWST) by aligning the non-seismically qualified refueling water purification system to the safety related and seismically qualified RWST without recognizing that the action rendered the RWST inoperable. As a result, on multiple occasions, the RWST was inoperable for a period longer than allowed by Technical Specification (TS) Limiting Condition for Operation 3.5.4, Emergency Core Cooling Systems Refueling Water Storage Tank. 

'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR). 

"A clearance order has been placed in effect to ensure restrictions for piping that could affect the operability of the RWST remain in place. 

"This event was described in Licensee Event Report 2011-001-00 and was initially reported in accordance with 10 CFR 50.73(a)(2)(i)(B), any operation or condition which was prohibited by the plant's Technical Specifications. However, further reviews determined at 0800 on June 11, 2012, that the event is also reportable under 10 CFR 50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a safety function. 

"During the three year period prior to May 4, 2011, it is estimated that the purification loop was in service aligned to the RWST while on-line nine times, totaling 297 days." 

The licensee has notified the NRC Resident Inspector.

 


#10351 From: "Hill, Dan S." <dshill@...>
Date: Wed Jun 13, 2012 1:33 pm
Subject: RE: an interesting 40 y/o problem!
wallyz8
Send Email Send Email
 

I don’t have time to discuss this more right now but I can tell you that the same condition has existed at Vogtle 1&2.  This may add to the overall discussion.  I will try to slip in on the discussion later ; deadlines and other pressing work for now.

Danny

 

Daniel S. Hill 
Root Cause Analyst Plant Vogtle
7821 River road  
Waynesboro, GA  30830
DSHILL@...
706-826-3484  8-695-3484

 

OE36060 - Seismically Qualified RWST Aligned to Non-Seismic Piping (Vogtle Unit 1)

 

Abstract:

On February 15, 2012, with the unit at 100 percent power, it was determined that opening the boundary valve between the safety related and seismically qualified Refueling Water Storage Tank (RWST and the non-safety related and non-seismically qualified Spent Fuel Pool Purification (SFPP) system in Modes 1-4, renders the RWST inoperable. Plant procedures had been revised in 2009 to allow opening this boundary valve in Modes 1-4 under administrative controls. The 10 CFR 50.59 safety evaluation that had been performed to support the procedure change had concluded that the administrative controls would allow the RWST to remain operable. However, in consideration of the new interpretation provided in NRC Information Notice 2012-01, it was judged that the RWST would be considered to be inoperable regardless of the administrative controls established when the RWST was aligned to non-seismic piping in Modes 1-4. Since the boundary valve had been opened in Mode 1 under administrative controls and the one hour completion time of Technical Specification 3.5.4 Condition D was not entered, under this recent interpretation, this represented a condition prohibited by Technical Specifications and is reportable pursuant to 10 CFR 50.73(a)(2)(i)(8). This event had no significant safety consequence since a seismic event had not occurred while the SFPP system was in service on the RWST.

 

 

Event Date:

2/15/2012

 

 

Site Name/Unit Number:

Vogtle Unit 1

 

 

Significance /Consequence:

Nonconsequential - This event is significant in that a Technical Specification required component was rendered inoperable and not recognized as being inoperable.  However, during the time the RWST was inoperable there was no demand for ECCS operation.  

 

 

Lessons Learned for the Industry:

The lesson learned from this event is that more rigor needs to be applied to safety evaluations when manual operator actions are credited to ensure all regulatory requirements are satisfied.

 

 

Applicability:

Operations

Engineering

 

 

Description:

On February 15, 2012, during review of the new interpretation provided in NRC Information Notice 2012-01, it was determined that one of the items described in the information notice was applicable to Vogtle Electric Generating Plant (VEGP). Specifically, the information notice identified a utility that had received a non-cited violation (NCV) for crediting administrative controls to close a boundary valve to isolate the non-seismic piping system from the seismically qualified RWST. During the review, it was recognized that, considering the information provided in NRC Information Notice 2012-01, the RWST would be judged to be inoperable regardless of the administrative controls established when the RWST was aligned to non-seismic piping in Modes 1 -4.

At VEGP, the RWST is seismically qualified, safety related and within the scope of the plant Technical Specifications (TS). The plant design includes the capability to align the Spent Fuel Pool Purification (SFPP) system for cleanup of the RWST. The SFPP is a non-safety, non-seismic system that is normally isolated from the RWST by a normally closed, safety related manually operated valve.

A review of system operating procedures identified that VEGP allowed the SFPP system boundary valve to be opened under administrative controls while the unit was operating in Modes 1-4 without declaring the RWST inoperable per TS LCO 3.5.4 Condition D. TS LCO 3.5.4 Condition D requires that the RWST be returned to Operable status with a completion time of 1 hour. If the RWST is not returned to operable status within 1 hour, TS LCO 3.5.4 Condition E requires that the unit be placed in Mode 3 within 6 hours and be in Mode 5 within 36 hours. A review of the Unit 2 Control Room logs for the past three years did not identify an instance where the Unit 2 boundary valve was opened in Modes 1-4 for greater than 1 hour. However, a review of the Unit 1 control room logs, for the past three years, identified that in the fall of 2009 with the unit in Mode 1, the boundary valve had been opened under administrative controls for longer than 1 hour on several occasions. Since the RWST was not declared inoperable, TS LCO actions were not entered. This resulted in operation of the unit which, under the interpretation provided by NRC Information Notice 2012-01, is considered to be a condition prohibited by TS and is reportable pursuant to 10 CFR 50.73(a)(2)(i)(6).

 

Causes:

The direct cause of this event was an incorrect application of the use of compensatory measures (i.e., manual operator actions), when placing the non-seismic SFPP system in service on seismically qualified systems/components (RWST) during modes of operation when they are needed to perform their safety function. Prior to the issuance of NRC Information Notice 2012-01, manual operator actions had been evaluated and deemed acceptable in accordance with processes and procedures in place at that time. However, recently it has been determined that licensees cannot use compensatory measures when compromising the seismic qualification of a system/component.

 

Corrective Actions:

The procedures that allowed opening the boundary valve in operational Modes 1-4 were revised to remove this capability. Additionally, the boundary valve between the RWST and SFPP system was locked closed and included in the safety related locked valve program.

 

Previous Industry OE:

OE35564 - Preliminary - Unplanned LCO 3.5.4 Entry Due To Placing Refueling Water Storage Tank (RWST) On Purification (H. B. Robinson, Unit #2)

 

CONFIDENTIALITY NOTE

This e-mail and any of its attachments may contain proprietary Southern Company and/or affiliate information that is privileged, confidential, or protected by copyright belonging to Southern Company and/or its affiliates. This e-mail is intended solely for the use of the individual or entity for which it is intended. If you are not the intended recipient of this e-mail, any dissemination, distribution, copying, or action taken in relation to the contents of and attachments to this e-mail is contrary to the rights of Southern Company and/or its affiliates and is prohibited. If you are not the intended recipient of this e-mail, please notify the sender immediately by return e-mail and permanently delete the original and any copy or printout of this e-mail and any attachments. Thank you.

 

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Arsenault, Gerry
Sent: Wednesday, June 13, 2012 9:19 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: RE: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!

 




AECL - OFFICIAL USE ONLY | À USAGE EXCLUSIF - EACL

 

How was the “cause” determined in this case?

Apply the same methodology in an extent of cause assessment to other systems that have seismic requirements.

 

The cockroach principle tells you if there is one on the floor there are fifty under the fridge.

It is quite likely  additional examples of non-compliance to seismic requirements in other systems are  lying in wait to be found.

 

G.

 

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, June 13, 2012 8:27 AM
To: Root_Cause_State_of_the_Practice@yahoogroups.com
Subject: Re: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!

 

What were the factors that resulted in "the cause" existing for forty years?

 

What were the earlier, cheaper, safer, more responsible, more compliant ways that the problem and the factors that resulted in it could have been found?

 

How many more instances of "the cause" exist in this plant and others?

 

Take care,
 
Bill Corcoran

 
William  R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts Corporation
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779
William.R.Corcoran@...
http://www.linkedin.com/in/williamcorcoranphdpe


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.

Method: Mastering Investigative Technology

Mindset: A good business issue investigation makes the despicable explicable.

Memory: The harmful factors of every adverse event to date have included insufficient transparency.

Mantra: Fix the nonconformities that resulted in the enormities.

 

****Internet Email Confidentiality Footer****

 

Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.

 


From: "Salot, William" <william.salot@...>
To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>; DR WILLIAM CORCORAN <William.R.Corcoran@...>
Sent: Tuesday, June 12, 2012 2:27 PM
Subject: RE: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!

 

 

Congratulations!  After 40 years, “Nukes” have finally identified a problem with but a single cause, and such a simple cause it is!  I am impressed!

Bill Salot

 

From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Arnie Gundersen
Sent: Tuesday, June 12, 2012 1:58 PM
To: Root_Cause_State_of_the_Practice@yahoogroups.com; DR WILLIAM CORCORAN
Subject: [Root_Cause_State_of_the_Practice] an interesting 40 y/o problem!

 

 

'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR).

 

Power Reactor

Event Number: 48011

Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: RICH ROGALSKI
HQ OPS Officer: DONG HWA PARK

Notification Date: 06/11/2012
Notification Time: 10:03 [ET]
Event Date: 05/04/2011
Event Time: 13:25 [EDT]
Last Update Date: 06/11/2012

Emergency Class: NON EMERGENCY
10 CFR Section: 
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION

Person (Organization): 
MALCOLM WIDMANN (R2DO)

 

Unit

SCRAM Code

RX CRIT

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

2

N

Y

100

Power Operation

100

Power Operation

Event Text

REFUELING WATER STORAGE TANK CONNECTED TO NON-SEISMICALLY QUALIFIED SYSTEM 

"On May 4, 2011, at approximately 1325 Eastern Daylight Time (EDT), with H. B. Robinson Steam Electric Plant (HBRSEP), Unit No. 2, in Mode 1 at 100% power, it was determined that over the last 40 years, HBRSEP, Unit No. 2 periodically performed cleanup of the Refueling Water Storage Tank (RWST) by aligning the non-seismically qualified refueling water purification system to the safety related and seismically qualified RWST without recognizing that the action rendered the RWST inoperable. As a result, on multiple occasions, the RWST was inoperable for a period longer than allowed by Technical Specification (TS) Limiting Condition for Operation 3.5.4, Emergency Core Cooling Systems Refueling Water Storage Tank. 

'The cause of this event was that regulatory requirements for the separation of seismically qualified and non-qualified systems, structures, and components were not adequately incorporated into the Design Basis Document (DBD) and Updated Final Safety Analysis Report (UFSAR). 

"A clearance order has been placed in effect to ensure restrictions for piping that could affect the operability of the RWST remain in place. 

"This event was described in Licensee Event Report 2011-001-00 and was initially reported in accordance with 10 CFR 50.73(a)(2)(i)(B), any operation or condition which was prohibited by the plant's Technical Specifications. However, further reviews determined at 0800 on June 11, 2012, that the event is also reportable under 10 CFR 50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a safety function. 

"During the three year period prior to May 4, 2011, it is estimated that the purification loop was in service aligned to the RWST while on-line nine times, totaling 297 days." 

The licensee has notified the NRC Resident Inspector.

 





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