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: �"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.
> >
> > 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 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 â€�"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.
> >
>

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POLL QUESTION: A top attribute of a good safety culture is that the people call
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      - 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


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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!

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

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

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