My standard process, from which I deviate when
appropriate, is to begin with a Comparative TimeLine(c). This gives me all the
information I need to start a "Why Staircase Tree".
Then I do a Why Staircase Tree.
Then I do "insight tables", e.g., Missed
Opportunity Matrix (MOM), Barrier Analysis Matrix (BAM), Eight Question
If I need more insights I will map the Why
Staircase Tree into a flow chart.
It turns out that the Why Staircase Tree is
topologically equivalent to a project Work Breakdown Structure and can, at least
conceptually, be mapped into a PERT Chart (Planning Logic Network or Activity
Network Diagram) and a Gantt Chart!!
Examples of many of these concepts are posted in
the files section and the databases section of
I am tentatively beginning to see that an Event and
Causal Factors Chart is a false flow chart because it cannot be mapped into a
Why Staircase Tree!!
W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts
Windsor, CT 06095-1634
lives, pain, assets, and careers through thoughtful inquiry.
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----- Original Message -----
Sent: Monday, June 03, 2002 5:12 PM
Subject: [rootcauseconference] Re:
Bob, the link reflects a different perspective for
investigation,rather than adding to the root cause perspective of
accidents, as I understand it.
The prespective is to view an
accident or incident as a special
process producing an undesired
outcome by interactions
among the process' components.
can be flow charted if you can determine, by
investigation, what happened.
( "If you can't flow chart it, you
don't understand it" per
Bill Johnson. )
You can then take your finished properly
prepared flow chart
describing the accident, and by examining each
(coupled event pair or set ) in the flow chart, work
through the problem discovery, definition and resolution
as described in the Guide.
rootcauseconference@y..., "bobnelms" <bobnelms@c...>
> Thanks for this link. I'll be adding it to our
> I wish you could summarize the perspective it
adds. I visited
the link, but
> it's rather lengthy.
Would you mind whetting our appetites?
> Bob Nelms
> Root Cause LIVE
s.yahoo.com] On Behalf Of sallust4
Sent: Sunday, June 02, 2002 5:42 PM
Subject: [rootcauseconference] Re: Problem
> Riley et al,
problem statement questions, for a wholly different
> perspective and
approach, you might find the task guidance
discovery, definition and remedial action development
> of value.
> --- In
rootcauseconference@y..., "toadyriley" <toady@s...>
> Howdy to the Group....
> > I've found that one of
the most difficult areas of our Craft is
> > defining the problem
statement. My philosophy being that if
> > can't
properly define the problem, then you're probably going
solve the wrong problem.
> > For instance.... A
craftsman incorrectly assembles a valve,
> > the
procedures for assembling the valve were incorrect.
> > would jump at a problem statement that reads something
> > assembly procedures are deficient"
(which is a cause).
> Although this
> > would solve the
procedure problem, it would fail to ask any
that might involve training, qualifications, QC inspection, etc.,
> > I would state the problem as, "Valve failed."
> > How do the rest of you develop your problem
> > Always ready to learn.
> > Riley
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