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Using Safety Devices for Operational Purposes: I need your help

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  • Dr. Bill Corcoran
    Colleague, I am investigating an event in which operators routinely used a safety device for operational purposes. After thousands of successful evolutions
    Message 1 of 27 , Apr 10, 2004
      Colleague,
       
      I am investigating an event in which operators routinely used a safety device for operational purposes.
       
      After thousands of successful evolutions there was an evolution in which the safety device was in a by-passed condition.
       
      Of course, an accident occurred.
       
      Would you be so kind as to
      1. tell me your thoughts in this area,
      2. let me know what corrective actions come to mind, and
      3. give me any examples you can think of?
      Thanks ever so much.
       
      Take care,
       
      Bill Corcoran
       
      W. R. Corcoran, Ph.D., P.E.
      Nuclear Safety Review Concepts
      21 Broadleaf Circle
      Windsor, CT 06095-1634
      860-285-8779
      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
       
      Check out our e-groups  at
      http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
      where you will find the back issues of "The Firebird Forum" through 2003 and at
      http://groups.yahoo.com/group/DBRVH_LTBL_II/
      where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.
       
      For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...
    • Terry Herrmann
      Dr. Bill, A little more information would be helpful. What type of safety device was this? How was it used in order to perform the evolution? What was the
      Message 2 of 27 , Apr 10, 2004
        Dr. Bill,

        A little more information would be helpful.

        What type of safety device was this?

        How was it used in order to perform the evolution?

        What was the probability that an accident would occur if the safety device
        were not used? (I'm wondering if it was REALLY used thousands of times or
        just reported that way.)

        Was the action so conditioned as to be able to be performed totally from
        memory without hardly thinking about it? (I'm trying to see if we're talking
        about a skill-based or rule-based type of error)

        What was the perceived effort (burden) for using this device rather than not
        use the device?

        How many times had the operator involved with the accident performed the
        evolution correctly (as determined by observation)?

        I dislike offering initial thoughts towards corrective actions without fully
        understanding the cause. "Jumping to cause" tends to create more problems
        and tends to not solve the initial problem.

        Terry Herrmann


        From: "Dr. Bill Corcoran" <firebird.one@...>
        Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
        To:
        <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_of_the_Practice_II"
        <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
        Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices for
        Operational Purposes: I need your help
        Date: Sat, 10 Apr 2004 10:34:12 -0400

        Colleague,

        I am investigating an event in which operators routinely used a safety
        device for operational purposes.

        After thousands of successful evolutions there was an evolution in which the
        safety device was in a by-passed condition.

        Of course, an accident occurred.

        Would you be so kind as to
        1.. tell me your thoughts in this area,
        2.. let me know what corrective actions come to mind, and
        3.. give me any examples you can think of?
        Thanks ever so much.

        Take care,

        Bill Corcoran

        W. R. Corcoran, Ph.D., P.E.
        Nuclear Safety Review Concepts
        21 Broadleaf Circle
        Windsor, CT 06095-1634
        860-285-8779
        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

        Check out our e-groups at
        http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
        where you will find the back issues of "The Firebird Forum" through 2003 and
        at
        http://groups.yahoo.com/group/DBRVH_LTBL_II/
        where you will find a dialogue on the Davis-Besse near miss LOCA., including
        photos, polls, files, tables, and links.

        For a complimentary subscription to our e-newsletter on root cause,
        organizational learning, and safety send a message to
        firebird.one@...

        _________________________________________________________________
        Get rid of annoying pop-up ads with the new MSN Toolbar � FREE!
        http://toolbar.msn.com/go/onm00200414ave/direct/01/
      • Lawrence B. Durham
        Bill, bear in mind that I m watching the Masters Golf Tournament as I think about your questions and write this response. I ve seen some of the world s best
        Message 3 of 27 , Apr 10, 2004

          Bill, bear in mind that I’m watching the Masters’ Golf Tournament as I think about your questions and write this response.  I’ve seen some of the world’s best players muff shots like ones that they’ve made successfully literally thousands of times.  To my knowledge, the PGA won’t be kicking anyone out of the organization for those errors.  (Granted lives do not typically depend on golf shots.)  Each golf professional is more eager than anyone else to maintain and improve his (or her) game.  Hopefully, the operators are in an organizational environment that also doesn’t “go after” people who make mistakes and where individuals are self-motivated to constantly seek to improve and avoid mistakes.

           

          Nonetheless, an accident happened.  My first thoughts ran toward checking if, how, and when the relevant evolutions were included in pre-briefings and/or training exercises.  For years, I have shared with many folks the feeling that the nuclear industry is so attentive to the avoidance of abnormal conditions that it overlooks providing sufficient attention to reinforcing the proper execution of routine operating procedures.  My second wave of thought on this matter went to the realm of effective three-way communication.  Back to golf, top players ask their caddies for advice and feedback – both before and after their shots.  I don’t see much of that type of behavior among our nuclear workforce.  How was the intra-team communication in this case?

           

          As for suggested corrective actions, your hardest job in this case may be persuading plant management that it may not be a training problem.  Even though I have already suggested looking at the related training, please don’t mistake that question for my having jumped to the same conclusion – insufficient (and, maybe, inadequate) training.  Based on your sketch, it would seem that they had already demonstrated many times that they knew what to do and how to do it.  Thus, the question is why didn’t they do it as they had before?  Though I sound like an echo of you, I have to remind even you to “just ask them”.  Frankly, this sounds very much like a complacency and operational attitude situation.  I would respectfully suggest an environmental analysis of the organizational culture.  I would make a small wager that such an investigation would detect a number of other less-visible errors that have stayed “below the radar”.  You taught me too well to get me to “bite” on specific corrective action(s) absent further data.

          However, this one “feels” very much like a supervisory and, therefore, management problem that unfortunately manifested itself in a critical manner.  I would suggest that after the company is comfortable that the root causes have been identified that the cognizant manager and the directly-involved employee(s) should provide “lessons-learned” briefings to their associates throughout the plant and develop a case study for INPO dissemination.

           

          The best examples that come to mind were reported in the airline cases (poor communications and teamwork) reported out several years ago.  I don’t remember the specific reference, but I’ll bet you know it and probably have a copy.  (If so, please send the reference back to me.)  And, regrettably, it also has certain tones of the Davis-Besse inattention-to-detail, “business-as-usual” syndrome.  On a matter that I polled this network about last year, the realm of medical mistakes also offers all too many potential comparisons – from mis-filled prescriptions to amputating the wrong limbs to fatal anesthesia techniques.  And, finally, to return to my golfing analogy, rules and procedures that are typically followed so faithfully to avoid disqualification are, nonetheless, sometimes broken by top players who make stupid mistakes like not signing their cards after a completed round or by inadvertently moving a ball by not walking carefully in the woods as one looks for it after an errant shot.

           

          I hope that this helps.  As always, I would appreciate your assessment of my critique and observations and suggestions.  As more details are releasable, please share them and the course of action that is followed by the company.

           

          HAPPY EASTER!

           

          VR/LBD

           

           

          -----Original Message-----
          From: Dr. Bill Corcoran [mailto:firebird.one@...]
          Sent: Saturday, April 10, 2004 9:34 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com; Root_Cause_State_of_the_Practice_II
          Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

           

          Colleague,

           

          I am investigating an event in which operators routinely used a safety device for operational purposes.

           

          After thousands of successful evolutions there was an evolution in which the safety device was in a by-passed condition.

           

          Of course, an accident occurred.

           

          Would you be so kind as to

          1.      tell me your thoughts in this area,

          2.      let me know what corrective actions come to mind, and

          3.      give me any examples you can think of?

          Thanks ever so much.

           

          Take care,

           

          Bill Corcoran

           

          W. R. Corcoran, Ph.D., P.E.
          Nuclear Safety Review Concepts
          21 Broadleaf Circle
          Windsor, CT 06095-1634
          860-285-8779
          Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
           
          Check out our e-groups  at
          http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
          where you will find the back issues of "The Firebird Forum" through 2003 and at
          http://groups.yahoo.com/group/DBRVH_LTBL_II/
          where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

           

          For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...



        • Lawrence B. Durham
          Amen, Terry. Larry ... From: Terry Herrmann [mailto:jherrmt@hotmail.com] Sent: Saturday, April 10, 2004 2:35 PM To:
          Message 4 of 27 , Apr 10, 2004
            Amen, Terry.

            Larry

            -----Original Message-----
            From: Terry Herrmann [mailto:jherrmt@...]
            Sent: Saturday, April 10, 2004 2:35 PM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com;
            Root_Cause_State_of_the_Practice_II@yahoogroups.com
            Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
            Operational Purposes: I need your help

            Dr. Bill,

            A little more information would be helpful.

            What type of safety device was this?

            How was it used in order to perform the evolution?

            What was the probability that an accident would occur if the safety device
            were not used? (I'm wondering if it was REALLY used thousands of times or
            just reported that way.)

            Was the action so conditioned as to be able to be performed totally from
            memory without hardly thinking about it? (I'm trying to see if we're talking

            about a skill-based or rule-based type of error)

            What was the perceived effort (burden) for using this device rather than not

            use the device?

            How many times had the operator involved with the accident performed the
            evolution correctly (as determined by observation)?

            I dislike offering initial thoughts towards corrective actions without fully

            understanding the cause. "Jumping to cause" tends to create more problems
            and tends to not solve the initial problem.

            Terry Herrmann


            From: "Dr. Bill Corcoran" <firebird.one@...>
            Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
            To:
            <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_of_the_
            Practice_II"
            <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
            Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices for
            Operational Purposes: I need your help
            Date: Sat, 10 Apr 2004 10:34:12 -0400

            Colleague,

            I am investigating an event in which operators routinely used a safety
            device for operational purposes.

            After thousands of successful evolutions there was an evolution in which the

            safety device was in a by-passed condition.

            Of course, an accident occurred.

            Would you be so kind as to
            1.. tell me your thoughts in this area,
            2.. let me know what corrective actions come to mind, and
            3.. give me any examples you can think of?
            Thanks ever so much.

            Take care,

            Bill Corcoran

            W. R. Corcoran, Ph.D., P.E.
            Nuclear Safety Review Concepts
            21 Broadleaf Circle
            Windsor, CT 06095-1634
            860-285-8779
            Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

            Check out our e-groups at
            http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
            where you will find the back issues of "The Firebird Forum" through 2003 and

            at
            http://groups.yahoo.com/group/DBRVH_LTBL_II/
            where you will find a dialogue on the Davis-Besse near miss LOCA., including

            photos, polls, files, tables, and links.

            For a complimentary subscription to our e-newsletter on root cause,
            organizational learning, and safety send a message to
            firebird.one@...

            _________________________________________________________________
            Get rid of annoying pop-up ads with the new MSN Toolbar - FREE!
            http://toolbar.msn.com/go/onm00200414ave/direct/01/





            Yahoo! Groups Links
          • William R. Corcoran, Ph.D.,P.E.
            Terry, The device was a physical travel limit stop. It was being used to stop the travel of a piece of equipment day in and day out. One day the physical
            Message 5 of 27 , Apr 11, 2004
              Terry,

              The device was a physical travel limit stop. It was being used to
              stop the travel of a piece of equipment day in and day out.

              One day the physical travel limit stop was out of position and the
              piece of equipment kept going to cause damage to itself.

              I am looking for similar examples and generic avenues of corrective
              actions.

              Thanks ever so much,

              Bill

              --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
              Herrmann" <jherrmt@h...> wrote:
              > Dr. Bill,
              >
              > A little more information would be helpful.
              >
              > What type of safety device was this?
              >
              > How was it used in order to perform the evolution?
              >
              > What was the probability that an accident would occur if the
              safety device
              > were not used? (I'm wondering if it was REALLY used thousands of
              times or
              > just reported that way.)
              >
              > Was the action so conditioned as to be able to be performed
              totally from
              > memory without hardly thinking about it? (I'm trying to see if
              we're talking
              > about a skill-based or rule-based type of error)
              >
              > What was the perceived effort (burden) for using this device
              rather than not
              > use the device?
              >
              > How many times had the operator involved with the accident
              performed the
              > evolution correctly (as determined by observation)?
              >
              > I dislike offering initial thoughts towards corrective actions
              without fully
              > understanding the cause. "Jumping to cause" tends to create more
              problems
              > and tends to not solve the initial problem.
              >
              > Terry Herrmann
              >
              >
              > From: "Dr. Bill Corcoran" <firebird.one@a...>
              > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
              > To:
              >
              <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
              of_the_Practice_II"
              > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
              > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
              for
              > Operational Purposes: I need your help
              > Date: Sat, 10 Apr 2004 10:34:12 -0400
              >
              > Colleague,
              >
              > I am investigating an event in which operators routinely used a
              safety
              > device for operational purposes.
              >
              > After thousands of successful evolutions there was an evolution in
              which the
              > safety device was in a by-passed condition.
              >
              > Of course, an accident occurred.
              >
              > Would you be so kind as to
              > 1.. tell me your thoughts in this area,
              > 2.. let me know what corrective actions come to mind, and
              > 3.. give me any examples you can think of?
              > Thanks ever so much.
              >
              > Take care,
              >
              > Bill Corcoran
              >
              > W. R. Corcoran, Ph.D., P.E.
              > Nuclear Safety Review Concepts
              > 21 Broadleaf Circle
              > Windsor, CT 06095-1634
              > 860-285-8779
              > Mission: Saving lives, pain, assets, and careers through
              thoughtful inquiry.
              >
              > Check out our e-groups at
              > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
              > where you will find the back issues of "The Firebird Forum"
              through 2003 and
              > at
              > http://groups.yahoo.com/group/DBRVH_LTBL_II/
              > where you will find a dialogue on the Davis-Besse near miss LOCA.,
              including
              > photos, polls, files, tables, and links.
              >
              > For a complimentary subscription to our e-newsletter on root
              cause,
              > organizational learning, and safety send a message to
              > firebird.one@a...
              >
              > _________________________________________________________________
              > Get rid of annoying pop-up ads with the new MSN Toolbar – FREE!
              > http://toolbar.msn.com/go/onm00200414ave/direct/01/
            • Terry Herrmann
              Bill, I guess it would all depend on whether the stop became loose and was unnoticed or was intentionally bypassed. I ve seen limit switches become loose over
              Message 6 of 27 , Apr 11, 2004
                Bill,

                I guess it would all depend on whether the stop became loose and was
                unnoticed or was intentionally bypassed.

                I've seen limit switches become loose over time and not perform their
                function. In this case, I'd suggest connecting the travel stop so that it
                does not allow the device to move at all unless it is in proper working
                order.

                If it was intentionally bypassed (I've seen people do this with lawnmower
                and snowblower engine cutouts that are intended to do what I'm suggesting
                above), then you need an independent check by someone that doesn't benefit
                from the time savings gained by bypassing the safety device followed up by
                random observations. A good observation program has a number of benefits in
                addition to this, but willful negligence is tough to overcome. You
                esentially have to change the individual's perception of risk so "It's not
                worth the time savings if I get caught."

                Terry Herrmann


                From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                Operational Purposes: I need your help
                Date: Sun, 11 Apr 2004 09:41:30 -0000

                Terry,

                The device was a physical travel limit stop. It was being used to
                stop the travel of a piece of equipment day in and day out.

                One day the physical travel limit stop was out of position and the
                piece of equipment kept going to cause damage to itself.

                I am looking for similar examples and generic avenues of corrective
                actions.

                Thanks ever so much,

                Bill

                --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                Herrmann" <jherrmt@h...> wrote:
                > Dr. Bill,
                >
                > A little more information would be helpful.
                >
                > What type of safety device was this?
                >
                > How was it used in order to perform the evolution?
                >
                > What was the probability that an accident would occur if the
                safety device
                > were not used? (I'm wondering if it was REALLY used thousands of
                times or
                > just reported that way.)
                >
                > Was the action so conditioned as to be able to be performed
                totally from
                > memory without hardly thinking about it? (I'm trying to see if
                we're talking
                > about a skill-based or rule-based type of error)
                >
                > What was the perceived effort (burden) for using this device
                rather than not
                > use the device?
                >
                > How many times had the operator involved with the accident
                performed the
                > evolution correctly (as determined by observation)?
                >
                > I dislike offering initial thoughts towards corrective actions
                without fully
                > understanding the cause. "Jumping to cause" tends to create more
                problems
                > and tends to not solve the initial problem.
                >
                > Terry Herrmann
                >
                >
                > From: "Dr. Bill Corcoran" <firebird.one@a...>
                > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                > To:
                >
                <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                of_the_Practice_II"
                > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                for
                > Operational Purposes: I need your help
                > Date: Sat, 10 Apr 2004 10:34:12 -0400
                >
                > Colleague,
                >
                > I am investigating an event in which operators routinely used a
                safety
                > device for operational purposes.
                >
                > After thousands of successful evolutions there was an evolution in
                which the
                > safety device was in a by-passed condition.
                >
                > Of course, an accident occurred.
                >
                > Would you be so kind as to
                > 1.. tell me your thoughts in this area,
                > 2.. let me know what corrective actions come to mind, and
                > 3.. give me any examples you can think of?
                > Thanks ever so much.
                >
                > Take care,
                >
                > Bill Corcoran
                >
                > W. R. Corcoran, Ph.D., P.E.
                > Nuclear Safety Review Concepts
                > 21 Broadleaf Circle
                > Windsor, CT 06095-1634
                > 860-285-8779
                > Mission: Saving lives, pain, assets, and careers through
                thoughtful inquiry.
                >
                > Check out our e-groups at
                > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                > where you will find the back issues of "The Firebird Forum"
                through 2003 and
                > at
                > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                > where you will find a dialogue on the Davis-Besse near miss LOCA.,
                including
                > photos, polls, files, tables, and links.
                >
                > For a complimentary subscription to our e-newsletter on root
                cause,
                > organizational learning, and safety send a message to
                > firebird.one@a...
                >
                > _________________________________________________________________
                > Get rid of annoying pop-up ads with the new MSN Toolbar � FREE!
                > http://toolbar.msn.com/go/onm00200414ave/direct/01/

                _________________________________________________________________
                Is your PC infected? Get a FREE online computer virus scan from McAfee�
                Security. http://clinic.mcafee.com/clinic/ibuy/campaign.asp?cid=3963
              • William R. Corcoran, Ph.D.,P.E.
                Terry, Is it acceptable to use a travel limit stop routinely to stop the travel? Or should the operators be told to stop the travel before it hits the stop? We
                Message 7 of 27 , Apr 11, 2004
                  Terry,

                  Is it acceptable to use a travel limit stop routinely to stop the
                  travel? Or should the operators be told to stop the travel before it
                  hits the stop?

                  We don't know for sure, but it looks like the repeated collisions of
                  the equipment with the stop may have damaged the stop and
                  contributed to its being out of place.

                  I'm still looking for more examples.

                  T/c,

                  Bill

                  --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                  Herrmann" <jherrmt@h...> wrote:
                  > Bill,
                  >
                  > I guess it would all depend on whether the stop became loose and
                  was
                  > unnoticed or was intentionally bypassed.
                  >
                  > I've seen limit switches become loose over time and not perform
                  their
                  > function. In this case, I'd suggest connecting the travel stop so
                  that it
                  > does not allow the device to move at all unless it is in proper
                  working
                  > order.
                  >
                  > If it was intentionally bypassed (I've seen people do this with
                  lawnmower
                  > and snowblower engine cutouts that are intended to do what I'm
                  suggesting
                  > above), then you need an independent check by someone that doesn't
                  benefit
                  > from the time savings gained by bypassing the safety device
                  followed up by
                  > random observations. A good observation program has a number of
                  benefits in
                  > addition to this, but willful negligence is tough to overcome.
                  You
                  > esentially have to change the individual's perception of risk
                  so "It's not
                  > worth the time savings if I get caught."
                  >
                  > Terry Herrmann
                  >
                  >
                  > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                  Devices for
                  > Operational Purposes: I need your help
                  > Date: Sun, 11 Apr 2004 09:41:30 -0000
                  >
                  > Terry,
                  >
                  > The device was a physical travel limit stop. It was being used to
                  > stop the travel of a piece of equipment day in and day out.
                  >
                  > One day the physical travel limit stop was out of position and the
                  > piece of equipment kept going to cause damage to itself.
                  >
                  > I am looking for similar examples and generic avenues of corrective
                  > actions.
                  >
                  > Thanks ever so much,
                  >
                  > Bill
                  >
                  > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                  > Herrmann" <jherrmt@h...> wrote:
                  > > Dr. Bill,
                  > >
                  > > A little more information would be helpful.
                  > >
                  > > What type of safety device was this?
                  > >
                  > > How was it used in order to perform the evolution?
                  > >
                  > > What was the probability that an accident would occur if the
                  > safety device
                  > > were not used? (I'm wondering if it was REALLY used thousands of
                  > times or
                  > > just reported that way.)
                  > >
                  > > Was the action so conditioned as to be able to be performed
                  > totally from
                  > > memory without hardly thinking about it? (I'm trying to see if
                  > we're talking
                  > > about a skill-based or rule-based type of error)
                  > >
                  > > What was the perceived effort (burden) for using this device
                  > rather than not
                  > > use the device?
                  > >
                  > > How many times had the operator involved with the accident
                  > performed the
                  > > evolution correctly (as determined by observation)?
                  > >
                  > > I dislike offering initial thoughts towards corrective actions
                  > without fully
                  > > understanding the cause. "Jumping to cause" tends to create
                  more
                  > problems
                  > > and tends to not solve the initial problem.
                  > >
                  > > Terry Herrmann
                  > >
                  > >
                  > > From: "Dr. Bill Corcoran" <firebird.one@a...>
                  > > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  > > To:
                  > >
                  >
                  <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                  > of_the_Practice_II"
                  > > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                  > > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                  > for
                  > > Operational Purposes: I need your help
                  > > Date: Sat, 10 Apr 2004 10:34:12 -0400
                  > >
                  > > Colleague,
                  > >
                  > > I am investigating an event in which operators routinely used a
                  > safety
                  > > device for operational purposes.
                  > >
                  > > After thousands of successful evolutions there was an evolution
                  in
                  > which the
                  > > safety device was in a by-passed condition.
                  > >
                  > > Of course, an accident occurred.
                  > >
                  > > Would you be so kind as to
                  > > 1.. tell me your thoughts in this area,
                  > > 2.. let me know what corrective actions come to mind, and
                  > > 3.. give me any examples you can think of?
                  > > Thanks ever so much.
                  > >
                  > > Take care,
                  > >
                  > > Bill Corcoran
                  > >
                  > > W. R. Corcoran, Ph.D., P.E.
                  > > Nuclear Safety Review Concepts
                  > > 21 Broadleaf Circle
                  > > Windsor, CT 06095-1634
                  > > 860-285-8779
                  > > Mission: Saving lives, pain, assets, and careers through
                  > thoughtful inquiry.
                  > >
                  > > Check out our e-groups at
                  > > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                  > > where you will find the back issues of "The Firebird Forum"
                  > through 2003 and
                  > > at
                  > > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                  > > where you will find a dialogue on the Davis-Besse near miss
                  LOCA.,
                  > including
                  > > photos, polls, files, tables, and links.
                  > >
                  > > For a complimentary subscription to our e-newsletter on root
                  > cause,
                  > > organizational learning, and safety send a message to
                  > > firebird.one@a...
                  > >
                  > >
                  _________________________________________________________________
                  > > Get rid of annoying pop-up ads with the new MSN Toolbar – FREE!
                  > > http://toolbar.msn.com/go/onm00200414ave/direct/01/
                  >
                  > _________________________________________________________________
                  > Is your PC infected? Get a FREE online computer virus scan from
                  McAfee®
                  > Security. http://clinic.mcafee.com/clinic/ibuy/campaign.asp?
                  cid=3963
                • Michael Mulligan
                  Bill, How difficult was the installation of the stop. I d be wondering if this was a typical way of the operator s dealing with problems -where did they learn
                  Message 8 of 27 , Apr 11, 2004
                    Bill,

                    How difficult was the installation of the stop. I'd be
                    wondering if this was a typical way of the operator's
                    dealing with problems -where did they learn that they
                    can get away with it? Did they need help with another
                    dept -with installing this device and a coordination
                    problem? Was it a matter of operator skill or
                    attention in controlling the equipment -or did the
                    equipment inexplicably go out of control?

                    mike





                    --- "William R. Corcoran, Ph.D.,P.E."
                    <firebird.one@...> wrote:
                    > Terry,
                    >
                    > The device was a physical travel limit stop. It was
                    > being used to
                    > stop the travel of a piece of equipment day in and
                    > day out.
                    >
                    > One day the physical travel limit stop was out of
                    > position and the
                    > piece of equipment kept going to cause damage to
                    > itself.
                    >
                    > I am looking for similar examples and generic
                    > avenues of corrective
                    > actions.
                    >
                    > Thanks ever so much,
                    >
                    > Bill
                    >
                    > --- In
                    > Root_Cause_State_of_the_Practice@yahoogroups.com,
                    > "Terry
                    > Herrmann" <jherrmt@h...> wrote:
                    > > Dr. Bill,
                    > >
                    > > A little more information would be helpful.
                    > >
                    > > What type of safety device was this?
                    > >
                    > > How was it used in order to perform the evolution?
                    > >
                    > > What was the probability that an accident would
                    > occur if the
                    > safety device
                    > > were not used? (I'm wondering if it was REALLY
                    > used thousands of
                    > times or
                    > > just reported that way.)
                    > >
                    > > Was the action so conditioned as to be able to be
                    > performed
                    > totally from
                    > > memory without hardly thinking about it? (I'm
                    > trying to see if
                    > we're talking
                    > > about a skill-based or rule-based type of error)
                    > >
                    > > What was the perceived effort (burden) for using
                    > this device
                    > rather than not
                    > > use the device?
                    > >
                    > > How many times had the operator involved with the
                    > accident
                    > performed the
                    > > evolution correctly (as determined by
                    > observation)?
                    > >
                    > > I dislike offering initial thoughts towards
                    > corrective actions
                    > without fully
                    > > understanding the cause. "Jumping to cause" tends
                    > to create more
                    > problems
                    > > and tends to not solve the initial problem.
                    > >
                    > > Terry Herrmann
                    > >
                    > >
                    > > From: "Dr. Bill Corcoran" <firebird.one@a...>
                    > > Reply-To:
                    > Root_Cause_State_of_the_Practice@yahoogroups.com
                    > > To:
                    > >
                    >
                    <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                    > of_the_Practice_II"
                    > >
                    >
                    <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                    > > Subject: [Root_Cause_State_of_the_Practice] Using
                    > Safety Devices
                    > for
                    > > Operational Purposes: I need your help
                    > > Date: Sat, 10 Apr 2004 10:34:12 -0400
                    > >
                    > > Colleague,
                    > >
                    > > I am investigating an event in which operators
                    > routinely used a
                    > safety
                    > > device for operational purposes.
                    > >
                    > > After thousands of successful evolutions there was
                    > an evolution in
                    > which the
                    > > safety device was in a by-passed condition.
                    > >
                    > > Of course, an accident occurred.
                    > >
                    > > Would you be so kind as to
                    > > 1.. tell me your thoughts in this area,
                    > > 2.. let me know what corrective actions come to
                    > mind, and
                    > > 3.. give me any examples you can think of?
                    > > Thanks ever so much.
                    > >
                    > > Take care,
                    > >
                    > > Bill Corcoran
                    > >
                    > > W. R. Corcoran, Ph.D., P.E.
                    > > Nuclear Safety Review Concepts
                    > > 21 Broadleaf Circle
                    > > Windsor, CT 06095-1634
                    > > 860-285-8779
                    > > Mission: Saving lives, pain, assets, and careers
                    > through
                    > thoughtful inquiry.
                    > >
                    > > Check out our e-groups at
                    > >
                    >
                    http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                    > > where you will find the back issues of "The
                    > Firebird Forum"
                    > through 2003 and
                    > > at
                    > > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                    > > where you will find a dialogue on the Davis-Besse
                    > near miss LOCA.,
                    > including
                    > > photos, polls, files, tables, and links.
                    > >
                    > > For a complimentary subscription to our
                    > e-newsletter on root
                    > cause,
                    > > organizational learning, and safety send a message
                    > to
                    > > firebird.one@a...
                    > >
                    > >
                    >
                    _________________________________________________________________
                    > > Get rid of annoying pop-up ads with the new MSN
                    > Toolbar � FREE!
                    > >
                    > http://toolbar.msn.com/go/onm00200414ave/direct/01/
                    >
                    >


                    __________________________________
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                  • Dr. Bill Corcoran
                    Larry, I apologize for not being clear about what it is to: a.. Challenge a safety device or b.. Use a safety device for operational purposes. The two are
                    Message 9 of 27 , Apr 12, 2004
                      Larry,
                       
                      I apologize for not being clear about what it is to:
                      • Challenge a safety device or
                      • Use a safety device for operational purposes.
                      The two are closely related, but not identical.
                       
                      Challenging a safety device:
                      1. Attempting to open the inner door of a torpedo tube when the outer door is know to be open. (The safety device is the interlock.)
                      2. Attempting to parallel two sources of AC when they are know to be out of synch. (The safety device is the synch lockout feature.)
                       
                      Using a safety device for operational purposes:
                      1. Using a single travel limit stop to stop equipment travel. (The safety device is the travel limit stop.)
                      2. Pushing the garage door close button when the cat is in the line of travel of the door. (The safety device is the electric eye door stop.)
                       
                      A closely related element of questionable safety culture is
                      resuming work before the causes of a safety device actuation are known and corrected:
                       
                      1. Restarting a reactor before knowing what caused the automatic shutdown (trip/scram).
                      2. Reclosing a circuit breaker without knowing what tripped it.
                      3. Repressurizing a vessel without knowing what caused the overpressure devices to actuate.
                      4. Reloading any machine or system without knowing what caused the machine of system alarm.
                      5. Restarting a pipeline pump/compressor without knowing what caused it to trip.
                       
                      And now we get to more subtle and more troublesome behaviors, e.g.,
                      continuing/resuming work/operation after an anomaly without knowing what caused the anomaly nor what the anomaly means:
                      1. Continuing to launch shuttles at low temperature even though there is evidence that low temperature degrades O-ring performance.
                      2. Continuing to load diesel fuel even though the filter delta-P alarm has actuated.
                      3. Continuing to launch shuttles even though there are frequent foam strikes on the orbiter wing.
                      4. Continuing to operate pressurized water reactors even though it is known that the PORV's have a tendency to stick open.
                      5. Continuing to operate boiling water reactors even though it is know that exhaust fans trip without tripping the supply fans.
                      6. Continuing to operate a pressurized water reactor even though the rad monitor filter clogs more frequently than it had before.
                      7. Continuing to operate a pressurized water reactor even though the containment air coolers foul more frequently than they had before.
                       
                      May we have some more examples of all four?
                       
                      Take care,
                       
                      Bill Corcoran
                       
                      W. R. Corcoran, Ph.D., P.E.
                      Nuclear Safety Review Concepts
                      21 Broadleaf Circle
                      Windsor, CT 06095-1634
                      860-285-8779
                      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                       
                      Check out our e-groups  at
                      http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                      where you will find the back issues of "The Firebird Forum" through 2003 and at
                      http://groups.yahoo.com/group/DBRVH_LTBL_II/
                      where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.
                       
                      For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...
                      ----- Original Message -----
                      Sent: Sunday, April 11, 2004 9:07 PM
                      Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                      No, the airline publication was popularized in the nuclear industry through INPO, but I thought that it had come from a federal agency study.  It involved multiple incidents.

                       

                      You asked: “Are there other examples of activities that challenge safety devices?”:  Not putting on seat belts in automobiles; unfastening them after take-off on airplanes; not checking batteries regularly in home smoke detectors; driving after drinking alcoholic beverages; and, smoking and chewing tobacco!

                       

                      VR/LBD

                       

                       

                      -----Original Message-----
                      From: Dr. Bill Corcoran [mailto:firebird.one@...]
                      Sent: Sunday, April 11, 2004 4:33 AM
                      To: Root_Cause_State_of_the_Practice@yahoogroups.com; Root_Cause_State_of_the_Practice_II
                      Subject: Fw: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                       

                      Larry,

                       

                      Thanks for your insights. The airline accident you are referring to is probably ValuJet 592. I don't recall it as involving using a safety device for operational purposes, but it did involve communications and it did involve safety devices.

                       

                      The venue for the safety device incident that prompted my request was not a nuclear power plant, but that probably doesn't matter.

                       

                      I am still scratching my head over why all of the people who knew that the safety device was being used for operational purposes didn't speak up. This is a teamwork issue if they realized what they were seeing.

                       

                      How many of us never turn off our headlights until after we have opened the driver's door and received the "headlights still on" warning light?

                       

                      Are there still people out there who house a crane hoist by actuating the two-block limit switch?

                       

                      Are there other examples of activities that challenge safety devices?

                       

                      Take care,

                       

                      Bill Corcoran

                       

                      W. R. Corcoran, Ph.D., P.E.
                      Nuclear Safety Review Concepts
                      21 Broadleaf Circle
                      Windsor, CT 06095-1634
                      860-285-8779
                      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                       
                      Check out our e-groups  at
                      http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                      where you will find the back issues of "The Firebird Forum" through 2003 and at
                      http://groups.yahoo.com/group/DBRVH_LTBL_II/
                      where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                       

                      For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                      ----- Original Message -----

                       
                    • Michael Mulligan
                      Did the operators have adiquate visual feedback and control -as the crane approached the stop? Is it a design and cost issue -cheapest- in that there wasn t an
                      Message 10 of 27 , Apr 12, 2004
                        Did the operators have adiquate visual feedback and
                        control -as the crane approached the stop? Is it a
                        design and cost issue -cheapest- in that there wasn't
                        an automatic shutoff? Is it about the job setup -where
                        everyone knows it's a critical path -and much talk
                        about timelyness of this particular job -so you just
                        bang around equipment. So was the crane operation
                        designed for it's use -banging around in a rushed use.
                        mike



                        --- "William R. Corcoran, Ph.D.,P.E."
                        <firebird.one@...> wrote:
                        > Terry,
                        >
                        > Is it acceptable to use a travel limit stop
                        > routinely to stop the
                        > travel? Or should the operators be told to stop the
                        > travel before it
                        > hits the stop?
                        >
                        > We don't know for sure, but it looks like the
                        > repeated collisions of
                        > the equipment with the stop may have damaged the
                        > stop and
                        > contributed to its being out of place.
                        >
                        > I'm still looking for more examples.
                        >
                        > T/c,
                        >
                        > Bill
                        >
                        > --- In
                        > Root_Cause_State_of_the_Practice@yahoogroups.com,
                        > "Terry
                        > Herrmann" <jherrmt@h...> wrote:
                        > > Bill,
                        > >
                        > > I guess it would all depend on whether the stop
                        > became loose and
                        > was
                        > > unnoticed or was intentionally bypassed.
                        > >
                        > > I've seen limit switches become loose over time
                        > and not perform
                        > their
                        > > function. In this case, I'd suggest connecting
                        > the travel stop so
                        > that it
                        > > does not allow the device to move at all unless
                        > it is in proper
                        > working
                        > > order.
                        > >
                        > > If it was intentionally bypassed (I've seen people
                        > do this with
                        > lawnmower
                        > > and snowblower engine cutouts that are intended to
                        > do what I'm
                        > suggesting
                        > > above), then you need an independent check by
                        > someone that doesn't
                        > benefit
                        > > from the time savings gained by bypassing the
                        > safety device
                        > followed up by
                        > > random observations. A good observation program
                        > has a number of
                        > benefits in
                        > > addition to this, but willful negligence is tough
                        > to overcome.
                        > You
                        > > esentially have to change the individual's
                        > perception of risk
                        > so "It's not
                        > > worth the time savings if I get caught."
                        > >
                        > > Terry Herrmann
                        > >
                        > >
                        > > From: "William R. Corcoran, Ph.D.,P.E."
                        > <firebird.one@a...>
                        > > Reply-To:
                        > Root_Cause_State_of_the_Practice@yahoogroups.com
                        > > To:
                        > Root_Cause_State_of_the_Practice@yahoogroups.com
                        > > Subject: [Root_Cause_State_of_the_Practice] Re:
                        > Using Safety
                        > Devices for
                        > > Operational Purposes: I need your help
                        > > Date: Sun, 11 Apr 2004 09:41:30 -0000
                        > >
                        > > Terry,
                        > >
                        > > The device was a physical travel limit stop. It
                        > was being used to
                        > > stop the travel of a piece of equipment day in and
                        > day out.
                        > >
                        > > One day the physical travel limit stop was out of
                        > position and the
                        > > piece of equipment kept going to cause damage to
                        > itself.
                        > >
                        > > I am looking for similar examples and generic
                        > avenues of corrective
                        > > actions.
                        > >
                        > > Thanks ever so much,
                        > >
                        > > Bill
                        > >
                        > > --- In
                        > Root_Cause_State_of_the_Practice@yahoogroups.com,
                        > "Terry
                        > > Herrmann" <jherrmt@h...> wrote:
                        > > > Dr. Bill,
                        > > >
                        > > > A little more information would be helpful.
                        > > >
                        > > > What type of safety device was this?
                        > > >
                        > > > How was it used in order to perform the
                        > evolution?
                        > > >
                        > > > What was the probability that an accident would
                        > occur if the
                        > > safety device
                        > > > were not used? (I'm wondering if it was REALLY
                        > used thousands of
                        > > times or
                        > > > just reported that way.)
                        > > >
                        > > > Was the action so conditioned as to be able to
                        > be performed
                        > > totally from
                        > > > memory without hardly thinking about it? (I'm
                        > trying to see if
                        > > we're talking
                        > > > about a skill-based or rule-based type of
                        > error)
                        > > >
                        > > > What was the perceived effort (burden) for
                        > using this device
                        > > rather than not
                        > > > use the device?
                        > > >
                        > > > How many times had the operator involved with
                        > the accident
                        > > performed the
                        > > > evolution correctly (as determined by
                        > observation)?
                        > > >
                        > > > I dislike offering initial thoughts towards
                        > corrective actions
                        > > without fully
                        > > > understanding the cause. "Jumping to cause"
                        > tends to create
                        > more
                        > > problems
                        > > > and tends to not solve the initial problem.
                        > > >
                        > > > Terry Herrmann
                        > > >
                        > > >
                        > > > From: "Dr. Bill Corcoran" <firebird.one@a...>
                        > > > Reply-To:
                        > Root_Cause_State_of_the_Practice@yahoogroups.com
                        > > > To:
                        > > >
                        > >
                        >
                        <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                        > > of_the_Practice_II"
                        > > >
                        >
                        <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                        > > > Subject: [Root_Cause_State_of_the_Practice]
                        > Using Safety Devices
                        > > for
                        > > > Operational Purposes: I need your help
                        > > > Date: Sat, 10 Apr 2004 10:34:12 -0400
                        > > >
                        > > > Colleague,
                        > > >
                        > > > I am investigating an event in which operators
                        > routinely used a
                        > > safety
                        > > > device for operational purposes.
                        > > >
                        > > > After thousands of successful evolutions there
                        > was an evolution
                        > in
                        > > which the
                        > > > safety device was in a by-passed condition.
                        > > >
                        > > > Of course, an accident occurred.
                        > > >
                        > > > Would you be so kind as to
                        > > > 1.. tell me your thoughts in this area,
                        > > > 2.. let me know what corrective actions come
                        > to mind, and
                        > > > 3.. give me any examples you can think of?
                        > > > Thanks ever so much.
                        > > >
                        > > > Take care,
                        > > >
                        > > > Bill Corcoran
                        > > >
                        > > > W. R. Corcoran, Ph.D., P.E.
                        > > > Nuclear Safety Review Concepts
                        > > > 21 Broadleaf Circle
                        > > > Windsor, CT 06095-1634
                        > > > 860-285-8779
                        > > > Mission: Saving lives, pain, assets, and
                        > careers
                        === message truncated ===


                        __________________________________
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                      • Dr. Bill Corcoran
                        Mike, Great lines of inquiry. I will be pulling those strings. Thanks ever so much. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review
                        Message 11 of 27 , Apr 12, 2004
                          Mike,

                          Great lines of inquiry.

                          I will be pulling those strings.

                          Thanks ever so much.

                          Take care,

                          Bill Corcoran

                          W. R. Corcoran, Ph.D., P.E.
                          Nuclear Safety Review Concepts
                          21 Broadleaf Circle
                          Windsor, CT 06095-1634
                          860-285-8779
                          Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                          Check out our e-groups at
                          http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                          where you will find the back issues of "The Firebird Forum" through 2003 and
                          at
                          http://groups.yahoo.com/group/DBRVH_LTBL_II/
                          where you will find a dialogue on the Davis-Besse near miss LOCA., including
                          photos, polls, files, tables, and links.

                          For a complimentary subscription to our e-newsletter on root cause,
                          organizational learning, and safety send a message to
                          firebird.one@...

                          ----- Original Message -----
                          From: "Michael Mulligan" <steamshovel2002@...>
                          To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                          Sent: Sunday, April 11, 2004 9:49 AM
                          Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                          Operational Purposes: I need your help


                          > Bill,
                          >
                          > How difficult was the installation of the stop. I'd be
                          > wondering if this was a typical way of the operator's
                          > dealing with problems -where did they learn that they
                          > can get away with it? Did they need help with another
                          > dept -with installing this device and a coordination
                          > problem? Was it a matter of operator skill or
                          > attention in controlling the equipment -or did the
                          > equipment inexplicably go out of control?
                          >
                          > mike
                          >
                          >
                          >
                          >
                          >
                          > --- "William R. Corcoran, Ph.D.,P.E."
                          > <firebird.one@...> wrote:
                          > > Terry,
                          > >
                          > > The device was a physical travel limit stop. It was
                          > > being used to
                          > > stop the travel of a piece of equipment day in and
                          > > day out.
                          > >
                          > > One day the physical travel limit stop was out of
                          > > position and the
                          > > piece of equipment kept going to cause damage to
                          > > itself.
                          > >
                          > > I am looking for similar examples and generic
                          > > avenues of corrective
                          > > actions.
                          > >
                          > > Thanks ever so much,
                          > >
                          > > Bill
                          > >
                          > > --- In
                          > > Root_Cause_State_of_the_Practice@yahoogroups.com,
                          > > "Terry
                          > > Herrmann" <jherrmt@h...> wrote:
                          > > > Dr. Bill,
                          > > >
                          > > > A little more information would be helpful.
                          > > >
                          > > > What type of safety device was this?
                          > > >
                          > > > How was it used in order to perform the evolution?
                          > > >
                          > > > What was the probability that an accident would
                          > > occur if the
                          > > safety device
                          > > > were not used? (I'm wondering if it was REALLY
                          > > used thousands of
                          > > times or
                          > > > just reported that way.)
                          > > >
                          > > > Was the action so conditioned as to be able to be
                          > > performed
                          > > totally from
                          > > > memory without hardly thinking about it? (I'm
                          > > trying to see if
                          > > we're talking
                          > > > about a skill-based or rule-based type of error)
                          > > >
                          > > > What was the perceived effort (burden) for using
                          > > this device
                          > > rather than not
                          > > > use the device?
                          > > >
                          > > > How many times had the operator involved with the
                          > > accident
                          > > performed the
                          > > > evolution correctly (as determined by
                          > > observation)?
                          > > >
                          > > > I dislike offering initial thoughts towards
                          > > corrective actions
                          > > without fully
                          > > > understanding the cause. "Jumping to cause" tends
                          > > to create more
                          > > problems
                          > > > and tends to not solve the initial problem.
                          > > >
                          > > > Terry Herrmann
                          > > >
                          > > >
                          > > > From: "Dr. Bill Corcoran" <firebird.one@a...>
                          > > > Reply-To:
                          > > Root_Cause_State_of_the_Practice@yahoogroups.com
                          > > > To:
                          > > >
                          > >
                          > <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                          > > of_the_Practice_II"
                          > > >
                          > >
                          > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                          > > > Subject: [Root_Cause_State_of_the_Practice] Using
                          > > Safety Devices
                          > > for
                          > > > Operational Purposes: I need your help
                          > > > Date: Sat, 10 Apr 2004 10:34:12 -0400
                          > > >
                          > > > Colleague,
                          > > >
                          > > > I am investigating an event in which operators
                          > > routinely used a
                          > > safety
                          > > > device for operational purposes.
                          > > >
                          > > > After thousands of successful evolutions there was
                          > > an evolution in
                          > > which the
                          > > > safety device was in a by-passed condition.
                          > > >
                          > > > Of course, an accident occurred.
                          > > >
                          > > > Would you be so kind as to
                          > > > 1.. tell me your thoughts in this area,
                          > > > 2.. let me know what corrective actions come to
                          > > mind, and
                          > > > 3.. give me any examples you can think of?
                          > > > Thanks ever so much.
                          > > >
                          > > > Take care,
                          > > >
                          > > > Bill Corcoran
                          > > >
                          > > > W. R. Corcoran, Ph.D., P.E.
                          > > > Nuclear Safety Review Concepts
                          > > > 21 Broadleaf Circle
                          > > > Windsor, CT 06095-1634
                          > > > 860-285-8779
                          > > > Mission: Saving lives, pain, assets, and careers
                          > > through
                          > > thoughtful inquiry.
                          > > >
                          > > > Check out our e-groups at
                          > > >
                          > >
                          > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                          > > > where you will find the back issues of "The
                          > > Firebird Forum"
                          > > through 2003 and
                          > > > at
                          > > > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                          > > > where you will find a dialogue on the Davis-Besse
                          > > near miss LOCA.,
                          > > including
                          > > > photos, polls, files, tables, and links.
                          > > >
                          > > > For a complimentary subscription to our
                          > > e-newsletter on root
                          > > cause,
                          > > > organizational learning, and safety send a message
                          > > to
                          > > > firebird.one@a...
                          > > >
                          > > >
                          > >
                          > _________________________________________________________________
                          > > > Get rid of annoying pop-up ads with the new MSN
                          > > Toolbar - FREE!
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                        • Terry Herrmann
                          Bill C., It would not be considered acceptable to use a travel limit stop as the braking device (assuming you have a braking device). The accepted design
                          Message 12 of 27 , Apr 12, 2004
                            Bill C.,

                            It would not be considered acceptable to use a travel limit stop as the
                            braking device (assuming you have a braking device). The accepted design
                            practice is to provide a visual cue for where to stop travel (line on the
                            floor, etc.) and then the travel limit stop is the safety device on the off
                            chance that the brake fails.

                            I'd first verify that the operators were able to stop the crane without
                            hitting the stop (i.e. the brake was in good working order and properly
                            adjusted). If not, then I'd focus on how the maintenance was prioritized.
                            If the brake works as intended, then I'd focus the investigation on what led
                            to the practice of using the travel stop. Is it a "We've always done it
                            that way." thing where it's become institutionalized without anyone even
                            knowing why or is it a more recent development?

                            Terry Herrmann


                            From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                            Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                            Operational Purposes: I need your help
                            Date: Sun, 11 Apr 2004 10:04:03 -0000

                            Terry,

                            Is it acceptable to use a travel limit stop routinely to stop the
                            travel? Or should the operators be told to stop the travel before it
                            hits the stop?

                            We don't know for sure, but it looks like the repeated collisions of
                            the equipment with the stop may have damaged the stop and
                            contributed to its being out of place.

                            I'm still looking for more examples.

                            T/c,

                            Bill

                            --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                            Herrmann" <jherrmt@h...> wrote:
                            > Bill,
                            >
                            > I guess it would all depend on whether the stop became loose and
                            was
                            > unnoticed or was intentionally bypassed.
                            >
                            > I've seen limit switches become loose over time and not perform
                            their
                            > function. In this case, I'd suggest connecting the travel stop so
                            that it
                            > does not allow the device to move at all unless it is in proper
                            working
                            > order.
                            >
                            > If it was intentionally bypassed (I've seen people do this with
                            lawnmower
                            > and snowblower engine cutouts that are intended to do what I'm
                            suggesting
                            > above), then you need an independent check by someone that doesn't
                            benefit
                            > from the time savings gained by bypassing the safety device
                            followed up by
                            > random observations. A good observation program has a number of
                            benefits in
                            > addition to this, but willful negligence is tough to overcome.
                            You
                            > esentially have to change the individual's perception of risk
                            so "It's not
                            > worth the time savings if I get caught."
                            >
                            > Terry Herrmann
                            >
                            >
                            > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                            > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                            Devices for
                            > Operational Purposes: I need your help
                            > Date: Sun, 11 Apr 2004 09:41:30 -0000
                            >
                            > Terry,
                            >
                            > The device was a physical travel limit stop. It was being used to
                            > stop the travel of a piece of equipment day in and day out.
                            >
                            > One day the physical travel limit stop was out of position and the
                            > piece of equipment kept going to cause damage to itself.
                            >
                            > I am looking for similar examples and generic avenues of corrective
                            > actions.
                            >
                            > Thanks ever so much,
                            >
                            > Bill
                            >
                            > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                            > Herrmann" <jherrmt@h...> wrote:
                            > > Dr. Bill,
                            > >
                            > > A little more information would be helpful.
                            > >
                            > > What type of safety device was this?
                            > >
                            > > How was it used in order to perform the evolution?
                            > >
                            > > What was the probability that an accident would occur if the
                            > safety device
                            > > were not used? (I'm wondering if it was REALLY used thousands of
                            > times or
                            > > just reported that way.)
                            > >
                            > > Was the action so conditioned as to be able to be performed
                            > totally from
                            > > memory without hardly thinking about it? (I'm trying to see if
                            > we're talking
                            > > about a skill-based or rule-based type of error)
                            > >
                            > > What was the perceived effort (burden) for using this device
                            > rather than not
                            > > use the device?
                            > >
                            > > How many times had the operator involved with the accident
                            > performed the
                            > > evolution correctly (as determined by observation)?
                            > >
                            > > I dislike offering initial thoughts towards corrective actions
                            > without fully
                            > > understanding the cause. "Jumping to cause" tends to create
                            more
                            > problems
                            > > and tends to not solve the initial problem.
                            > >
                            > > Terry Herrmann
                            > >
                            > >
                            > > From: "Dr. Bill Corcoran" <firebird.one@a...>
                            > > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            > > To:
                            > >
                            >
                            <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                            > of_the_Practice_II"
                            > > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                            > > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                            > for
                            > > Operational Purposes: I need your help
                            > > Date: Sat, 10 Apr 2004 10:34:12 -0400
                            > >
                            > > Colleague,
                            > >
                            > > I am investigating an event in which operators routinely used a
                            > safety
                            > > device for operational purposes.
                            > >
                            > > After thousands of successful evolutions there was an evolution
                            in
                            > which the
                            > > safety device was in a by-passed condition.
                            > >
                            > > Of course, an accident occurred.
                            > >
                            > > Would you be so kind as to
                            > > 1.. tell me your thoughts in this area,
                            > > 2.. let me know what corrective actions come to mind, and
                            > > 3.. give me any examples you can think of?
                            > > Thanks ever so much.
                            > >
                            > > Take care,
                            > >
                            > > Bill Corcoran
                            > >
                            > > W. R. Corcoran, Ph.D., P.E.
                            > > Nuclear Safety Review Concepts
                            > > 21 Broadleaf Circle
                            > > Windsor, CT 06095-1634
                            > > 860-285-8779
                            > > Mission: Saving lives, pain, assets, and careers through
                            > thoughtful inquiry.
                            > >
                            > > Check out our e-groups at
                            > > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                            > > where you will find the back issues of "The Firebird Forum"
                            > through 2003 and
                            > > at
                            > > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                            > > where you will find a dialogue on the Davis-Besse near miss
                            LOCA.,
                            > including
                            > > photos, polls, files, tables, and links.
                            > >
                            > > For a complimentary subscription to our e-newsletter on root
                            > cause,
                            > > organizational learning, and safety send a message to
                            > > firebird.one@a...
                            > >
                            > >
                            _________________________________________________________________
                            > > Get rid of annoying pop-up ads with the new MSN Toolbar � FREE!
                            > > http://toolbar.msn.com/go/onm00200414ave/direct/01/
                            >
                            > _________________________________________________________________
                            > Is your PC infected? Get a FREE online computer virus scan from
                            McAfee�
                            > Security. http://clinic.mcafee.com/clinic/ibuy/campaign.asp?
                            cid=3963

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                            and advice. http://gerd.msn.com/default.asp
                          • Dr. Bill Corcoran
                            Terry, That s very helpful. I think I ll recommend some visual cue for a safety zone next to the travel stop. The operators will be told not to move the
                            Message 13 of 27 , Apr 13, 2004
                              Terry,

                              That's very helpful.

                              I think I'll recommend some visual cue for a "safety zone" next to the
                              travel stop. The operators will be told not to move the equipment into that
                              zone unless 1) it is under positive control and 2) the travel stop has been
                              checked.

                              What do you think about the safety culture of using travel limit stops as
                              operational devices?

                              Take care,

                              Bill Corcoran

                              W. R. Corcoran, Ph.D., P.E.
                              Nuclear Safety Review Concepts
                              21 Broadleaf Circle
                              Windsor, CT 06095-1634
                              860-285-8779
                              Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                              Check out our e-groups at
                              http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                              where you will find the back issues of "The Firebird Forum" through 2003 and
                              at
                              http://groups.yahoo.com/group/DBRVH_LTBL_II/
                              where you will find a dialogue on the Davis-Besse near miss LOCA., including
                              photos, polls, files, tables, and links.

                              For a complimentary subscription to our e-newsletter on root cause,
                              organizational learning, and safety send a message to
                              firebird.one@...

                              ----- Original Message -----
                              From: "Terry Herrmann" <jherrmt@...>
                              To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                              Sent: Monday, April 12, 2004 5:32 PM
                              Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                              Operational Purposes: I need your help


                              > Bill C.,
                              >
                              > It would not be considered acceptable to use a travel limit stop as the
                              > braking device (assuming you have a braking device). The accepted design
                              > practice is to provide a visual cue for where to stop travel (line on the
                              > floor, etc.) and then the travel limit stop is the safety device on the
                              off
                              > chance that the brake fails.
                              >
                              > I'd first verify that the operators were able to stop the crane without
                              > hitting the stop (i.e. the brake was in good working order and properly
                              > adjusted). If not, then I'd focus on how the maintenance was prioritized.
                              > If the brake works as intended, then I'd focus the investigation on what
                              led
                              > to the practice of using the travel stop. Is it a "We've always done it
                              > that way." thing where it's become institutionalized without anyone even
                              > knowing why or is it a more recent development?
                              >
                              > Terry Herrmann
                              >
                              >
                              > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                              > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                              > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                              > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                              > Operational Purposes: I need your help
                              > Date: Sun, 11 Apr 2004 10:04:03 -0000
                              >
                              > Terry,
                              >
                              > Is it acceptable to use a travel limit stop routinely to stop the
                              > travel? Or should the operators be told to stop the travel before it
                              > hits the stop?
                              >
                              > We don't know for sure, but it looks like the repeated collisions of
                              > the equipment with the stop may have damaged the stop and
                              > contributed to its being out of place.
                              >
                              > I'm still looking for more examples.
                              >
                              > T/c,
                              >
                              > Bill
                              >
                              > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                              > Herrmann" <jherrmt@h...> wrote:
                              > > Bill,
                              > >
                              > > I guess it would all depend on whether the stop became loose and
                              > was
                              > > unnoticed or was intentionally bypassed.
                              > >
                              > > I've seen limit switches become loose over time and not perform
                              > their
                              > > function. In this case, I'd suggest connecting the travel stop so
                              > that it
                              > > does not allow the device to move at all unless it is in proper
                              > working
                              > > order.
                              > >
                              > > If it was intentionally bypassed (I've seen people do this with
                              > lawnmower
                              > > and snowblower engine cutouts that are intended to do what I'm
                              > suggesting
                              > > above), then you need an independent check by someone that doesn't
                              > benefit
                              > > from the time savings gained by bypassing the safety device
                              > followed up by
                              > > random observations. A good observation program has a number of
                              > benefits in
                              > > addition to this, but willful negligence is tough to overcome.
                              > You
                              > > esentially have to change the individual's perception of risk
                              > so "It's not
                              > > worth the time savings if I get caught."
                              > >
                              > > Terry Herrmann
                              > >
                              > >
                              > > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                              > > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                              > > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                              > > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                              > Devices for
                              > > Operational Purposes: I need your help
                              > > Date: Sun, 11 Apr 2004 09:41:30 -0000
                              > >
                              > > Terry,
                              > >
                              > > The device was a physical travel limit stop. It was being used to
                              > > stop the travel of a piece of equipment day in and day out.
                              > >
                              > > One day the physical travel limit stop was out of position and the
                              > > piece of equipment kept going to cause damage to itself.
                              > >
                              > > I am looking for similar examples and generic avenues of corrective
                              > > actions.
                              > >
                              > > Thanks ever so much,
                              > >
                              > > Bill
                              > >
                              > > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                              > > Herrmann" <jherrmt@h...> wrote:
                              > > > Dr. Bill,
                              > > >
                              > > > A little more information would be helpful.
                              > > >
                              > > > What type of safety device was this?
                              > > >
                              > > > How was it used in order to perform the evolution?
                              > > >
                              > > > What was the probability that an accident would occur if the
                              > > safety device
                              > > > were not used? (I'm wondering if it was REALLY used thousands of
                              > > times or
                              > > > just reported that way.)
                              > > >
                              > > > Was the action so conditioned as to be able to be performed
                              > > totally from
                              > > > memory without hardly thinking about it? (I'm trying to see if
                              > > we're talking
                              > > > about a skill-based or rule-based type of error)
                              > > >
                              > > > What was the perceived effort (burden) for using this device
                              > > rather than not
                              > > > use the device?
                              > > >
                              > > > How many times had the operator involved with the accident
                              > > performed the
                              > > > evolution correctly (as determined by observation)?
                              > > >
                              > > > I dislike offering initial thoughts towards corrective actions
                              > > without fully
                              > > > understanding the cause. "Jumping to cause" tends to create
                              > more
                              > > problems
                              > > > and tends to not solve the initial problem.
                              > > >
                              > > > Terry Herrmann
                              > > >
                              > > >
                              > > > From: "Dr. Bill Corcoran" <firebird.one@a...>
                              > > > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                              > > > To:
                              > > >
                              > >
                              > <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                              > > of_the_Practice_II"
                              > > > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                              > > > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                              > > for
                              > > > Operational Purposes: I need your help
                              > > > Date: Sat, 10 Apr 2004 10:34:12 -0400
                              > > >
                              > > > Colleague,
                              > > >
                              > > > I am investigating an event in which operators routinely used a
                              > > safety
                              > > > device for operational purposes.
                              > > >
                              > > > After thousands of successful evolutions there was an evolution
                              > in
                              > > which the
                              > > > safety device was in a by-passed condition.
                              > > >
                              > > > Of course, an accident occurred.
                              > > >
                              > > > Would you be so kind as to
                              > > > 1.. tell me your thoughts in this area,
                              > > > 2.. let me know what corrective actions come to mind, and
                              > > > 3.. give me any examples you can think of?
                              > > > Thanks ever so much.
                              > > >
                              > > > Take care,
                              > > >
                              > > > Bill Corcoran
                              > > >
                              > > > W. R. Corcoran, Ph.D., P.E.
                              > > > Nuclear Safety Review Concepts
                              > > > 21 Broadleaf Circle
                              > > > Windsor, CT 06095-1634
                              > > > 860-285-8779
                              > > > Mission: Saving lives, pain, assets, and careers through
                              > > thoughtful inquiry.
                              > > >
                              > > > Check out our e-groups at
                              > > > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                              > > > where you will find the back issues of "The Firebird Forum"
                              > > through 2003 and
                              > > > at
                              > > > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                              > > > where you will find a dialogue on the Davis-Besse near miss
                              > LOCA.,
                              > > including
                              > > > photos, polls, files, tables, and links.
                              > > >
                              > > > For a complimentary subscription to our e-newsletter on root
                              > > cause,
                              > > > organizational learning, and safety send a message to
                              > > > firebird.one@a...
                              > > >
                              > > >
                              > _________________________________________________________________
                              > > > Get rid of annoying pop-up ads with the new MSN Toolbar - FREE!
                              > > > http://toolbar.msn.com/go/onm00200414ave/direct/01/
                              > >
                              > > _________________________________________________________________
                              > > Is your PC infected? Get a FREE online computer virus scan from
                              > McAfee®
                              > > Security. http://clinic.mcafee.com/clinic/ibuy/campaign.asp?
                              > cid=3963
                              >
                              > _________________________________________________________________
                              > Persistent heartburn? Check out Digestive Health & Wellness for
                              information
                              > and advice. http://gerd.msn.com/default.asp
                              >
                              >
                              >
                              >
                              >
                              > Yahoo! Groups Links
                              >
                              >
                              >
                              >
                            • Noyes, Peter M.
                              Bill C., We have an overhead crane which has indicator lamps that light when you get to the end of the travel zone. A yellow lamp lights when you are near end
                              Message 14 of 27 , Apr 13, 2004
                                Bill C.,
                                 
                                We have an overhead crane which has indicator lamps that light when you get to the end of the travel zone.  A yellow lamp lights when you are near end of travel.  A red indicator lamp lights when you are at the end of travel.  There is also a travel stop, which is the final device.
                                 
                                This does not mean that our personnel never use the travel stop.  There are times when there may be a need to get a piece of equipment in that zone.  The operator uses the lights to get close , then jogs the crane the last final inches to the stop.  Although I have heard, and felt the crane hitting the hard stops.
                                 
                                Cranes need to be inspected on a periodic basis.  The travel stops should be an item on that inspection.
                                 
                                Peter
                                -----Original Message-----
                                From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                Sent: Tuesday, April 13, 2004 5:31 AM
                                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                Terry,

                                That's very helpful.

                                I think I'll recommend some visual cue for a "safety zone" next to the
                                travel stop. The operators will be told not to move the equipment into that
                                zone unless 1) it is under positive control and 2) the travel stop has been
                                checked.

                                What do you think about the safety culture of using travel limit stops as
                                operational devices?

                                Take care,

                                Bill Corcoran

                                W. R. Corcoran, Ph.D., P.E.
                                Nuclear Safety Review Concepts
                                21 Broadleaf Circle
                                Windsor, CT 06095-1634
                                860-285-8779
                                Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                Check out our e-groups  at
                                http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                where you will find the back issues of "The Firebird Forum" through 2003 and
                                at
                                http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                photos, polls, files, tables, and links.

                                For a complimentary subscription to our e-newsletter on root cause,
                                organizational learning, and safety send a message to
                                firebird.one@...

                                ----- Original Message -----
                                From: "Terry Herrmann" <jherrmt@...>
                                To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                Sent: Monday, April 12, 2004 5:32 PM
                                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                Operational Purposes: I need your help


                                > Bill C.,
                                >
                                > It would not be considered acceptable to use a travel limit stop as the
                                > braking device (assuming you have a braking device).  The accepted design
                                > practice is to provide a visual cue for where to stop travel (line on the
                                > floor, etc.) and then the travel limit stop is the safety device on the
                                off
                                > chance that the brake fails.
                                >
                                > I'd first verify that the operators were able to stop the crane without
                                > hitting the stop (i.e. the brake was in good working order and properly
                                > adjusted).  If not, then I'd focus on how the maintenance was prioritized.
                                > If the brake works as intended, then I'd focus the investigation on what
                                led
                                > to the practice of using the travel stop.  Is it a "We've always done it
                                > that way." thing where it's become institutionalized without anyone even
                                > knowing why or is it a more recent development?
                                >
                                > Terry Herrmann
                                >
                                >
                                > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                                > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                > Operational Purposes: I need your help
                                > Date: Sun, 11 Apr 2004 10:04:03 -0000
                                >
                                > Terry,
                                >
                                > Is it acceptable to use a travel limit stop routinely to stop the
                                > travel? Or should the operators be told to stop the travel before it
                                > hits the stop?
                                >
                                > We don't know for sure, but it looks like the repeated collisions of
                                > the equipment with the stop may have damaged the stop and
                                > contributed to its being out of place.
                                >
                                > I'm still looking for more examples.
                                >
                                > T/c,
                                >
                                > Bill
                                >
                                > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                > Herrmann" <jherrmt@h...> wrote:
                                >  > Bill,
                                >  >
                                >  > I guess it would all depend on whether the stop became loose and
                                > was
                                >  > unnoticed or was intentionally bypassed.
                                >  >
                                >  > I've seen limit switches become loose over time and not perform
                                > their
                                >  > function.  In this case, I'd suggest connecting the travel stop so
                                > that it
                                >  > does not allow the device to move at all  unless it is in proper
                                > working
                                >  > order.
                                >  >
                                >  > If it was intentionally bypassed (I've seen people do this with
                                > lawnmower
                                >  > and snowblower engine cutouts that are intended to do what I'm
                                > suggesting
                                >  > above), then you need an independent check by someone that doesn't
                                > benefit
                                >  > from the time savings gained by bypassing the safety device
                                > followed up by
                                >  > random observations.  A good observation program has a number of
                                > benefits in
                                >  > addition to this, but willful negligence is tough to overcome.
                                > You
                                >  > esentially have to change the individual's perception of risk
                                > so "It's not
                                >  > worth the time savings if I get caught."
                                >  >
                                >  > Terry Herrmann
                                >  >
                                >  >
                                >  > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                                >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                >  > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                >  > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                                > Devices for
                                >  > Operational Purposes: I need your help
                                >  > Date: Sun, 11 Apr 2004 09:41:30 -0000
                                >  >
                                >  > Terry,
                                >  >
                                >  > The device was a physical travel limit stop. It was being used to
                                >  > stop the travel of a piece of equipment day in and day out.
                                >  >
                                >  > One day the physical travel limit stop was out of position and the
                                >  > piece of equipment kept going to cause damage to itself.
                                >  >
                                >  > I am looking for similar examples and generic avenues of corrective
                                >  > actions.
                                >  >
                                >  > Thanks ever so much,
                                >  >
                                >  > Bill
                                >  >
                                >  > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                >  > Herrmann" <jherrmt@h...> wrote:
                                >  >  > Dr. Bill,
                                >  >  >
                                >  >  > A little more information would be helpful.
                                >  >  >
                                >  >  > What type of safety device was this?
                                >  >  >
                                >  >  > How was it used in order to perform the evolution?
                                >  >  >
                                >  >  > What was the probability that an accident would occur if the
                                >  > safety device
                                >  >  > were not used? (I'm wondering if it was REALLY used thousands of
                                >  > times or
                                >  >  > just reported that way.)
                                >  >  >
                                >  >  > Was the action so conditioned as to be able to be performed
                                >  > totally from
                                >  >  > memory without hardly thinking about it? (I'm trying to see if
                                >  > we're talking
                                >  >  > about a skill-based or rule-based type of error)
                                >  >  >
                                >  >  > What was the perceived effort (burden) for using this device
                                >  > rather than not
                                >  >  > use the device?
                                >  >  >
                                >  >  > How many times had the operator involved with the accident
                                >  > performed the
                                >  >  > evolution correctly (as determined by observation)?
                                >  >  >
                                >  >  > I dislike offering initial thoughts towards corrective actions
                                >  > without fully
                                >  >  > understanding the cause.  "Jumping to cause" tends to create
                                > more
                                >  > problems
                                >  >  > and tends to not solve the initial problem.
                                >  >  >
                                >  >  > Terry Herrmann
                                >  >  >
                                >  >  >
                                >  >  > From: "Dr. Bill Corcoran" <firebird.one@a...>
                                >  >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                >  >  > To:
                                >  >  >
                                >  >
                                > <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                                >  > of_the_Practice_II"
                                >  >  > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                                >  >  > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                                >  > for
                                >  >  > Operational Purposes: I need your help
                                >  >  > Date: Sat, 10 Apr 2004 10:34:12 -0400
                                >  >  >
                                >  >  > Colleague,
                                >  >  >
                                >  >  > I am investigating an event in which operators routinely used a
                                >  > safety
                                >  >  > device for operational purposes.
                                >  >  >
                                >  >  > After thousands of successful evolutions there was an evolution
                                > in
                                >  > which the
                                >  >  > safety device was in a by-passed condition.
                                >  >  >
                                >  >  > Of course, an accident occurred.
                                >  >  >
                                >  >  > Would you be so kind as to
                                >  >  >    1.. tell me your thoughts in this area,
                                >  >  >    2.. let me know what corrective actions come to mind, and
                                >  >  >    3.. give me any examples you can think of?
                                >  >  > Thanks ever so much.
                                >  >  >
                                >  >  > Take care,
                                >  >  >
                                >  >  > Bill Corcoran
                                >  >  >
                                >  >  > W. R. Corcoran, Ph.D., P.E.
                                >  >  > Nuclear Safety Review Concepts
                                >  >  > 21 Broadleaf Circle
                                >  >  > Windsor, CT 06095-1634
                                >  >  > 860-285-8779
                                >  >  > Mission: Saving lives, pain, assets, and careers through
                                >  > thoughtful inquiry.
                                >  >  >
                                >  >  > Check out our e-groups  at
                                >  >  > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                >  >  > where you will find the back issues of "The Firebird Forum"
                                >  > through 2003 and
                                >  >  > at
                                >  >  > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                >  >  > where you will find a dialogue on the Davis-Besse near miss
                                > LOCA.,
                                >  > including
                                >  >  > photos, polls, files, tables, and links.
                                >  >  >
                                >  >  > For a complimentary subscription to our e-newsletter on root
                                >  > cause,
                                >  >  > organizational learning, and safety send a message to
                                >  >  > firebird.one@a...
                                >  >  >
                                >  >  >
                                > _________________________________________________________________
                                >  >  > Get rid of annoying pop-up ads with the new MSN Toolbar - FREE!
                                >  >  > http://toolbar.msn.com/go/onm00200414ave/direct/01/
                                >  >
                                >  > _________________________________________________________________
                                >  > Is your PC infected? Get a FREE online computer virus scan from
                                > McAfee®
                                >  > Security. http://clinic.mcafee.com/clinic/ibuy/campaign.asp?
                                > cid=3963
                                >
                                > _________________________________________________________________
                                > Persistent heartburn? Check out Digestive Health & Wellness for
                                information
                                > and advice. http://gerd.msn.com/default.asp
                                >
                                >
                                >
                                >
                                >
                                > Yahoo! Groups Links
                                >
                                >
                                >
                                >





                              • Lawrence B. Durham
                                They re used on home (and, probably) woodworking equipment all the time - particularly saws and drill presses. Larry ... From: Dr. Bill Corcoran
                                Message 15 of 27 , Apr 13, 2004
                                  They're used on home (and, probably) woodworking equipment all the time -
                                  particularly saws and drill presses.

                                  Larry

                                  -----Original Message-----
                                  From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                  Sent: Tuesday, April 13, 2004 4:31 AM
                                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                  Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                  Operational Purposes: I need your help

                                  Terry,

                                  That's very helpful.

                                  I think I'll recommend some visual cue for a "safety zone" next to the
                                  travel stop. The operators will be told not to move the equipment into that
                                  zone unless 1) it is under positive control and 2) the travel stop has been
                                  checked.

                                  What do you think about the safety culture of using travel limit stops as
                                  operational devices?

                                  Take care,

                                  Bill Corcoran

                                  W. R. Corcoran, Ph.D., P.E.
                                  Nuclear Safety Review Concepts
                                  21 Broadleaf Circle
                                  Windsor, CT 06095-1634
                                  860-285-8779
                                  Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                  Check out our e-groups at
                                  http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                  where you will find the back issues of "The Firebird Forum" through 2003 and
                                  at
                                  http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                  where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                  photos, polls, files, tables, and links.

                                  For a complimentary subscription to our e-newsletter on root cause,
                                  organizational learning, and safety send a message to
                                  firebird.one@...

                                  ----- Original Message -----
                                  From: "Terry Herrmann" <jherrmt@...>
                                  To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                  Sent: Monday, April 12, 2004 5:32 PM
                                  Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                  Operational Purposes: I need your help


                                  > Bill C.,
                                  >
                                  > It would not be considered acceptable to use a travel limit stop as the
                                  > braking device (assuming you have a braking device). The accepted design
                                  > practice is to provide a visual cue for where to stop travel (line on the
                                  > floor, etc.) and then the travel limit stop is the safety device on the
                                  off
                                  > chance that the brake fails.
                                  >
                                  > I'd first verify that the operators were able to stop the crane without
                                  > hitting the stop (i.e. the brake was in good working order and properly
                                  > adjusted). If not, then I'd focus on how the maintenance was prioritized.
                                  > If the brake works as intended, then I'd focus the investigation on what
                                  led
                                  > to the practice of using the travel stop. Is it a "We've always done it
                                  > that way." thing where it's become institutionalized without anyone even
                                  > knowing why or is it a more recent development?
                                  >
                                  > Terry Herrmann
                                  >
                                  >
                                  > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                                  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                  > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                  > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                  > Operational Purposes: I need your help
                                  > Date: Sun, 11 Apr 2004 10:04:03 -0000
                                  >
                                  > Terry,
                                  >
                                  > Is it acceptable to use a travel limit stop routinely to stop the
                                  > travel? Or should the operators be told to stop the travel before it
                                  > hits the stop?
                                  >
                                  > We don't know for sure, but it looks like the repeated collisions of
                                  > the equipment with the stop may have damaged the stop and
                                  > contributed to its being out of place.
                                  >
                                  > I'm still looking for more examples.
                                  >
                                  > T/c,
                                  >
                                  > Bill
                                  >
                                  > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                  > Herrmann" <jherrmt@h...> wrote:
                                  > > Bill,
                                  > >
                                  > > I guess it would all depend on whether the stop became loose and
                                  > was
                                  > > unnoticed or was intentionally bypassed.
                                  > >
                                  > > I've seen limit switches become loose over time and not perform
                                  > their
                                  > > function. In this case, I'd suggest connecting the travel stop so
                                  > that it
                                  > > does not allow the device to move at all unless it is in proper
                                  > working
                                  > > order.
                                  > >
                                  > > If it was intentionally bypassed (I've seen people do this with
                                  > lawnmower
                                  > > and snowblower engine cutouts that are intended to do what I'm
                                  > suggesting
                                  > > above), then you need an independent check by someone that doesn't
                                  > benefit
                                  > > from the time savings gained by bypassing the safety device
                                  > followed up by
                                  > > random observations. A good observation program has a number of
                                  > benefits in
                                  > > addition to this, but willful negligence is tough to overcome.
                                  > You
                                  > > esentially have to change the individual's perception of risk
                                  > so "It's not
                                  > > worth the time savings if I get caught."
                                  > >
                                  > > Terry Herrmann
                                  > >
                                  > >
                                  > > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                                  > > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                  > > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                  > > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                                  > Devices for
                                  > > Operational Purposes: I need your help
                                  > > Date: Sun, 11 Apr 2004 09:41:30 -0000
                                  > >
                                  > > Terry,
                                  > >
                                  > > The device was a physical travel limit stop. It was being used to
                                  > > stop the travel of a piece of equipment day in and day out.
                                  > >
                                  > > One day the physical travel limit stop was out of position and the
                                  > > piece of equipment kept going to cause damage to itself.
                                  > >
                                  > > I am looking for similar examples and generic avenues of corrective
                                  > > actions.
                                  > >
                                  > > Thanks ever so much,
                                  > >
                                  > > Bill
                                  > >
                                  > > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                  > > Herrmann" <jherrmt@h...> wrote:
                                  > > > Dr. Bill,
                                  > > >
                                  > > > A little more information would be helpful.
                                  > > >
                                  > > > What type of safety device was this?
                                  > > >
                                  > > > How was it used in order to perform the evolution?
                                  > > >
                                  > > > What was the probability that an accident would occur if the
                                  > > safety device
                                  > > > were not used? (I'm wondering if it was REALLY used thousands of
                                  > > times or
                                  > > > just reported that way.)
                                  > > >
                                  > > > Was the action so conditioned as to be able to be performed
                                  > > totally from
                                  > > > memory without hardly thinking about it? (I'm trying to see if
                                  > > we're talking
                                  > > > about a skill-based or rule-based type of error)
                                  > > >
                                  > > > What was the perceived effort (burden) for using this device
                                  > > rather than not
                                  > > > use the device?
                                  > > >
                                  > > > How many times had the operator involved with the accident
                                  > > performed the
                                  > > > evolution correctly (as determined by observation)?
                                  > > >
                                  > > > I dislike offering initial thoughts towards corrective actions
                                  > > without fully
                                  > > > understanding the cause. "Jumping to cause" tends to create
                                  > more
                                  > > problems
                                  > > > and tends to not solve the initial problem.
                                  > > >
                                  > > > Terry Herrmann
                                  > > >
                                  > > >
                                  > > > From: "Dr. Bill Corcoran" <firebird.one@a...>
                                  > > > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                  > > > To:
                                  > > >
                                  > >
                                  > <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                                  > > of_the_Practice_II"
                                  > > > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                                  > > > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                                  > > for
                                  > > > Operational Purposes: I need your help
                                  > > > Date: Sat, 10 Apr 2004 10:34:12 -0400
                                  > > >
                                  > > > Colleague,
                                  > > >
                                  > > > I am investigating an event in which operators routinely used a
                                  > > safety
                                  > > > device for operational purposes.
                                  > > >
                                  > > > After thousands of successful evolutions there was an evolution
                                  > in
                                  > > which the
                                  > > > safety device was in a by-passed condition.
                                  > > >
                                  > > > Of course, an accident occurred.
                                  > > >
                                  > > > Would you be so kind as to
                                  > > > 1.. tell me your thoughts in this area,
                                  > > > 2.. let me know what corrective actions come to mind, and
                                  > > > 3.. give me any examples you can think of?
                                  > > > Thanks ever so much.
                                  > > >
                                  > > > Take care,
                                  > > >
                                  > > > Bill Corcoran
                                  > > >
                                  > > > W. R. Corcoran, Ph.D., P.E.
                                  > > > Nuclear Safety Review Concepts
                                  > > > 21 Broadleaf Circle
                                  > > > Windsor, CT 06095-1634
                                  > > > 860-285-8779
                                  > > > Mission: Saving lives, pain, assets, and careers through
                                  > > thoughtful inquiry.
                                  > > >
                                  > > > Check out our e-groups at
                                  > > > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                  > > > where you will find the back issues of "The Firebird Forum"
                                  > > through 2003 and
                                  > > > at
                                  > > > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                  > > > where you will find a dialogue on the Davis-Besse near miss
                                  > LOCA.,
                                  > > including
                                  > > > photos, polls, files, tables, and links.
                                  > > >
                                  > > > For a complimentary subscription to our e-newsletter on root
                                  > > cause,
                                  > > > organizational learning, and safety send a message to
                                  > > > firebird.one@a...
                                  > > >
                                  > > >
                                  > _________________________________________________________________
                                  > > > Get rid of annoying pop-up ads with the new MSN Toolbar - FREE!
                                  > > > http://toolbar.msn.com/go/onm00200414ave/direct/01/
                                  > >
                                  > > _________________________________________________________________
                                  > > Is your PC infected? Get a FREE online computer virus scan from
                                  > McAfeeR
                                  > > Security. http://clinic.mcafee.com/clinic/ibuy/campaign.asp?
                                  > cid=3963
                                  >
                                  > _________________________________________________________________
                                  > Persistent heartburn? Check out Digestive Health & Wellness for
                                  information
                                  > and advice. http://gerd.msn.com/default.asp
                                  >
                                  >
                                  >
                                  >
                                  >
                                  > Yahoo! Groups Links
                                  >
                                  >
                                  >
                                  >





                                  Yahoo! Groups Links
                                • Dr. Bill Corcoran
                                  Larry, What are the safety devices you are referring to? How are they used as operational controls? Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E.
                                  Message 16 of 27 , Apr 13, 2004
                                    Larry,
                                     
                                    What are the safety devices you are referring to?
                                    How are they used as operational controls?
                                     
                                    Take care,
                                     
                                    Bill Corcoran
                                     
                                    W. R. Corcoran, Ph.D., P.E.
                                    Nuclear Safety Review Concepts
                                    21 Broadleaf Circle
                                    Windsor, CT 06095-1634
                                    860-285-8779
                                    Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                     
                                    Check out our e-groups  at
                                    http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                    where you will find the back issues of "The Firebird Forum" through 2003 and at
                                    http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                    where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.
                                     
                                    For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...
                                    ----- Original Message -----
                                    Sent: Tuesday, April 13, 2004 9:27 AM
                                    Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                    They're used on home (and, probably) woodworking equipment all the time -
                                    particularly saws and drill presses.

                                    Larry

                                    -----Original Message-----
                                    From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                    Sent: Tuesday, April 13, 2004 4:31 AM
                                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                    Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                    Operational Purposes: I need your help

                                    Terry,

                                    That's very helpful.

                                    I think I'll recommend some visual cue for a "safety zone" next to the
                                    travel stop. The operators will be told not to move the equipment into that
                                    zone unless 1) it is under positive control and 2) the travel stop has been
                                    checked.

                                    What do you think about the safety culture of using travel limit stops as
                                    operational devices?

                                    Take care,

                                    Bill Corcoran

                                    W. R. Corcoran, Ph.D., P.E.
                                    Nuclear Safety Review Concepts
                                    21 Broadleaf Circle
                                    Windsor, CT 06095-1634
                                    860-285-8779
                                    Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                    Check out our e-groups  at
                                    http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                    where you will find the back issues of "The Firebird Forum" through 2003 and
                                    at
                                    http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                    where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                    photos, polls, files, tables, and links.

                                    For a complimentary subscription to our e-newsletter on root cause,
                                    organizational learning, and safety send a message to
                                    firebird.one@...

                                    ----- Original Message -----
                                    From: "Terry Herrmann" <jherrmt@...>
                                    To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                    Sent: Monday, April 12, 2004 5:32 PM
                                    Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                    Operational Purposes: I need your help


                                    > Bill C.,
                                    >
                                    > It would not be considered acceptable to use a travel limit stop as the
                                    > braking device (assuming you have a braking device).  The accepted design
                                    > practice is to provide a visual cue for where to stop travel (line on the
                                    > floor, etc.) and then the travel limit stop is the safety device on the
                                    off
                                    > chance that the brake fails.
                                    >
                                    > I'd first verify that the operators were able to stop the crane without
                                    > hitting the stop (i.e. the brake was in good working order and properly
                                    > adjusted).  If not, then I'd focus on how the maintenance was prioritized.
                                    > If the brake works as intended, then I'd focus the investigation on what
                                    led
                                    > to the practice of using the travel stop.  Is it a "We've always done it
                                    > that way." thing where it's become institutionalized without anyone even
                                    > knowing why or is it a more recent development?
                                    >
                                    > Terry Herrmann
                                    >
                                    >
                                    > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                                    > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                    > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                    > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                    > Operational Purposes: I need your help
                                    > Date: Sun, 11 Apr 2004 10:04:03 -0000
                                    >
                                    > Terry,
                                    >
                                    > Is it acceptable to use a travel limit stop routinely to stop the
                                    > travel? Or should the operators be told to stop the travel before it
                                    > hits the stop?
                                    >
                                    > We don't know for sure, but it looks like the repeated collisions of
                                    > the equipment with the stop may have damaged the stop and
                                    > contributed to its being out of place.
                                    >
                                    > I'm still looking for more examples.
                                    >
                                    > T/c,
                                    >
                                    > Bill
                                    >
                                    > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                    > Herrmann" <jherrmt@h...> wrote:
                                    >  > Bill,
                                    >  >
                                    >  > I guess it would all depend on whether the stop became loose and
                                    > was
                                    >  > unnoticed or was intentionally bypassed.
                                    >  >
                                    >  > I've seen limit switches become loose over time and not perform
                                    > their
                                    >  > function.  In this case, I'd suggest connecting the travel stop so
                                    > that it
                                    >  > does not allow the device to move at all  unless it is in proper
                                    > working
                                    >  > order.
                                    >  >
                                    >  > If it was intentionally bypassed (I've seen people do this with
                                    > lawnmower
                                    >  > and snowblower engine cutouts that are intended to do what I'm
                                    > suggesting
                                    >  > above), then you need an independent check by someone that doesn't
                                    > benefit
                                    >  > from the time savings gained by bypassing the safety device
                                    > followed up by
                                    >  > random observations.  A good observation program has a number of
                                    > benefits in
                                    >  > addition to this, but willful negligence is tough to overcome.
                                    > You
                                    >  > esentially have to change the individual's perception of risk
                                    > so "It's not
                                    >  > worth the time savings if I get caught."
                                    >  >
                                    >  > Terry Herrmann
                                    >  >
                                    >  >
                                    >  > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                                    >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                    >  > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                    >  > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                                    > Devices for
                                    >  > Operational Purposes: I need your help
                                    >  > Date: Sun, 11 Apr 2004 09:41:30 -0000
                                    >  >
                                    >  > Terry,
                                    >  >
                                    >  > The device was a physical travel limit stop. It was being used to
                                    >  > stop the travel of a piece of equipment day in and day out.
                                    >  >
                                    >  > One day the physical travel limit stop was out of position and the
                                    >  > piece of equipment kept going to cause damage to itself.
                                    >  >
                                    >  > I am looking for similar examples and generic avenues of corrective
                                    >  > actions.
                                    >  >
                                    >  > Thanks ever so much,
                                    >  >
                                    >  > Bill
                                    >  >
                                    >  > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                    >  > Herrmann" <jherrmt@h...> wrote:
                                    >  >  > Dr. Bill,
                                    >  >  >
                                    >  >  > A little more information would be helpful.
                                    >  >  >
                                    >  >  > What type of safety device was this?
                                    >  >  >
                                    >  >  > How was it used in order to perform the evolution?
                                    >  >  >
                                    >  >  > What was the probability that an accident would occur if the
                                    >  > safety device
                                    >  >  > were not used? (I'm wondering if it was REALLY used thousands of
                                    >  > times or
                                    >  >  > just reported that way.)
                                    >  >  >
                                    >  >  > Was the action so conditioned as to be able to be performed
                                    >  > totally from
                                    >  >  > memory without hardly thinking about it? (I'm trying to see if
                                    >  > we're talking
                                    >  >  > about a skill-based or rule-based type of error)
                                    >  >  >
                                    >  >  > What was the perceived effort (burden) for using this device
                                    >  > rather than not
                                    >  >  > use the device?
                                    >  >  >
                                    >  >  > How many times had the operator involved with the accident
                                    >  > performed the
                                    >  >  > evolution correctly (as determined by observation)?
                                    >  >  >
                                    >  >  > I dislike offering initial thoughts towards corrective actions
                                    >  > without fully
                                    >  >  > understanding the cause.  "Jumping to cause" tends to create
                                    > more
                                    >  > problems
                                    >  >  > and tends to not solve the initial problem.
                                    >  >  >
                                    >  >  > Terry Herrmann
                                    >  >  >
                                    >  >  >
                                    >  >  > From: "Dr. Bill Corcoran" <firebird.one@a...>
                                    >  >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                    >  >  > To:
                                    >  >  >
                                    >  >
                                    > <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                                    >  > of_the_Practice_II"
                                    >  >  > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                                    >  >  > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                                    >  > for
                                    >  >  > Operational Purposes: I need your help
                                    >  >  > Date: Sat, 10 Apr 2004 10:34:12 -0400
                                    >  >  >
                                    >  >  > Colleague,
                                    >  >  >
                                    >  >  > I am investigating an event in which operators routinely used a
                                    >  > safety
                                    >  >  > device for operational purposes.
                                    >  >  >
                                    >  >  > After thousands of successful evolutions there was an evolution
                                    > in
                                    >  > which the
                                    >  >  > safety device was in a by-passed condition.
                                    >  >  >
                                    >  >  > Of course, an accident occurred.
                                    >  >  >
                                    >  >  > Would you be so kind as to
                                    >  >  >    1.. tell me your thoughts in this area,
                                    >  >  >    2.. let me know what corrective actions come to mind, and
                                    >  >  >    3.. give me any examples you can think of?
                                    >  >  > Thanks ever so much.
                                    >  >  >
                                    >  >  > Take care,
                                    >  >  >
                                    >  >  > Bill Corcoran
                                    >  >  >
                                    >  >  > W. R. Corcoran, Ph.D., P.E.
                                    >  >  > Nuclear Safety Review Concepts
                                    >  >  > 21 Broadleaf Circle
                                    >  >  > Windsor, CT 06095-1634
                                    >  >  > 860-285-8779
                                    >  >  > Mission: Saving lives, pain, assets, and careers through
                                    >  > thoughtful inquiry.
                                    >  >  >
                                    >  >  > Check out our e-groups  at
                                    >  >  > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                    >  >  > where you will find the back issues of "The Firebird Forum"
                                    >  > through 2003 and
                                    >  >  > at
                                    >  >  > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                    >  >  > where you will find a dialogue on the Davis-Besse near miss
                                    > LOCA.,
                                    >  > including
                                    >  >  > photos, polls, files, tables, and links.
                                    >  >  >
                                    >  >  > For a complimentary subscription to our e-newsletter on root
                                    >  > cause,
                                    >  >  > organizational learning, and safety send a message to
                                    >  >  > firebird.one@a...
                                    >  >  >
                                    >  >  >
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                                  • Dr. Bill Corcoran
                                    Larry, It s a bigger problem than cranes. The problem is all on-site load movements. Take care, Bill Corcoran W. R. Corcoran, Ph.D., P.E. Nuclear Safety Review
                                    Message 17 of 27 , Apr 13, 2004
                                      Larry,
                                       
                                      It's a bigger problem than cranes.
                                       
                                      The problem is all on-site load movements.
                                       
                                      Take care,
                                       
                                      Bill Corcoran
                                       
                                      W. R. Corcoran, Ph.D., P.E.
                                      Nuclear Safety Review Concepts
                                      21 Broadleaf Circle
                                      Windsor, CT 06095-1634
                                      860-285-8779
                                      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                       
                                      Check out our e-groups  at
                                      http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                      where you will find the back issues of "The Firebird Forum" through 2003 and at
                                      http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                      where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.
                                       
                                      For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...
                                      ----- Original Message -----
                                      Sent: Tuesday, April 13, 2004 9:37 AM
                                      Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                      Based on further traffic on this issue, I will contribute that I have found crane training to be among the least attended to topics in nuclear power plants’ curricula.  In spite of Tech Spec requirements, it comes to be assumed almost as a “skill of the craft” function – sometimes even by auditors who should know better.  Your “incident” may yet have broader and deeper ramifications even though it’s not in a nuclear environment.  What about OSHA and ISO standards and procedures?

                                       

                                      LBD

                                       

                                      -----Original Message-----
                                      From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                      Sent: Sunday, April 11, 2004 4:33 AM
                                      To: Root_Cause_State_of_the_Practice@yahoogroups.com; Root_Cause_State_of_the_Practice_II
                                      Subject: Fw: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                       

                                      Larry,

                                       

                                      Thanks for your insights. The airline accident you are referring to is probably ValuJet 592. I don't recall it as involving using a safety device for operational purposes, but it did involve communications and it did involve safety devices.

                                       

                                      The venue for the safety device incident that prompted my request was not a nuclear power plant, but that probably doesn't matter.

                                       

                                      I am still scratching my head over why all of the people who knew that the safety device was being used for operational purposes didn't speak up. This is a teamwork issue if they realized what they were seeing.

                                       

                                      How many of us never turn off our headlights until after we have opened the driver's door and received the "headlights still on" warning light?

                                       

                                      Are there still people out there who house a crane hoist by actuating the two-block limit switch?

                                       

                                      Are there other examples of activities that challenge safety devices?

                                       

                                      Take care,

                                       

                                      Bill Corcoran

                                       

                                      W. R. Corcoran, Ph.D., P.E.
                                      Nuclear Safety Review Concepts
                                      21 Broadleaf Circle
                                      Windsor, CT 06095-1634
                                      860-285-8779
                                      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                       
                                      Check out our e-groups  at
                                      http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                      where you will find the back issues of "The Firebird Forum" through 2003 and at
                                      http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                      where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                                       

                                      For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                                      ----- Original Message -----

                                      Sent: Saturday, April 10, 2004 7:37 PM

                                      Subject: FW: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                       

                                      Bill,

                                       

                                      For some reason, I can’t mail out to the entire group as I tried to do.  You may forward this to whomever you wish if you wish.

                                       

                                      Best regards for a HAPPY EASTER!!!

                                       

                                      Larry

                                       

                                      -----Original Message-----
                                      From: Lawrence B. Durham [mailto:LBDurham@...]
                                      Sent: Saturday, April 10, 2004 6:03 PM
                                      To: Root_Cause_State_of_the_Practice@yahoogroups.com; 'Root_Cause_State_of_the_Practice_II'
                                      Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                       

                                      Bill, bear in mind that I’m watching the Masters’ Golf Tournament as I think about your questions and write this response.  I’ve seen some of the world’s best players muff shots like ones that they’ve made successfully literally thousands of times.  To my knowledge, the PGA won’t be kicking anyone out of the organization for those errors.  (Granted lives do not typically depend on golf shots.)  Each golf professional is more eager than anyone else to maintain and improve his (or her) game.  Hopefully, the operators are in an organizational environment that also doesn’t “go after” people who make mistakes and where individuals are self-motivated to constantly seek to improve and avoid mistakes.

                                       

                                      Nonetheless, an accident happened.  My first thoughts ran toward checking if, how, and when the relevant evolutions were included in pre-briefings and/or training exercises.  For years, I have shared with many folks the feeling that the nuclear industry is so attentive to the avoidance of abnormal conditions that it overlooks providing sufficient attention to reinforcing the proper execution of routine operating procedures.  My second wave of thought on this matter went to the realm of effective three-way communication.  Back to golf, top players ask their caddies for advice and feedback – both before and after their shots.  I don’t see much of that type of behavior among our nuclear workforce.  How was the intra-team communication in this case?

                                       

                                      As for suggested corrective actions, your hardest job in this case may be persuading plant management that it may not be a training problem.  Even though I have already suggested looking at the related training, please don’t mistake that question for my having jumped to the same conclusion – insufficient (and, maybe, inadequate) training.  Based on your sketch, it would seem that they had already demonstrated many times that they knew what to do and how to do it.  Thus, the question is why didn’t they do it as they had before?  Though I sound like an echo of you, I have to remind even you to “just ask them”.  Frankly, this sounds very much like a complacency and operational attitude situation.  I would respectfully suggest an environmental analysis of the organizational culture.  I would make a small wager that such an investigation would detect a number of other less-visible errors that have stayed “below the radar”.  You taught me too well to get me to “bite” on specific corrective action(s) absent further data.

                                      However, this one “feels” very much like a supervisory and, therefore, management problem that unfortunately manifested itself in a critical manner.  I would suggest that after the company is comfortable that the root causes have been identified that the cognizant manager and the directly-involved employee(s) should provide “lessons-learned” briefings to their associates throughout the plant and develop a case study for INPO dissemination.

                                       

                                      The best examples that come to mind were reported in the airline cases (poor communications and teamwork) reported out several years ago.  I don’t remember the specific reference, but I’ll bet you know it and probably have a copy.  (If so, please send the reference back to me.)  And, regrettably, it also has certain tones of the Davis-Besse inattention-to-detail, “business-as-usual” syndrome.  On a matter that I polled this network about last year, the realm of medical mistakes also offers all too many potential comparisons – from mis-filled prescriptions to amputating the wrong limbs to fatal anesthesia techniques.  And, finally, to return to my golfing analogy, rules and procedures that are typically followed so faithfully to avoid disqualification are, nonetheless, sometimes broken by top players who make stupid mistakes like not signing their cards after a completed round or by inadvertently moving a ball by not walking carefully in the woods as one looks for it after an errant shot.

                                       

                                      I hope that this helps.  As always, I would appreciate your assessment of my critique and observations and suggestions.  As more details are releasable, please share them and the course of action that is followed by the company.

                                       

                                      HAPPY EASTER!

                                       

                                      VR/LBD

                                       

                                       

                                      -----Original Message-----
                                      From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                      Sent: Saturday, April 10, 2004 9:34 AM
                                      To: Root_Cause_State_of_the_Practice@yahoogroups.com; Root_Cause_State_of_the_Practice_II
                                      Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                       

                                      Colleague,

                                       

                                      I am investigating an event in which operators routinely used a safety device for operational purposes.

                                       

                                      After thousands of successful evolutions there was an evolution in which the safety device was in a by-passed condition.

                                       

                                      Of course, an accident occurred.

                                       

                                      Would you be so kind as to

                                      1.      tell me your thoughts in this area,

                                      2.      let me know what corrective actions come to mind, and

                                      3.      give me any examples you can think of?

                                      Thanks ever so much.

                                       

                                      Take care,

                                       

                                      Bill Corcoran

                                       

                                      W. R. Corcoran, Ph.D., P.E.
                                      Nuclear Safety Review Concepts
                                      21 Broadleaf Circle
                                      Windsor, CT 06095-1634
                                      860-285-8779
                                      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                       
                                      Check out our e-groups  at
                                      http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                      where you will find the back issues of "The Firebird Forum" through 2003 and at
                                      http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                      where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                                       

                                      For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                                       

                                       



                                    • Lawrence B. Durham
                                      Collars around drill bits prevent deeper penetration than intended. They are close to or identical to the diameter of the bit and are tightened in place by a
                                      Message 18 of 27 , Apr 13, 2004

                                        Collars around drill bits prevent deeper penetration than intended.  They are close to or identical to the diameter of the bit and are tightened in place by a set screw (typically with an Allen wrench).  Routers can have similar governing devices both in terms of depth and distance from an edge to the material being routed.  Table saws can have stops to prevent the circular blades from being elevated too high (from underneath the table surface) and thereby preventing contact between the blade and the table.  They and routers also have width “stops” or guides that control cutting dimensions.  Saws regularly have plastic blade enclosures that “give” as the work passes through the blade.  And, a variety of switch covers, “hold-ins” and “hold-downs” are used to control the position of the material being cut.  (Visit either a Home Depot or a Lowe’s store to see these devices being employed to custom cut material for customers.) 

                                         

                                        Lathe tools (similar to chisels) also frequently have hard (or, sometimes, soft like tape) collars placed at desired penetration depths to prevent deeper cuts than intended.  And, my bandsaw has a recessed blade the housing for which prevents my fingers from accidentally hitting the blade.  Even primitive (and modern) wood planes can be outfitted with guides and “stops” of sorts to assure safety and dimensional control.  Grinders and emery wheels typically have both guide bars for resting the tool or material being worked on and shields to deflect the particles downward away from the operator.

                                         

                                        Granted, these are primarily dimension guides (except for keeping the saw blade from hitting the table and the particles away from the grinder operator); however, they are commonly used aides in doing the job right the first time.  Measure twice; cut once.  While I’m more familiar with the use of hand tools, I can’t imagine that machine shops don’t use these and other similar devices and techniques on a routine basis.  The use of such devices dates back at least to the European craft guilds – probably much farther.  (There’s even such a thing as a “hammer shield” – a “V” cut strip with an elevated handle to protect both the surface being nailed into and the “other hand” not wielding the hammer!)

                                         

                                        Different scale equipment, but the same principles apply.  Hope this helps.

                                         

                                        Larry

                                         

                                         

                                         

                                        -----Original Message-----
                                        From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                        Sent: Tuesday, April 13, 2004 8:46 AM
                                        To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                        Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                         

                                        Larry,

                                         

                                        What are the safety devices you are referring to?

                                        How are they used as operational controls?

                                         

                                        Take care,

                                         

                                        Bill Corcoran

                                         

                                        W. R. Corcoran, Ph.D., P.E.
                                        Nuclear Safety Review Concepts
                                        21 Broadleaf Circle
                                        Windsor, CT 06095-1634
                                        860-285-8779
                                        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                         
                                        Check out our e-groups  at
                                        http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                        where you will find the back issues of "The Firebird Forum" through 2003 and at
                                        http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                        where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                                         

                                        For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                                        ----- Original Message -----

                                        Sent: Tuesday, April 13, 2004 9:27 AM

                                        Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                         

                                        They're used on home (and, probably) woodworking equipment all the time -
                                        particularly saws and drill presses.

                                        Larry

                                        -----Original Message-----
                                        From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                        Sent: Tuesday, April 13, 2004 4:31 AM
                                        To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                        Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                        Operational Purposes: I need your help

                                        Terry,

                                        That's very helpful.

                                        I think I'll recommend some visual cue for a "safety zone" next to the
                                        travel stop. The operators will be told not to move the equipment into that
                                        zone unless 1) it is under positive control and 2) the travel stop has been
                                        checked.

                                        What do you think about the safety culture of using travel limit stops as
                                        operational devices?

                                        Take care,

                                        Bill Corcoran

                                        W. R. Corcoran, Ph.D., P.E.
                                        Nuclear Safety Review Concepts
                                        21 Broadleaf Circle
                                        Windsor, CT 06095-1634
                                        860-285-8779
                                        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                        Check out our e-groups  at
                                        http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                        where you will find the back issues of "The Firebird Forum" through 2003 and
                                        at
                                        http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                        where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                        photos, polls, files, tables, and links.

                                        For a complimentary subscription to our e-newsletter on root cause,
                                        organizational learning, and safety send a message to
                                        firebird.one@...

                                        ----- Original Message -----
                                        From: "Terry Herrmann" <jherrmt@...>
                                        To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                        Sent: Monday, April 12, 2004 5:32 PM
                                        Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                        Operational Purposes: I need your help


                                        > Bill C.,
                                        >
                                        > It would not be considered acceptable to use a travel limit stop as the
                                        > braking device (assuming you have a braking device).  The accepted design
                                        > practice is to provide a visual cue for where to stop travel (line on the
                                        > floor, etc.) and then the travel limit stop is the safety device on the
                                        off
                                        > chance that the brake fails.
                                        >
                                        > I'd first verify that the operators were able to stop the crane without
                                        > hitting the stop (i.e. the brake was in good working order and properly
                                        > adjusted).  If not, then I'd focus on how the maintenance was prioritized.
                                        > If the brake works as intended, then I'd focus the investigation on what
                                        led
                                        > to the practice of using the travel stop.  Is it a "We've always done it
                                        > that way." thing where it's become institutionalized without anyone even
                                        > knowing why or is it a more recent development?
                                        >
                                        > Terry Herrmann
                                        >
                                        >
                                        > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                                        > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                        > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                        > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                        > Operational Purposes: I need your help
                                        > Date: Sun, 11 Apr 2004 10:04:03 -0000
                                        >
                                        > Terry,
                                        >
                                        > Is it acceptable to use a travel limit stop routinely to stop the
                                        > travel? Or should the operators be told to stop the travel before it
                                        > hits the stop?
                                        >
                                        > We don't know for sure, but it looks like the repeated collisions of
                                        > the equipment with the stop may have damaged the stop and
                                        > contributed to its being out of place.
                                        >
                                        > I'm still looking for more examples.
                                        >
                                        > T/c,
                                        >
                                        > Bill
                                        >
                                        > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                        > Herrmann" <jherrmt@h...> wrote:
                                        >  > Bill,
                                        >  >
                                        >  > I guess it would all depend on whether the stop became loose and
                                        > was
                                        >  > unnoticed or was intentionally bypassed.
                                        >  >
                                        >  > I've seen limit switches become loose over time and not perform
                                        > their
                                        >  > function.  In this case, I'd suggest connecting the travel stop so
                                        > that it
                                        >  > does not allow the device to move at all  unless it is in proper
                                        > working
                                        >  > order.
                                        >  >
                                        >  > If it was intentionally bypassed (I've seen people do this with
                                        > lawnmower
                                        >  > and snowblower engine cutouts that are intended to do what I'm
                                        > suggesting
                                        >  > above), then you need an independent check by someone that doesn't
                                        > benefit
                                        >  > from the time savings gained by bypassing the safety device
                                        > followed up by
                                        >  > random observations.  A good observation program has a number of
                                        > benefits in
                                        >  > addition to this, but willful negligence is tough to overcome.
                                        > You
                                        >  > esentially have to change the individual's perception of risk
                                        > so "It's not
                                        >  > worth the time savings if I get caught."
                                        >  >
                                        >  > Terry Herrmann
                                        >  >
                                        >  >
                                        >  > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                                        >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                        >  > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                        >  > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                                        > Devices for
                                        >  > Operational Purposes: I need your help
                                        >  > Date: Sun, 11 Apr 2004 09:41:30 -0000
                                        >  >
                                        >  > Terry,
                                        >  >
                                        >  > The device was a physical travel limit stop. It was being used to
                                        >  > stop the travel of a piece of equipment day in and day out.
                                        >  >
                                        >  > One day the physical travel limit stop was out of position and the
                                        >  > piece of equipment kept going to cause damage to itself.
                                        >  >
                                        >  > I am looking for similar examples and generic avenues of corrective
                                        >  > actions.
                                        >  >
                                        >  > Thanks ever so much,
                                        >  >
                                        >  > Bill
                                        >  >
                                        >  > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                        >  > Herrmann" <jherrmt@h...> wrote:
                                        >  >  > Dr. Bill,
                                        >  >  >
                                        >  >  > A little more information would be helpful.
                                        >  >  >
                                        >  >  > What type of safety device was this?
                                        >  >  >
                                        >  >  > How was it used in order to perform the evolution?
                                        >  >  >
                                        >  >  > What was the probability that an accident would occur if the
                                        >  > safety device
                                        >  >  > were not used? (I'm wondering if it was REALLY used thousands of
                                        >  > times or
                                        >  >  > just reported that way.)
                                        >  >  >
                                        >  >  > Was the action so conditioned as to be able to be performed
                                        >  > totally from
                                        >  >  > memory without hardly thinking about it? (I'm trying to see if
                                        >  > we're talking
                                        >  >  > about a skill-based or rule-based type of error)
                                        >  >  >
                                        >  >  > What was the perceived effort (burden) for using this device
                                        >  > rather than not
                                        >  >  > use the device?
                                        >  >  >
                                        >  >  > How many times had the operator involved with the accident
                                        >  > performed the
                                        >  >  > evolution correctly (as determined by observation)?
                                        >  >  >
                                        >  >  > I dislike offering initial thoughts towards corrective actions
                                        >  > without fully
                                        >  >  > understanding the cause.  "Jumping to cause" tends to create
                                        > more
                                        >  > problems
                                        >  >  > and tends to not solve the initial problem.
                                        >  >  >
                                        >  >  > Terry Herrmann
                                        >  >  >
                                        >  >  >
                                        >  >  > From: "Dr. Bill Corcoran" <firebird.one@a...>
                                        >  >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                        >  >  > To:
                                        >  >  >
                                        >  >
                                        > <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                                        >  > of_the_Practice_II"
                                        >  >  > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                                        >  >  > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                                        >  > for
                                        >  >  > Operational Purposes: I need your help
                                        >  >  > Date: Sat, 10 Apr 2004 10:34:12 -0400
                                        >  >  >
                                        >  >  > Colleague,
                                        >  >  >
                                        >  >  > I am investigating an event in which operators routinely used a
                                        >  > safety
                                        >  >  > device for operational purposes.
                                        >  >  >
                                        >  >  > After thousands of successful evolutions there was an evolution
                                        > in
                                        >  > which the
                                        >  >  > safety device was in a by-passed condition.
                                        >  >  >
                                        >  >  > Of course, an accident occurred.
                                        >  >  >
                                        >  >  > Would you be so kind as to
                                        >  >  >    1.. tell me your thoughts in this area,
                                        >  >  >    2.. let me know what corrective actions come to mind, and
                                        >  >  >    3.. give me any examples you can think of?
                                        >  >  > Thanks ever so much.
                                        >  >  >
                                        >  >  > Take care,
                                        >  >  >
                                        >  >  > Bill Corcoran
                                        >  >  >
                                        >  >  > W. R. Corcoran, Ph.D., P.E.
                                        >  >  > Nuclear Safety Review Concepts
                                        >  >  > 21 Broadleaf Circle
                                        >  >  > Windsor, CT 06095-1634
                                        >  >  > 860-285-8779
                                        >  >  > Mission: Saving lives, pain, assets, and careers through
                                        >  > thoughtful inquiry.
                                        >  >  >
                                        >  >  > Check out our e-groups  at
                                        >  >  > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                        >  >  > where you will find the back issues of "The Firebird Forum"
                                        >  > through 2003 and
                                        >  >  > at
                                        >  >  > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                        >  >  > where you will find a dialogue on the Davis-Besse near miss
                                        > LOCA.,
                                        >  > including
                                        >  >  > photos, polls, files, tables, and links.
                                        >  >  >
                                        >  >  > For a complimentary subscription to our e-newsletter on root
                                        >  > cause,
                                        >  >  > organizational learning, and safety send a message to
                                        >  >  > firebird.one@a...
                                        >  >  >
                                        >  >  >
                                        > _________________________________________________________________
                                        >  >  > Get rid of annoying pop-up ads with the new MSN Toolbar - FREE!
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                                        > McAfeeR
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                                      • Lawrence B. Durham
                                        That s why in my first response I suggested that the issue(s) transcended the manifestations of problems. The more I hear on this matter, the more I suspect a
                                        Message 19 of 27 , Apr 13, 2004

                                          That’s why in my first response I suggested that the issue(s) transcended the manifestations of problems.  The more I hear on this matter, the more I suspect a lax safety attitude site-wide.  And, of course, that has its “root cause” in the front office not on the shop floor or in the site yard spaces.  Depending on the situation, this could even be a corporate culture problem and, perhaps, related work scheduling pressure demands that could be emanating from marketing.  I’ve seen marketing pressure quality control pressure production in a plant start-up of a chemical fiber plant.  Our Process Assistance Group had to detect it and step in to mediate solutions acceptable to all parties.  That one was complicated by the construction group’s wanting to turn the plant over to manufacturing before QC would agree that the product was within design specs.  Fun!

                                           

                                          Am I too far afield?  Maybe; maybe not.

                                           

                                          VR/ Larry

                                           

                                          -----Original Message-----
                                          From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                          Sent: Tuesday, April 13, 2004 9:22 AM
                                          To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                          Subject: Re: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                           

                                          Larry,

                                           

                                          It's a bigger problem than cranes.

                                           

                                          The problem is all on-site load movements.

                                           

                                          Take care,

                                           

                                          Bill Corcoran

                                           

                                          W. R. Corcoran, Ph.D., P.E.
                                          Nuclear Safety Review Concepts
                                          21 Broadleaf Circle
                                          Windsor, CT 06095-1634
                                          860-285-8779
                                          Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                           
                                          Check out our e-groups  at
                                          http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                          where you will find the back issues of "The Firebird Forum" through 2003 and at
                                          http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                          where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                                           

                                          For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                                          ----- Original Message -----

                                          Sent: Tuesday, April 13, 2004 9:37 AM

                                          Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                           

                                          Based on further traffic on this issue, I will contribute that I have found crane training to be among the least attended to topics in nuclear power plants’ curricula.  In spite of Tech Spec requirements, it comes to be assumed almost as a “skill of the craft” function – sometimes even by auditors who should know better.  Your “incident” may yet have broader and deeper ramifications even though it’s not in a nuclear environment.  What about OSHA and ISO standards and procedures?

                                           

                                          LBD

                                           

                                          -----Original Message-----
                                          From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                          Sent: Sunday, April 11, 2004 4:33 AM
                                          To: Root_Cause_State_of_the_Practice@yahoogroups.com; Root_Cause_State_of_the_Practice_II
                                          Subject: Fw: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                           

                                          Larry,

                                           

                                          Thanks for your insights. The airline accident you are referring to is probably ValuJet 592. I don't recall it as involving using a safety device for operational purposes, but it did involve communications and it did involve safety devices.

                                           

                                          The venue for the safety device incident that prompted my request was not a nuclear power plant, but that probably doesn't matter.

                                           

                                          I am still scratching my head over why all of the people who knew that the safety device was being used for operational purposes didn't speak up. This is a teamwork issue if they realized what they were seeing.

                                           

                                          How many of us never turn off our headlights until after we have opened the driver's door and received the "headlights still on" warning light?

                                           

                                          Are there still people out there who house a crane hoist by actuating the two-block limit switch?

                                           

                                          Are there other examples of activities that challenge safety devices?

                                           

                                          Take care,

                                           

                                          Bill Corcoran

                                           

                                          W. R. Corcoran, Ph.D., P.E.
                                          Nuclear Safety Review Concepts
                                          21 Broadleaf Circle
                                          Windsor, CT 06095-1634
                                          860-285-8779
                                          Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                           
                                          Check out our e-groups  at
                                          http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                          where you will find the back issues of "The Firebird Forum" through 2003 and at
                                          http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                          where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                                           

                                          For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                                          ----- Original Message -----

                                          Sent: Saturday, April 10, 2004 7:37 PM

                                          Subject: FW: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                           

                                          Bill,

                                           

                                          For some reason, I can’t mail out to the entire group as I tried to do.  You may forward this to whomever you wish if you wish.

                                           

                                          Best regards for a HAPPY EASTER!!!

                                           

                                          Larry

                                           

                                          -----Original Message-----
                                          From: Lawrence B. Durham [mailto:LBDurham@...]
                                          Sent: Saturday, April 10, 2004 6:03 PM
                                          To: Root_Cause_State_of_the_Practice@yahoogroups.com; 'Root_Cause_State_of_the_Practice_II'
                                          Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                           

                                          Bill, bear in mind that I’m watching the Masters’ Golf Tournament as I think about your questions and write this response.  I’ve seen some of the world’s best players muff shots like ones that they’ve made successfully literally thousands of times.  To my knowledge, the PGA won’t be kicking anyone out of the organization for those errors.  (Granted lives do not typically depend on golf shots.)  Each golf professional is more eager than anyone else to maintain and improve his (or her) game.  Hopefully, the operators are in an organizational environment that also doesn’t “go after” people who make mistakes and where individuals are self-motivated to constantly seek to improve and avoid mistakes.

                                           

                                          Nonetheless, an accident happened.  My first thoughts ran toward checking if, how, and when the relevant evolutions were included in pre-briefings and/or training exercises.  For years, I have shared with many folks the feeling that the nuclear industry is so attentive to the avoidance of abnormal conditions that it overlooks providing sufficient attention to reinforcing the proper execution of routine operating procedures.  My second wave of thought on this matter went to the realm of effective three-way communication.  Back to golf, top players ask their caddies for advice and feedback – both before and after their shots.  I don’t see much of that type of behavior among our nuclear workforce.  How was the intra-team communication in this case?

                                           

                                          As for suggested corrective actions, your hardest job in this case may be persuading plant management that it may not be a training problem.  Even though I have already suggested looking at the related training, please don’t mistake that question for my having jumped to the same conclusion – insufficient (and, maybe, inadequate) training.  Based on your sketch, it would seem that they had already demonstrated many times that they knew what to do and how to do it.  Thus, the question is why didn’t they do it as they had before?  Though I sound like an echo of you, I have to remind even you to “just ask them”.  Frankly, this sounds very much like a complacency and operational attitude situation.  I would respectfully suggest an environmental analysis of the organizational culture.  I would make a small wager that such an investigation would detect a number of other less-visible errors that have stayed “below the radar”.  You taught me too well to get me to “bite” on specific corrective action(s) absent further data.

                                          However, this one “feels” very much like a supervisory and, therefore, management problem that unfortunately manifested itself in a critical manner.  I would suggest that after the company is comfortable that the root causes have been identified that the cognizant manager and the directly-involved employee(s) should provide “lessons-learned” briefings to their associates throughout the plant and develop a case study for INPO dissemination.

                                           

                                          The best examples that come to mind were reported in the airline cases (poor communications and teamwork) reported out several years ago.  I don’t remember the specific reference, but I’ll bet you know it and probably have a copy.  (If so, please send the reference back to me.)  And, regrettably, it also has certain tones of the Davis-Besse inattention-to-detail, “business-as-usual” syndrome.  On a matter that I polled this network about last year, the realm of medical mistakes also offers all too many potential comparisons – from mis-filled prescriptions to amputating the wrong limbs to fatal anesthesia techniques.  And, finally, to return to my golfing analogy, rules and procedures that are typically followed so faithfully to avoid disqualification are, nonetheless, sometimes broken by top players who make stupid mistakes like not signing their cards after a completed round or by inadvertently moving a ball by not walking carefully in the woods as one looks for it after an errant shot.

                                           

                                          I hope that this helps.  As always, I would appreciate your assessment of my critique and observations and suggestions.  As more details are releasable, please share them and the course of action that is followed by the company.

                                           

                                          HAPPY EASTER!

                                           

                                          VR/LBD

                                           

                                           

                                          -----Original Message-----
                                          From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                          Sent: Saturday, April 10, 2004 9:34 AM
                                          To: Root_Cause_State_of_the_Practice@yahoogroups.com; Root_Cause_State_of_the_Practice_II
                                          Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices for Operational Purposes: I need your help

                                           

                                          Colleague,

                                           

                                          I am investigating an event in which operators routinely used a safety device for operational purposes.

                                           

                                          After thousands of successful evolutions there was an evolution in which the safety device was in a by-passed condition.

                                           

                                          Of course, an accident occurred.

                                           

                                          Would you be so kind as to

                                          1.      tell me your thoughts in this area,

                                          2.      let me know what corrective actions come to mind, and

                                          3.      give me any examples you can think of?

                                          Thanks ever so much.

                                           

                                          Take care,

                                           

                                          Bill Corcoran

                                           

                                          W. R. Corcoran, Ph.D., P.E.
                                          Nuclear Safety Review Concepts
                                          21 Broadleaf Circle
                                          Windsor, CT 06095-1634
                                          860-285-8779
                                          Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                           
                                          Check out our e-groups  at
                                          http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                          where you will find the back issues of "The Firebird Forum" through 2003 and at
                                          http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                          where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                                           

                                          For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                                           

                                           

                                           

                                           

                                        • Dr. Bill Corcoran
                                          Larry, In a sense you are right. A travel stop is a travel stop. But all travel stops are not created equal. The ones I am concerned with are intended to
                                          Message 20 of 27 , Apr 13, 2004
                                            Larry,
                                             
                                            In a sense you are right. A travel stop is a travel stop.
                                             
                                            But all travel stops are not created equal.
                                             
                                            The ones I am concerned with are intended to protect people.
                                             
                                            They may protect other things as well, but they are personnel safety devices.
                                             
                                            In an FMEA involving these devices one of the effects of a failure would be personnel injury.
                                             
                                            In a barrier analysis of these devices one of the "targets" would be people and the "threats" would include "impact," "collision," or the like.
                                             
                                            Take care,
                                             
                                            Bill Corcoran
                                             
                                            W. R. Corcoran, Ph.D., P.E.
                                            Nuclear Safety Review Concepts
                                            21 Broadleaf Circle
                                            Windsor, CT 06095-1634
                                            860-285-8779
                                            Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                             
                                            Check out our e-groups  at
                                            http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                            where you will find the back issues of "The Firebird Forum" through 2003 and at
                                            http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                            where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.
                                             
                                            For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...
                                            ----- Original Message -----
                                            Sent: Tuesday, April 13, 2004 11:22 AM
                                            Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                            Collars around drill bits prevent deeper penetration than intended.  They are close to or identical to the diameter of the bit and are tightened in place by a set screw (typically with an Allen wrench).  Routers can have similar governing devices both in terms of depth and distance from an edge to the material being routed.  Table saws can have stops to prevent the circular blades from being elevated too high (from underneath the table surface) and thereby preventing contact between the blade and the table.  They and routers also have width “stops” or guides that control cutting dimensions.  Saws regularly have plastic blade enclosures that “give” as the work passes through the blade.  And, a variety of switch covers, “hold-ins” and “hold-downs” are used to control the position of the material being cut.  (Visit either a Home Depot or a Lowe’s store to see these devices being employed to custom cut material for customers.) 

                                             

                                            Lathe tools (similar to chisels) also frequently have hard (or, sometimes, soft like tape) collars placed at desired penetration depths to prevent deeper cuts than intended.  And, my bandsaw has a recessed blade the housing for which prevents my fingers from accidentally hitting the blade.  Even primitive (and modern) wood planes can be outfitted with guides and “stops” of sorts to assure safety and dimensional control.  Grinders and emery wheels typically have both guide bars for resting the tool or material being worked on and shields to deflect the particles downward away from the operator.

                                             

                                            Granted, these are primarily dimension guides (except for keeping the saw blade from hitting the table and the particles away from the grinder operator); however, they are commonly used aides in doing the job right the first time.  Measure twice; cut once.  While I’m more familiar with the use of hand tools, I can’t imagine that machine shops don’t use these and other similar devices and techniques on a routine basis.  The use of such devices dates back at least to the European craft guilds – probably much farther.  (There’s even such a thing as a “hammer shield” – a “V” cut strip with an elevated handle to protect both the surface being nailed into and the “other hand” not wielding the hammer!)

                                             

                                            Different scale equipment, but the same principles apply.  Hope this helps.

                                             

                                            Larry

                                             

                                             

                                             

                                            -----Original Message-----
                                            From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                            Sent: Tuesday, April 13, 2004 8:46 AM
                                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                            Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                             

                                            Larry,

                                             

                                            What are the safety devices you are referring to?

                                            How are they used as operational controls?

                                             

                                            Take care,

                                             

                                            Bill Corcoran

                                             

                                            W. R. Corcoran, Ph.D., P.E.
                                            Nuclear Safety Review Concepts
                                            21 Broadleaf Circle
                                            Windsor, CT 06095-1634
                                            860-285-8779
                                            Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                             
                                            Check out our e-groups  at
                                            http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                            where you will find the back issues of "The Firebird Forum" through 2003 and at
                                            http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                            where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                                             

                                            For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                                            ----- Original Message -----

                                            Sent: Tuesday, April 13, 2004 9:27 AM

                                            Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                             

                                            They're used on home (and, probably) woodworking equipment all the time -
                                            particularly saws and drill presses.

                                            Larry

                                            -----Original Message-----
                                            From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                            Sent: Tuesday, April 13, 2004 4:31 AM
                                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                            Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                            Operational Purposes: I need your help

                                            Terry,

                                            That's very helpful.

                                            I think I'll recommend some visual cue for a "safety zone" next to the
                                            travel stop. The operators will be told not to move the equipment into that
                                            zone unless 1) it is under positive control and 2) the travel stop has been
                                            checked.

                                            What do you think about the safety culture of using travel limit stops as
                                            operational devices?

                                            Take care,

                                            Bill Corcoran

                                            W. R. Corcoran, Ph.D., P.E.
                                            Nuclear Safety Review Concepts
                                            21 Broadleaf Circle
                                            Windsor, CT 06095-1634
                                            860-285-8779
                                            Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                            Check out our e-groups  at
                                            http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                            where you will find the back issues of "The Firebird Forum" through 2003 and
                                            at
                                            http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                            where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                            photos, polls, files, tables, and links.

                                            For a complimentary subscription to our e-newsletter on root cause,
                                            organizational learning, and safety send a message to
                                            firebird.one@...

                                            ----- Original Message -----
                                            From: "Terry Herrmann" <jherrmt@...>
                                            To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                            Sent: Monday, April 12, 2004 5:32 PM
                                            Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                            Operational Purposes: I need your help


                                            > Bill C.,
                                            >
                                            > It would not be considered acceptable to use a travel limit stop as the
                                            > braking device (assuming you have a braking device).  The accepted design
                                            > practice is to provide a visual cue for where to stop travel (line on the
                                            > floor, etc.) and then the travel limit stop is the safety device on the
                                            off
                                            > chance that the brake fails.
                                            >
                                            > I'd first verify that the operators were able to stop the crane without
                                            > hitting the stop (i.e. the brake was in good working order and properly
                                            > adjusted).  If not, then I'd focus on how the maintenance was prioritized.
                                            > If the brake works as intended, then I'd focus the investigation on what
                                            led
                                            > to the practice of using the travel stop.  Is it a "We've always done it
                                            > that way." thing where it's become institutionalized without anyone even
                                            > knowing why or is it a more recent development?
                                            >
                                            > Terry Herrmann
                                            >
                                            >
                                            > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                                            > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                            > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                            > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                            > Operational Purposes: I need your help
                                            > Date: Sun, 11 Apr 2004 10:04:03 -0000
                                            >
                                            > Terry,
                                            >
                                            > Is it acceptable to use a travel limit stop routinely to stop the
                                            > travel? Or should the operators be told to stop the travel before it
                                            > hits the stop?
                                            >
                                            > We don't know for sure, but it looks like the repeated collisions of
                                            > the equipment with the stop may have damaged the stop and
                                            > contributed to its being out of place.
                                            >
                                            > I'm still looking for more examples.
                                            >
                                            > T/c,
                                            >
                                            > Bill
                                            >
                                            > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                            > Herrmann" <jherrmt@h...> wrote:
                                            >  > Bill,
                                            >  >
                                            >  > I guess it would all depend on whether the stop became loose and
                                            > was
                                            >  > unnoticed or was intentionally bypassed.
                                            >  >
                                            >  > I've seen limit switches become loose over time and not perform
                                            > their
                                            >  > function.  In this case, I'd suggest connecting the travel stop so
                                            > that it
                                            >  > does not allow the device to move at all  unless it is in proper
                                            > working
                                            >  > order.
                                            >  >
                                            >  > If it was intentionally bypassed (I've seen people do this with
                                            > lawnmower
                                            >  > and snowblower engine cutouts that are intended to do what I'm
                                            > suggesting
                                            >  > above), then you need an independent check by someone that doesn't
                                            > benefit
                                            >  > from the time savings gained by bypassing the safety device
                                            > followed up by
                                            >  > random observations.  A good observation program has a number of
                                            > benefits in
                                            >  > addition to this, but willful negligence is tough to overcome.
                                            > You
                                            >  > esentially have to change the individual's perception of risk
                                            > so "It's not
                                            >  > worth the time savings if I get caught."
                                            >  >
                                            >  > Terry Herrmann
                                            >  >
                                            >  >
                                            >  > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                                            >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                            >  > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                            >  > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                                            > Devices for
                                            >  > Operational Purposes: I need your help
                                            >  > Date: Sun, 11 Apr 2004 09:41:30 -0000
                                            >  >
                                            >  > Terry,
                                            >  >
                                            >  > The device was a physical travel limit stop. It was being used to
                                            >  > stop the travel of a piece of equipment day in and day out.
                                            >  >
                                            >  > One day the physical travel limit stop was out of position and the
                                            >  > piece of equipment kept going to cause damage to itself.
                                            >  >
                                            >  > I am looking for similar examples and generic avenues of corrective
                                            >  > actions.
                                            >  >
                                            >  > Thanks ever so much,
                                            >  >
                                            >  > Bill
                                            >  >
                                            >  > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                            >  > Herrmann" <jherrmt@h...> wrote:
                                            >  >  > Dr. Bill,
                                            >  >  >
                                            >  >  > A little more information would be helpful.
                                            >  >  >
                                            >  >  > What type of safety device was this?
                                            >  >  >
                                            >  >  > How was it used in order to perform the evolution?
                                            >  >  >
                                            >  >  > What was the probability that an accident would occur if the
                                            >  > safety device
                                            >  >  > were not used? (I'm wondering if it was REALLY used thousands of
                                            >  > times or
                                            >  >  > just reported that way.)
                                            >  >  >
                                            >  >  > Was the action so conditioned as to be able to be performed
                                            >  > totally from
                                            >  >  > memory without hardly thinking about it? (I'm trying to see if
                                            >  > we're talking
                                            >  >  > about a skill-based or rule-based type of error)
                                            >  >  >
                                            >  >  > What was the perceived effort (burden) for using this device
                                            >  > rather than not
                                            >  >  > use the device?
                                            >  >  >
                                            >  >  > How many times had the operator involved with the accident
                                            >  > performed the
                                            >  >  > evolution correctly (as determined by observation)?
                                            >  >  >
                                            >  >  > I dislike offering initial thoughts towards corrective actions
                                            >  > without fully
                                            >  >  > understanding the cause.  "Jumping to cause" tends to create
                                            > more
                                            >  > problems
                                            >  >  > and tends to not solve the initial problem.
                                            >  >  >
                                            >  >  > Terry Herrmann
                                            >  >  >
                                            >  >  >
                                            >  >  > From: "Dr. Bill Corcoran" <firebird.one@a...>
                                            >  >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                            >  >  > To:
                                            >  >  >
                                            >  >
                                            > <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                                            >  > of_the_Practice_II"
                                            >  >  > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                                            >  >  > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                                            >  > for
                                            >  >  > Operational Purposes: I need your help
                                            >  >  > Date: Sat, 10 Apr 2004 10:34:12 -0400
                                            >  >  >
                                            >  >  > Colleague,
                                            >  >  >
                                            >  >  > I am investigating an event in which operators routinely used a
                                            >  > safety
                                            >  >  > device for operational purposes.
                                            >  >  >
                                            >  >  > After thousands of successful evolutions there was an evolution
                                            > in
                                            >  > which the
                                            >  >  > safety device was in a by-passed condition.
                                            >  >  >
                                            >  >  > Of course, an accident occurred.
                                            >  >  >
                                            >  >  > Would you be so kind as to
                                            >  >  >    1.. tell me your thoughts in this area,
                                            >  >  >    2.. let me know what corrective actions come to mind, and
                                            >  >  >    3.. give me any examples you can think of?
                                            >  >  > Thanks ever so much.
                                            >  >  >
                                            >  >  > Take care,
                                            >  >  >
                                            >  >  > Bill Corcoran
                                            >  >  >
                                            >  >  > W. R. Corcoran, Ph.D., P.E.
                                            >  >  > Nuclear Safety Review Concepts
                                            >  >  > 21 Broadleaf Circle
                                            >  >  > Windsor, CT 06095-1634
                                            >  >  > 860-285-8779
                                            >  >  > Mission: Saving lives, pain, assets, and careers through
                                            >  > thoughtful inquiry.
                                            >  >  >
                                            >  >  > Check out our e-groups  at
                                            >  >  > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                            >  >  > where you will find the back issues of "The Firebird Forum"
                                            >  > through 2003 and
                                            >  >  > at
                                            >  >  > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                            >  >  > where you will find a dialogue on the Davis-Besse near miss
                                            > LOCA.,
                                            >  > including
                                            >  >  > photos, polls, files, tables, and links.
                                            >  >  >
                                            >  >  > For a complimentary subscription to our e-newsletter on root
                                            >  > cause,
                                            >  >  > organizational learning, and safety send a message to
                                            >  >  > firebird.one@a...
                                            >  >  >
                                            >  >  >
                                            > _________________________________________________________________
                                            >  >  > Get rid of annoying pop-up ads with the new MSN Toolbar - FREE!
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                                            > McAfeeR
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                                          • Lawrence B. Durham
                                            Certainly, in the main, your dichotomy is correct - I would only interject that people operate table saws, lathes, routers, and the like in the workplace as
                                            Message 21 of 27 , Apr 13, 2004

                                              Certainly, in the main, your dichotomy is correct – I would only interject that “people” operate table saws, lathes, routers, and the like in the workplace as well as at home.  And, if mistakes are made, those people can be injured rather severely.

                                               

                                              Take care,

                                               

                                              Larry 

                                               

                                              -----Original Message-----
                                              From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                              Sent: Tuesday, April 13, 2004 1:26 PM
                                              To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                              Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                               

                                              Larry,

                                               

                                              In a sense you are right. A travel stop is a travel stop.

                                               

                                              But all travel stops are not created equal.

                                               

                                              The ones I am concerned with are intended to protect people.

                                               

                                              They may protect other things as well, but they are personnel safety devices.

                                               

                                              In an FMEA involving these devices one of the effects of a failure would be personnel injury.

                                               

                                              In a barrier analysis of these devices one of the "targets" would be people and the "threats" would include "impact," "collision," or the like.

                                               

                                              Take care,

                                               

                                              Bill Corcoran

                                               

                                              W. R. Corcoran, Ph.D., P.E.
                                              Nuclear Safety Review Concepts
                                              21 Broadleaf Circle
                                              Windsor, CT 06095-1634
                                              860-285-8779
                                              Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                               
                                              Check out our e-groups  at
                                              http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                              where you will find the back issues of "The Firebird Forum" through 2003 and at
                                              http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                              where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                                               

                                              For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                                              ----- Original Message -----

                                              Sent: Tuesday, April 13, 2004 11:22 AM

                                              Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                               

                                              Collars around drill bits prevent deeper penetration than intended.  They are close to or identical to the diameter of the bit and are tightened in place by a set screw (typically with an Allen wrench).  Routers can have similar governing devices both in terms of depth and distance from an edge to the material being routed.  Table saws can have stops to prevent the circular blades from being elevated too high (from underneath the table surface) and thereby preventing contact between the blade and the table.  They and routers also have width “stops” or guides that control cutting dimensions.  Saws regularly have plastic blade enclosures that “give” as the work passes through the blade.  And, a variety of switch covers, “hold-ins” and “hold-downs” are used to control the position of the material being cut.  (Visit either a Home Depot or a Lowe’s store to see these devices being employed to custom cut material for customers.) 

                                               

                                              Lathe tools (similar to chisels) also frequently have hard (or, sometimes, soft like tape) collars placed at desired penetration depths to prevent deeper cuts than intended.  And, my bandsaw has a recessed blade the housing for which prevents my fingers from accidentally hitting the blade.  Even primitive (and modern) wood planes can be outfitted with guides and “stops” of sorts to assure safety and dimensional control.  Grinders and emery wheels typically have both guide bars for resting the tool or material being worked on and shields to deflect the particles downward away from the operator.

                                               

                                              Granted, these are primarily dimension guides (except for keeping the saw blade from hitting the table and the particles away from the grinder operator); however, they are commonly used aides in doing the job right the first time.  Measure twice; cut once.  While I’m more familiar with the use of hand tools, I can’t imagine that machine shops don’t use these and other similar devices and techniques on a routine basis.  The use of such devices dates back at least to the European craft guilds – probably much farther.  (There’s even such a thing as a “hammer shield” – a “V” cut strip with an elevated handle to protect both the surface being nailed into and the “other hand” not wielding the hammer!)

                                               

                                              Different scale equipment, but the same principles apply.  Hope this helps.

                                               

                                              Larry

                                               

                                               

                                               

                                              -----Original Message-----
                                              From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                              Sent: Tuesday, April 13, 2004 8:46 AM
                                              To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                              Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                               

                                              Larry,

                                               

                                              What are the safety devices you are referring to?

                                              How are they used as operational controls?

                                               

                                              Take care,

                                               

                                              Bill Corcoran

                                               

                                              W. R. Corcoran, Ph.D., P.E.
                                              Nuclear Safety Review Concepts
                                              21 Broadleaf Circle
                                              Windsor, CT 06095-1634
                                              860-285-8779
                                              Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                               
                                              Check out our e-groups  at
                                              http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                              where you will find the back issues of "The Firebird Forum" through 2003 and at
                                              http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                              where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.

                                               

                                              For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...

                                              ----- Original Message -----

                                              Sent: Tuesday, April 13, 2004 9:27 AM

                                              Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                               

                                              They're used on home (and, probably) woodworking equipment all the time -
                                              particularly saws and drill presses.

                                              Larry

                                              -----Original Message-----
                                              From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                              Sent: Tuesday, April 13, 2004 4:31 AM
                                              To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                              Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                              Operational Purposes: I need your help

                                              Terry,

                                              That's very helpful.

                                              I think I'll recommend some visual cue for a "safety zone" next to the
                                              travel stop. The operators will be told not to move the equipment into that
                                              zone unless 1) it is under positive control and 2) the travel stop has been
                                              checked.

                                              What do you think about the safety culture of using travel limit stops as
                                              operational devices?

                                              Take care,

                                              Bill Corcoran

                                              W. R. Corcoran, Ph.D., P.E.
                                              Nuclear Safety Review Concepts
                                              21 Broadleaf Circle
                                              Windsor, CT 06095-1634
                                              860-285-8779
                                              Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                              Check out our e-groups  at
                                              http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                              where you will find the back issues of "The Firebird Forum" through 2003 and
                                              at
                                              http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                              where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                              photos, polls, files, tables, and links.

                                              For a complimentary subscription to our e-newsletter on root cause,
                                              organizational learning, and safety send a message to
                                              firebird.one@...

                                              ----- Original Message -----
                                              From: "Terry Herrmann" <jherrmt@...>
                                              To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                              Sent: Monday, April 12, 2004 5:32 PM
                                              Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                              Operational Purposes: I need your help


                                              > Bill C.,
                                              >
                                              > It would not be considered acceptable to use a travel limit stop as the
                                              > braking device (assuming you have a braking device).  The accepted design
                                              > practice is to provide a visual cue for where to stop travel (line on the
                                              > floor, etc.) and then the travel limit stop is the safety device on the
                                              off
                                              > chance that the brake fails.
                                              >
                                              > I'd first verify that the operators were able to stop the crane without
                                              > hitting the stop (i.e. the brake was in good working order and properly
                                              > adjusted).  If not, then I'd focus on how the maintenance was prioritized.
                                              > If the brake works as intended, then I'd focus the investigation on what
                                              led
                                              > to the practice of using the travel stop.  Is it a "We've always done it
                                              > that way." thing where it's become institutionalized without anyone even
                                              > knowing why or is it a more recent development?
                                              >
                                              > Terry Herrmann
                                              >
                                              >
                                              > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                                              > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                              > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                              > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                              > Operational Purposes: I need your help
                                              > Date: Sun, 11 Apr 2004 10:04:03 -0000
                                              >
                                              > Terry,
                                              >
                                              > Is it acceptable to use a travel limit stop routinely to stop the
                                              > travel? Or should the operators be told to stop the travel before it
                                              > hits the stop?
                                              >
                                              > We don't know for sure, but it looks like the repeated collisions of
                                              > the equipment with the stop may have damaged the stop and
                                              > contributed to its being out of place.
                                              >
                                              > I'm still looking for more examples.
                                              >
                                              > T/c,
                                              >
                                              > Bill
                                              >
                                              > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                              > Herrmann" <jherrmt@h...> wrote:
                                              >  > Bill,
                                              >  >
                                              >  > I guess it would all depend on whether the stop became loose and
                                              > was
                                              >  > unnoticed or was intentionally bypassed.
                                              >  >
                                              >  > I've seen limit switches become loose over time and not perform
                                              > their
                                              >  > function.  In this case, I'd suggest connecting the travel stop so
                                              > that it
                                              >  > does not allow the device to move at all  unless it is in proper
                                              > working
                                              >  > order.
                                              >  >
                                              >  > If it was intentionally bypassed (I've seen people do this with
                                              > lawnmower
                                              >  > and snowblower engine cutouts that are intended to do what I'm
                                              > suggesting
                                              >  > above), then you need an independent check by someone that doesn't
                                              > benefit
                                              >  > from the time savings gained by bypassing the safety device
                                              > followed up by
                                              >  > random observations.  A good observation program has a number of
                                              > benefits in
                                              >  > addition to this, but willful negligence is tough to overcome.
                                              > You
                                              >  > esentially have to change the individual's perception of risk
                                              > so "It's not
                                              >  > worth the time savings if I get caught."
                                              >  >
                                              >  > Terry Herrmann
                                              >  >
                                              >  >
                                              >  > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                                              >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                              >  > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                              >  > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                                              > Devices for
                                              >  > Operational Purposes: I need your help
                                              >  > Date: Sun, 11 Apr 2004 09:41:30 -0000
                                              >  >
                                              >  > Terry,
                                              >  >
                                              >  > The device was a physical travel limit stop. It was being used to
                                              >  > stop the travel of a piece of equipment day in and day out.
                                              >  >
                                              >  > One day the physical travel limit stop was out of position and the
                                              >  > piece of equipment kept going to cause damage to itself.
                                              >  >
                                              >  > I am looking for similar examples and generic avenues of corrective
                                              >  > actions.
                                              >  >
                                              >  > Thanks ever so much,
                                              >  >
                                              >  > Bill
                                              >  >
                                              >  > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                              >  > Herrmann" <jherrmt@h...> wrote:
                                              >  >  > Dr. Bill,
                                              >  >  >
                                              >  >  > A little more information would be helpful.
                                              >  >  >
                                              >  >  > What type of safety device was this?
                                              >  >  >
                                              >  >  > How was it used in order to perform the evolution?
                                              >  >  >
                                              >  >  > What was the probability that an accident would occur if the
                                              >  > safety device
                                              >  >  > were not used? (I'm wondering if it was REALLY used thousands of
                                              >  > times or
                                              >  >  > just reported that way.)
                                              >  >  >
                                              >  >  > Was the action so conditioned as to be able to be performed
                                              >  > totally from
                                              >  >  > memory without hardly thinking about it? (I'm trying to see if
                                              >  > we're talking
                                              >  >  > about a skill-based or rule-based type of error)
                                              >  >  >
                                              >  >  > What was the perceived effort (burden) for using this device
                                              >  > rather than not
                                              >  >  > use the device?
                                              >  >  >
                                              >  >  > How many times had the operator involved with the accident
                                              >  > performed the
                                              >  >  > evolution correctly (as determined by observation)?
                                              >  >  >
                                              >  >  > I dislike offering initial thoughts towards corrective actions
                                              >  > without fully
                                              >  >  > understanding the cause.  "Jumping to cause" tends to create
                                              > more
                                              >  > problems
                                              >  >  > and tends to not solve the initial problem.
                                              >  >  >
                                              >  >  > Terry Herrmann
                                              >  >  >
                                              >  >  >
                                              >  >  > From: "Dr. Bill Corcoran" <firebird.one@a...>
                                              >  >  > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                              >  >  > To:
                                              >  >  >
                                              >  >
                                              > <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                                              >  > of_the_Practice_II"
                                              >  >  > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                                              >  >  > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                                              >  > for
                                              >  >  > Operational Purposes: I need your help
                                              >  >  > Date: Sat, 10 Apr 2004 10:34:12 -0400
                                              >  >  >
                                              >  >  > Colleague,
                                              >  >  >
                                              >  >  > I am investigating an event in which operators routinely used a
                                              >  > safety
                                              >  >  > device for operational purposes.
                                              >  >  >
                                              >  >  > After thousands of successful evolutions there was an evolution
                                              > in
                                              >  > which the
                                              >  >  > safety device was in a by-passed condition.
                                              >  >  >
                                              >  >  > Of course, an accident occurred.
                                              >  >  >
                                              >  >  > Would you be so kind as to
                                              >  >  >    1.. tell me your thoughts in this area,
                                              >  >  >    2.. let me know what corrective actions come to mind, and
                                              >  >  >    3.. give me any examples you can think of?
                                              >  >  > Thanks ever so much.
                                              >  >  >
                                              >  >  > Take care,
                                              >  >  >
                                              >  >  > Bill Corcoran
                                              >  >  >
                                              >  >  > W. R. Corcoran, Ph.D., P.E.
                                              >  >  > Nuclear Safety Review Concepts
                                              >  >  > 21 Broadleaf Circle
                                              >  >  > Windsor, CT 06095-1634
                                              >  >  > 860-285-8779
                                              >  >  > Mission: Saving lives, pain, assets, and careers through
                                              >  > thoughtful inquiry.
                                              >  >  >
                                              >  >  > Check out our e-groups  at
                                              >  >  > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                              >  >  > where you will find the back issues of "The Firebird Forum"
                                              >  > through 2003 and
                                              >  >  > at
                                              >  >  > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                              >  >  > where you will find a dialogue on the Davis-Besse near miss
                                              > LOCA.,
                                              >  > including
                                              >  >  > photos, polls, files, tables, and links.
                                              >  >  >
                                              >  >  > For a complimentary subscription to our e-newsletter on root
                                              >  > cause,
                                              >  >  > organizational learning, and safety send a message to
                                              >  >  > firebird.one@a...
                                              >  >  >
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                                              > _________________________________________________________________
                                              >  >  > Get rid of annoying pop-up ads with the new MSN Toolbar - FREE!
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                                            • Terry Herrmann
                                              I agree with Peter in that sometimes you need to use the stop when you must work near the end of travel. I wouldn t care to comment on anyone s safety
                                              Message 22 of 27 , Apr 15, 2004
                                                I agree with Peter in that sometimes you need to use the stop when you must
                                                work near the end of travel. I wouldn't care to comment on anyone's safety
                                                culture based on a single example of using a travel limit stop as an
                                                operational device. I'd look for other examples before trying to draw any
                                                conclusions.

                                                Terry Herrmann


                                                From: "Noyes, Peter M." <Peter.Noyes@...>
                                                Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                                Operational Purposes: I need your help
                                                Date: Tue, 13 Apr 2004 06:50:07 -0400

                                                Bill C.,

                                                We have an overhead crane which has indicator lamps that light when you get
                                                to the end of the travel zone. A yellow lamp lights when you are near end
                                                of travel. A red indicator lamp lights when you are at the end of travel.
                                                There is also a travel stop, which is the final device.

                                                This does not mean that our personnel never use the travel stop. There are
                                                times when there may be a need to get a piece of equipment in that zone.
                                                The operator uses the lights to get close , then jogs the crane the last
                                                final inches to the stop. Although I have heard, and felt the crane hitting
                                                the hard stops.

                                                Cranes need to be inspected on a periodic basis. The travel stops should be
                                                an item on that inspection.

                                                Peter

                                                -----Original Message-----
                                                From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                Sent: Tuesday, April 13, 2004 5:31 AM
                                                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                Subject: Re: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                                Operational Purposes: I need your help


                                                Terry,

                                                That's very helpful.

                                                I think I'll recommend some visual cue for a "safety zone" next to the
                                                travel stop. The operators will be told not to move the equipment into that
                                                zone unless 1) it is under positive control and 2) the travel stop has been
                                                checked.

                                                What do you think about the safety culture of using travel limit stops as
                                                operational devices?

                                                Take care,

                                                Bill Corcoran

                                                W. R. Corcoran, Ph.D., P.E.
                                                Nuclear Safety Review Concepts
                                                21 Broadleaf Circle
                                                Windsor, CT 06095-1634
                                                860-285-8779
                                                Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                                Check out our e-groups at
                                                http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                where you will find the back issues of "The Firebird Forum" through 2003 and
                                                at
                                                http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                                photos, polls, files, tables, and links.

                                                For a complimentary subscription to our e-newsletter on root cause,
                                                organizational learning, and safety send a message to
                                                firebird.one@...

                                                ----- Original Message -----
                                                From: "Terry Herrmann" <jherrmt@...>
                                                To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                                Sent: Monday, April 12, 2004 5:32 PM
                                                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                                Operational Purposes: I need your help


                                                > Bill C.,
                                                >
                                                > It would not be considered acceptable to use a travel limit stop as the
                                                > braking device (assuming you have a braking device). The accepted design
                                                > practice is to provide a visual cue for where to stop travel (line on the
                                                > floor, etc.) and then the travel limit stop is the safety device on the
                                                off
                                                > chance that the brake fails.
                                                >
                                                > I'd first verify that the operators were able to stop the crane without
                                                > hitting the stop (i.e. the brake was in good working order and properly
                                                > adjusted). If not, then I'd focus on how the maintenance was
                                                prioritized.
                                                > If the brake works as intended, then I'd focus the investigation on what
                                                led
                                                > to the practice of using the travel stop. Is it a "We've always done it
                                                > that way." thing where it's become institutionalized without anyone even
                                                > knowing why or is it a more recent development?
                                                >
                                                > Terry Herrmann
                                                >
                                                >
                                                > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@...>
                                                > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for
                                                > Operational Purposes: I need your help
                                                > Date: Sun, 11 Apr 2004 10:04:03 -0000
                                                >
                                                > Terry,
                                                >
                                                > Is it acceptable to use a travel limit stop routinely to stop the
                                                > travel? Or should the operators be told to stop the travel before it
                                                > hits the stop?
                                                >
                                                > We don't know for sure, but it looks like the repeated collisions of
                                                > the equipment with the stop may have damaged the stop and
                                                > contributed to its being out of place.
                                                >
                                                > I'm still looking for more examples.
                                                >
                                                > T/c,
                                                >
                                                > Bill
                                                >
                                                > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                                > Herrmann" <jherrmt@h...> wrote:
                                                > > Bill,
                                                > >
                                                > > I guess it would all depend on whether the stop became loose and
                                                > was
                                                > > unnoticed or was intentionally bypassed.
                                                > >
                                                > > I've seen limit switches become loose over time and not perform
                                                > their
                                                > > function. In this case, I'd suggest connecting the travel stop so
                                                > that it
                                                > > does not allow the device to move at all unless it is in proper
                                                > working
                                                > > order.
                                                > >
                                                > > If it was intentionally bypassed (I've seen people do this with
                                                > lawnmower
                                                > > and snowblower engine cutouts that are intended to do what I'm
                                                > suggesting
                                                > > above), then you need an independent check by someone that doesn't
                                                > benefit
                                                > > from the time savings gained by bypassing the safety device
                                                > followed up by
                                                > > random observations. A good observation program has a number of
                                                > benefits in
                                                > > addition to this, but willful negligence is tough to overcome.
                                                > You
                                                > > esentially have to change the individual's perception of risk
                                                > so "It's not
                                                > > worth the time savings if I get caught."
                                                > >
                                                > > Terry Herrmann
                                                > >
                                                > >
                                                > > From: "William R. Corcoran, Ph.D.,P.E." <firebird.one@a...>
                                                > > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                > > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                > > Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety
                                                > Devices for
                                                > > Operational Purposes: I need your help
                                                > > Date: Sun, 11 Apr 2004 09:41:30 -0000
                                                > >
                                                > > Terry,
                                                > >
                                                > > The device was a physical travel limit stop. It was being used to
                                                > > stop the travel of a piece of equipment day in and day out.
                                                > >
                                                > > One day the physical travel limit stop was out of position and the
                                                > > piece of equipment kept going to cause damage to itself.
                                                > >
                                                > > I am looking for similar examples and generic avenues of corrective
                                                > > actions.
                                                > >
                                                > > Thanks ever so much,
                                                > >
                                                > > Bill
                                                > >
                                                > > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Terry
                                                > > Herrmann" <jherrmt@h...> wrote:
                                                > > > Dr. Bill,
                                                > > >
                                                > > > A little more information would be helpful.
                                                > > >
                                                > > > What type of safety device was this?
                                                > > >
                                                > > > How was it used in order to perform the evolution?
                                                > > >
                                                > > > What was the probability that an accident would occur if the
                                                > > safety device
                                                > > > were not used? (I'm wondering if it was REALLY used thousands of
                                                > > times or
                                                > > > just reported that way.)
                                                > > >
                                                > > > Was the action so conditioned as to be able to be performed
                                                > > totally from
                                                > > > memory without hardly thinking about it? (I'm trying to see if
                                                > > we're talking
                                                > > > about a skill-based or rule-based type of error)
                                                > > >
                                                > > > What was the perceived effort (burden) for using this device
                                                > > rather than not
                                                > > > use the device?
                                                > > >
                                                > > > How many times had the operator involved with the accident
                                                > > performed the
                                                > > > evolution correctly (as determined by observation)?
                                                > > >
                                                > > > I dislike offering initial thoughts towards corrective actions
                                                > > without fully
                                                > > > understanding the cause. "Jumping to cause" tends to create
                                                > more
                                                > > problems
                                                > > > and tends to not solve the initial problem.
                                                > > >
                                                > > > Terry Herrmann
                                                > > >
                                                > > >
                                                > > > From: "Dr. Bill Corcoran" <firebird.one@a...>
                                                > > > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                > > > To:
                                                > > >
                                                > >
                                                > <Root_Cause_State_of_the_Practice@yahoogroups.com>,"Root_Cause_State_
                                                > > of_the_Practice_II"
                                                > > > <Root_Cause_State_of_the_Practice_II@yahoogroups.com>
                                                > > > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices
                                                > > for
                                                > > > Operational Purposes: I need your help
                                                > > > Date: Sat, 10 Apr 2004 10:34:12 -0400
                                                > > >
                                                > > > Colleague,
                                                > > >
                                                > > > I am investigating an event in which operators routinely used a
                                                > > safety
                                                > > > device for operational purposes.
                                                > > >
                                                > > > After thousands of successful evolutions there was an evolution
                                                > in
                                                > > which the
                                                > > > safety device was in a by-passed condition.
                                                > > >
                                                > > > Of course, an accident occurred.
                                                > > >
                                                > > > Would you be so kind as to
                                                > > > 1.. tell me your thoughts in this area,
                                                > > > 2.. let me know what corrective actions come to mind, and
                                                > > > 3.. give me any examples you can think of?
                                                > > > Thanks ever so much.
                                                > > >
                                                > > > Take care,
                                                > > >
                                                > > > Bill Corcoran
                                                > > >
                                                > > > W. R. Corcoran, Ph.D., P.E.
                                                > > > Nuclear Safety Review Concepts
                                                > > > 21 Broadleaf Circle
                                                > > > Windsor, CT 06095-1634
                                                > > > 860-285-8779
                                                > > > Mission: Saving lives, pain, assets, and careers through
                                                > > thoughtful inquiry.
                                                > > >
                                                > > > Check out our e-groups at
                                                > > > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                > > > where you will find the back issues of "The Firebird Forum"
                                                > > through 2003 and
                                                > > > at
                                                > > > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                > > > where you will find a dialogue on the Davis-Besse near miss
                                                > LOCA.,
                                                > > including
                                                > > > photos, polls, files, tables, and links.
                                                > > >
                                                > > > For a complimentary subscription to our e-newsletter on root
                                                > > cause,
                                                > > > organizational learning, and safety send a message to
                                                > > > firebird.one@a...
                                                > > >
                                                > > >
                                                > _________________________________________________________________
                                                > > > Get rid of annoying pop-up ads with the new MSN Toolbar - FREE!
                                                > > > http://toolbar.msn.com/go/onm00200414ave/direct/01/
                                                > >
                                                > > _________________________________________________________________
                                                > > Is your PC infected? Get a FREE online computer virus scan from
                                                > McAfee�
                                                > > Security. http://clinic.mcafee.com/clinic/ibuy/campaign.asp?
                                                > cid=3963
                                                >
                                                > _________________________________________________________________
                                                > Persistent heartburn? Check out Digestive Health & Wellness for
                                                information
                                                > and advice. http://gerd.msn.com/default.asp
                                                >
                                                >
                                                >
                                                >
                                                >
                                                > Yahoo! Groups Links
                                                >
                                                >
                                                >
                                                >



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                                              • Terry Herrmann
                                                While I agree that the front office contributes to the use of many poor work practices, making the assumption that it started there may be premature without
                                                Message 23 of 27 , Apr 16, 2004
                                                  While I agree that the front office contributes to the use of many poor work
                                                  practices, making the assumption that it started there may be premature
                                                  without further investigation.

                                                  I've worked on both ends of the job (field worker and office supervisor) and
                                                  I've seen many cases where the folks in the field inherited poor safety
                                                  practices from other workers and made efforts to hide this from the office
                                                  folks because they perceived OSHA and other safety rules as being "overkill"
                                                  (their words, not mine).

                                                  It all has to do with the PERCEIVED threat. If people have always done
                                                  something that seems to help them get the job done and they don't perceive
                                                  the practice to be likely to hurt anything based on their personal
                                                  experience, they will continue to do it.

                                                  I like to use the following equation when explaining this to our folks:

                                                  Likelihood of violating a known rule = Perceived burden / Perceived risk

                                                  Terry Herrmann


                                                  From: "Lawrence B. Durham" <LBDurham@...>
                                                  Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                  To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                                  Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                  Operational Purposes: I need your help
                                                  Date: Tue, 13 Apr 2004 10:33:13 -0500

                                                  That's why in my first response I suggested that the issue(s) transcended
                                                  the manifestations of problems. The more I hear on this matter, the more I
                                                  suspect a lax safety attitude site-wide. And, of course, that has its "root
                                                  cause" in the front office not on the shop floor or in the site yard spaces.
                                                  Depending on the situation, this could even be a corporate culture problem
                                                  and, perhaps, related work scheduling pressure demands that could be
                                                  emanating from marketing. I've seen marketing pressure quality control
                                                  pressure production in a plant start-up of a chemical fiber plant. Our
                                                  Process Assistance Group had to detect it and step in to mediate solutions
                                                  acceptable to all parties. That one was complicated by the construction
                                                  group's wanting to turn the plant over to manufacturing before QC would
                                                  agree that the product was within design specs. Fun!



                                                  Am I too far afield? Maybe; maybe not.



                                                  VR/ Larry



                                                  -----Original Message-----
                                                  From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                  Sent: Tuesday, April 13, 2004 9:22 AM
                                                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                  Subject: Re: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                  Operational Purposes: I need your help



                                                  Larry,



                                                  It's a bigger problem than cranes.



                                                  The problem is all on-site load movements.



                                                  Take care,



                                                  Bill Corcoran



                                                  W. R. Corcoran, Ph.D., P.E.
                                                  Nuclear Safety Review Concepts
                                                  21 Broadleaf Circle
                                                  Windsor, CT 06095-1634
                                                  860-285-8779
                                                  Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                                  Check out our e-groups at
                                                  http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                  where you will find the back issues of "The Firebird Forum" through 2003 and
                                                  at
                                                  http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                  where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                                  photos, polls, files, tables, and links.



                                                  For a complimentary subscription to our e-newsletter on root cause,
                                                  organizational learning, and safety send a message to
                                                  firebird.one@...

                                                  ----- Original Message -----

                                                  From: Lawrence B. <mailto:LBDurham@...> Durham

                                                  To: Root_Cause_State_of_the_Practice@yahoogroups.com

                                                  Sent: Tuesday, April 13, 2004 9:37 AM

                                                  Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                  Operational Purposes: I need your help



                                                  Based on further traffic on this issue, I will contribute that I have found
                                                  crane training to be among the least attended to topics in nuclear power
                                                  plants' curricula. In spite of Tech Spec requirements, it comes to be
                                                  assumed almost as a "skill of the craft" function - sometimes even by
                                                  auditors who should know better. Your "incident" may yet have broader and
                                                  deeper ramifications even though it's not in a nuclear environment. What
                                                  about OSHA and ISO standards and procedures?



                                                  LBD



                                                  -----Original Message-----
                                                  From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                  Sent: Sunday, April 11, 2004 4:33 AM
                                                  To: Root_Cause_State_of_the_Practice@yahoogroups.com;
                                                  Root_Cause_State_of_the_Practice_II
                                                  Subject: Fw: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                  Operational Purposes: I need your help



                                                  Larry,



                                                  Thanks for your insights. The airline accident you are referring to is
                                                  probably ValuJet 592. I don't recall it as involving using a safety device
                                                  for operational purposes, but it did involve communications and it did
                                                  involve safety devices.



                                                  The venue for the safety device incident that prompted my request was not a
                                                  nuclear power plant, but that probably doesn't matter.



                                                  I am still scratching my head over why all of the people who knew that the
                                                  safety device was being used for operational purposes didn't speak up. This
                                                  is a teamwork issue if they realized what they were seeing.



                                                  How many of us never turn off our headlights until after we have opened the
                                                  driver's door and received the "headlights still on" warning light?



                                                  Are there still people out there who house a crane hoist by actuating the
                                                  two-block limit switch?



                                                  Are there other examples of activities that challenge safety devices?



                                                  Take care,



                                                  Bill Corcoran



                                                  W. R. Corcoran, Ph.D., P.E.
                                                  Nuclear Safety Review Concepts
                                                  21 Broadleaf Circle
                                                  Windsor, CT 06095-1634
                                                  860-285-8779
                                                  Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                                  Check out our e-groups at
                                                  http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                  where you will find the back issues of "The Firebird Forum" through 2003 and
                                                  at
                                                  http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                  where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                                  photos, polls, files, tables, and links.



                                                  For a complimentary subscription to our e-newsletter on root cause,
                                                  organizational learning, and safety send a message to
                                                  firebird.one@...

                                                  ----- Original Message -----

                                                  From: Lawrence B. Durham <mailto:LBDurham@...>

                                                  To: William Corcoran <mailto:williamcorcoran@...>

                                                  Sent: Saturday, April 10, 2004 7:37 PM

                                                  Subject: FW: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                  Operational Purposes: I need your help



                                                  Bill,



                                                  For some reason, I can't mail out to the entire group as I tried to do. You
                                                  may forward this to whomever you wish if you wish.



                                                  Best regards for a HAPPY EASTER!!!



                                                  Larry



                                                  -----Original Message-----
                                                  From: Lawrence B. Durham [mailto:LBDurham@...]
                                                  Sent: Saturday, April 10, 2004 6:03 PM
                                                  To: Root_Cause_State_of_the_Practice@yahoogroups.com;
                                                  'Root_Cause_State_of_the_Practice_II'
                                                  Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                  Operational Purposes: I need your help



                                                  Bill, bear in mind that I'm watching the Masters' Golf Tournament as I think
                                                  about your questions and write this response. I've seen some of the world's
                                                  best players muff shots like ones that they've made successfully literally
                                                  thousands of times. To my knowledge, the PGA won't be kicking anyone out of
                                                  the organization for those errors. (Granted lives do not typically depend
                                                  on golf shots.) Each golf professional is more eager than anyone else to
                                                  maintain and improve his (or her) game. Hopefully, the operators are in an
                                                  organizational environment that also doesn't "go after" people who make
                                                  mistakes and where individuals are self-motivated to constantly seek to
                                                  improve and avoid mistakes.



                                                  Nonetheless, an accident happened. My first thoughts ran toward checking
                                                  if, how, and when the relevant evolutions were included in pre-briefings
                                                  and/or training exercises. For years, I have shared with many folks the
                                                  feeling that the nuclear industry is so attentive to the avoidance of
                                                  abnormal conditions that it overlooks providing sufficient attention to
                                                  reinforcing the proper execution of routine operating procedures. My second
                                                  wave of thought on this matter went to the realm of effective three-way
                                                  communication. Back to golf, top players ask their caddies for advice and
                                                  feedback - both before and after their shots. I don't see much of that type
                                                  of behavior among our nuclear workforce. How was the intra-team
                                                  communication in this case?



                                                  As for suggested corrective actions, your hardest job in this case may be
                                                  persuading plant management that it may not be a training problem. Even
                                                  though I have already suggested looking at the related training, please
                                                  don't mistake that question for my having jumped to the same conclusion -
                                                  insufficient (and, maybe, inadequate) training. Based on your sketch, it
                                                  would seem that they had already demonstrated many times that they knew what
                                                  to do and how to do it. Thus, the question is why didn't they do it as they
                                                  had before? Though I sound like an echo of you, I have to remind even you
                                                  to "just ask them". Frankly, this sounds very much like a complacency and
                                                  operational attitude situation. I would respectfully suggest an
                                                  environmental analysis of the organizational culture. I would make a small
                                                  wager that such an investigation would detect a number of other less-visible
                                                  errors that have stayed "below the radar". You taught me too well to get me
                                                  to "bite" on specific corrective action(s) absent further data.

                                                  However, this one "feels" very much like a supervisory and, therefore,
                                                  management problem that unfortunately manifested itself in a critical
                                                  manner. I would suggest that after the company is comfortable that the root
                                                  causes have been identified that the cognizant manager and the
                                                  directly-involved employee(s) should provide "lessons-learned" briefings to
                                                  their associates throughout the plant and develop a case study for INPO
                                                  dissemination.



                                                  The best examples that come to mind were reported in the airline cases (poor
                                                  communications and teamwork) reported out several years ago. I don't
                                                  remember the specific reference, but I'll bet you know it and probably have
                                                  a copy. (If so, please send the reference back to me.) And, regrettably,
                                                  it also has certain tones of the Davis-Besse inattention-to-detail,
                                                  "business-as-usual" syndrome. On a matter that I polled this network about
                                                  last year, the realm of medical mistakes also offers all too many potential
                                                  comparisons - from mis-filled prescriptions to amputating the wrong limbs to
                                                  fatal anesthesia techniques. And, finally, to return to my golfing analogy,
                                                  rules and procedures that are typically followed so faithfully to avoid
                                                  disqualification are, nonetheless, sometimes broken by top players who make
                                                  stupid mistakes like not signing their cards after a completed round or by
                                                  inadvertently moving a ball by not walking carefully in the woods as one
                                                  looks for it after an errant shot.



                                                  I hope that this helps. As always, I would appreciate your assessment of my
                                                  critique and observations and suggestions. As more details are releasable,
                                                  please share them and the course of action that is followed by the company.



                                                  HAPPY EASTER!



                                                  VR/LBD





                                                  -----Original Message-----
                                                  From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                  Sent: Saturday, April 10, 2004 9:34 AM
                                                  To: Root_Cause_State_of_the_Practice@yahoogroups.com;
                                                  Root_Cause_State_of_the_Practice_II
                                                  Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                  Operational Purposes: I need your help



                                                  Colleague,



                                                  I am investigating an event in which operators routinely used a safety
                                                  device for operational purposes.



                                                  After thousands of successful evolutions there was an evolution in which the
                                                  safety device was in a by-passed condition.



                                                  Of course, an accident occurred.



                                                  Would you be so kind as to

                                                  1. tell me your thoughts in this area,

                                                  2. let me know what corrective actions come to mind, and

                                                  3. give me any examples you can think of?

                                                  Thanks ever so much.



                                                  Take care,



                                                  Bill Corcoran



                                                  W. R. Corcoran, Ph.D., P.E.
                                                  Nuclear Safety Review Concepts
                                                  21 Broadleaf Circle
                                                  Windsor, CT 06095-1634
                                                  860-285-8779
                                                  Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                                  Check out our e-groups at
                                                  http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                  where you will find the back issues of "The Firebird Forum" through 2003 and
                                                  at
                                                  http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                  where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                                  photos, polls, files, tables, and links.



                                                  For a complimentary subscription to our e-newsletter on root cause,
                                                  organizational learning, and safety send a message to
                                                  firebird.one@...









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                                                • jathomas1949
                                                  I was trained early in my career in the US Navy Nuclear Propulsion program in the days when Admiral Rickover was at the helm. I was a nuclear submarine
                                                  Message 24 of 27 , Apr 16, 2004
                                                    I was trained early in my career in the US Navy Nuclear Propulsion
                                                    program in the days when Admiral Rickover was at the helm. I was a
                                                    nuclear submarine officer. Our philosophy was that operations would
                                                    never deliberately rely on a safety device to terminate or take
                                                    control of the process. The safety devices are there to protect when
                                                    operations fail. An additional philosophy was to always believe our
                                                    indications and respond to them as specified in our plans and
                                                    procedures unless there was positive proof that the indicator had
                                                    failed.

                                                    Much of this philosophy was echoed many years later when two
                                                    different commissions invstigated the accident at Three mile Island
                                                    (I've spent 20 years of my career cleaning up the mess created by
                                                    someone else's failure to implement a positive safety culture)

                                                    My opinion as a professional with considerable experiance in the
                                                    operation of cranes is that deliberately hitting the rail stop as a
                                                    means of terminating trolley movement is dangerous, irresponsible,
                                                    and indicative of a total lack of familiarity with ANSI B-30 series
                                                    of standards, OSHA requirements, and an operational attitude that
                                                    allows things to be done wrong until someone gets killed.

                                                    I apologize if I took an overly zealous stance in this posting,
                                                    especially since it is my first post. I work in the nuclear
                                                    decommissioning field and this issue touched a raw nerve. I've seen
                                                    too many situations involving misoperation, misuse, abuse of cranes
                                                    and lifting and handling equipment during my career. I believe that
                                                    serendipity and the grace of the almighty is all that has prevented
                                                    more death and destruction resulting from very poor lifting and
                                                    handling programs.

                                                    -- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Dr. Bill
                                                    Corcoran" <firebird.one@a...> wrote:
                                                    > Colleague,
                                                    >
                                                    > I am investigating an event in which operators routinely used a
                                                    safety device for operational purposes.
                                                    >
                                                    > After thousands of successful evolutions there was an evolution in
                                                    which the safety device was in a by-passed condition.
                                                    >
                                                    > Of course, an accident occurred.
                                                    >
                                                    > Would you be so kind as to
                                                    > 1.. tell me your thoughts in this area,
                                                    > 2.. let me know what corrective actions come to mind, and
                                                    > 3.. give me any examples you can think of?
                                                    > Thanks ever so much.
                                                    >
                                                    > Take care,
                                                    >
                                                    > Bill Corcoran
                                                    >
                                                    > W. R. Corcoran, Ph.D., P.E.
                                                    > Nuclear Safety Review Concepts
                                                    > 21 Broadleaf Circle
                                                    > Windsor, CT 06095-1634
                                                    > 860-285-8779
                                                    > Mission: Saving lives, pain, assets, and careers through thoughtful
                                                    inquiry.
                                                    >
                                                    > Check out our e-groups at
                                                    > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                    > where you will find the back issues of "The Firebird Forum" through
                                                    2003 and at
                                                    > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                    > where you will find a dialogue on the Davis-Besse near miss LOCA.,
                                                    including photos, polls, files, tables, and links.
                                                    >
                                                    > For a complimentary subscription to our e-newsletter on root cause,
                                                    organizational learning, and safety send a message to
                                                    firebird.one@a...
                                                  • Dr. Bill Corcoran
                                                    Terry, Although I love faux equations, I am suspicious of yours. My work indicates suggests that the probability of violating a know rule is, to first order
                                                    Message 25 of 27 , Apr 16, 2004
                                                      Terry,

                                                      Although I love faux equations, I am suspicious of yours.

                                                      My work indicates suggests that the probability of violating a know rule is,
                                                      to first order dominated, by the probability that the same rule had been
                                                      previously violated by the workers themselves or their co-workers.

                                                      I have never investigated an adverse event involving rule violation in which
                                                      the rule violation was claimed to have been a first time infraction.

                                                      Take care,

                                                      Bill Corcoran

                                                      W. R. Corcoran, Ph.D., P.E.
                                                      Nuclear Safety Review Concepts
                                                      21 Broadleaf Circle
                                                      Windsor, CT 06095-1634
                                                      860-285-8779
                                                      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                                      Check out our e-groups at
                                                      http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                      where you will find the back issues of "The Firebird Forum" through 2003 and
                                                      at
                                                      http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                      where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                                      photos, polls, files, tables, and links.

                                                      For a complimentary subscription to our e-newsletter on root cause,
                                                      organizational learning, and safety send a message to
                                                      firebird.one@...

                                                      ----- Original Message -----
                                                      From: "Terry Herrmann" <jherrmt@...>
                                                      To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                                      Sent: Friday, April 16, 2004 8:23 AM
                                                      Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                      Operational Purposes: I need your help


                                                      > While I agree that the front office contributes to the use of many poor
                                                      work
                                                      > practices, making the assumption that it started there may be premature
                                                      > without further investigation.
                                                      >
                                                      > I've worked on both ends of the job (field worker and office supervisor)
                                                      and
                                                      > I've seen many cases where the folks in the field inherited poor safety
                                                      > practices from other workers and made efforts to hide this from the office
                                                      > folks because they perceived OSHA and other safety rules as being
                                                      "overkill"
                                                      > (their words, not mine).
                                                      >
                                                      > It all has to do with the PERCEIVED threat. If people have always done
                                                      > something that seems to help them get the job done and they don't perceive
                                                      > the practice to be likely to hurt anything based on their personal
                                                      > experience, they will continue to do it.
                                                      >
                                                      > I like to use the following equation when explaining this to our folks:
                                                      >
                                                      > Likelihood of violating a known rule = Perceived burden / Perceived risk
                                                      >
                                                      > Terry Herrmann
                                                      >
                                                      >
                                                      > From: "Lawrence B. Durham" <LBDurham@...>
                                                      > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                      > To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                                      > Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                      > Operational Purposes: I need your help
                                                      > Date: Tue, 13 Apr 2004 10:33:13 -0500
                                                      >
                                                      > That's why in my first response I suggested that the issue(s) transcended
                                                      > the manifestations of problems. The more I hear on this matter, the more
                                                      I
                                                      > suspect a lax safety attitude site-wide. And, of course, that has its
                                                      "root
                                                      > cause" in the front office not on the shop floor or in the site yard
                                                      spaces.
                                                      > Depending on the situation, this could even be a corporate culture problem
                                                      > and, perhaps, related work scheduling pressure demands that could be
                                                      > emanating from marketing. I've seen marketing pressure quality control
                                                      > pressure production in a plant start-up of a chemical fiber plant. Our
                                                      > Process Assistance Group had to detect it and step in to mediate solutions
                                                      > acceptable to all parties. That one was complicated by the construction
                                                      > group's wanting to turn the plant over to manufacturing before QC would
                                                      > agree that the product was within design specs. Fun!
                                                      >
                                                      >
                                                      >
                                                      > Am I too far afield? Maybe; maybe not.
                                                      >
                                                      >
                                                      >
                                                      > VR/ Larry
                                                      >
                                                      >
                                                      >
                                                      > -----Original Message-----
                                                      > From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                      > Sent: Tuesday, April 13, 2004 9:22 AM
                                                      > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                      > Subject: Re: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                      > Operational Purposes: I need your help
                                                      >
                                                      >
                                                      >
                                                      > Larry,
                                                      >
                                                      >
                                                      >
                                                      > It's a bigger problem than cranes.
                                                      >
                                                      >
                                                      >
                                                      > The problem is all on-site load movements.
                                                      >
                                                      >
                                                      >
                                                      > Take care,
                                                      >
                                                      >
                                                      >
                                                      > Bill Corcoran
                                                      >
                                                      >
                                                      >
                                                      > W. R. Corcoran, Ph.D., P.E.
                                                      > Nuclear Safety Review Concepts
                                                      > 21 Broadleaf Circle
                                                      > Windsor, CT 06095-1634
                                                      > 860-285-8779
                                                      > Mission: Saving lives, pain, assets, and careers through thoughtful
                                                      inquiry.
                                                      >
                                                      > Check out our e-groups at
                                                      > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                      > where you will find the back issues of "The Firebird Forum" through 2003
                                                      and
                                                      > at
                                                      > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                      > where you will find a dialogue on the Davis-Besse near miss LOCA.,
                                                      including
                                                      > photos, polls, files, tables, and links.
                                                      >
                                                      >
                                                      >
                                                      > For a complimentary subscription to our e-newsletter on root cause,
                                                      > organizational learning, and safety send a message to
                                                      > firebird.one@...
                                                      >
                                                      > ----- Original Message -----
                                                      >
                                                      > From: Lawrence B. <mailto:LBDurham@...> Durham
                                                      >
                                                      > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                      >
                                                      > Sent: Tuesday, April 13, 2004 9:37 AM
                                                      >
                                                      > Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                      > Operational Purposes: I need your help
                                                      >
                                                      >
                                                      >
                                                      > Based on further traffic on this issue, I will contribute that I have
                                                      found
                                                      > crane training to be among the least attended to topics in nuclear power
                                                      > plants' curricula. In spite of Tech Spec requirements, it comes to be
                                                      > assumed almost as a "skill of the craft" function - sometimes even by
                                                      > auditors who should know better. Your "incident" may yet have broader and
                                                      > deeper ramifications even though it's not in a nuclear environment. What
                                                      > about OSHA and ISO standards and procedures?
                                                      >
                                                      >
                                                      >
                                                      > LBD
                                                      >
                                                      >
                                                      >
                                                      > -----Original Message-----
                                                      > From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                      > Sent: Sunday, April 11, 2004 4:33 AM
                                                      > To: Root_Cause_State_of_the_Practice@yahoogroups.com;
                                                      > Root_Cause_State_of_the_Practice_II
                                                      > Subject: Fw: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                      > Operational Purposes: I need your help
                                                      >
                                                      >
                                                      >
                                                      > Larry,
                                                      >
                                                      >
                                                      >
                                                      > Thanks for your insights. The airline accident you are referring to is
                                                      > probably ValuJet 592. I don't recall it as involving using a safety device
                                                      > for operational purposes, but it did involve communications and it did
                                                      > involve safety devices.
                                                      >
                                                      >
                                                      >
                                                      > The venue for the safety device incident that prompted my request was not
                                                      a
                                                      > nuclear power plant, but that probably doesn't matter.
                                                      >
                                                      >
                                                      >
                                                      > I am still scratching my head over why all of the people who knew that the
                                                      > safety device was being used for operational purposes didn't speak up.
                                                      This
                                                      > is a teamwork issue if they realized what they were seeing.
                                                      >
                                                      >
                                                      >
                                                      > How many of us never turn off our headlights until after we have opened
                                                      the
                                                      > driver's door and received the "headlights still on" warning light?
                                                      >
                                                      >
                                                      >
                                                      > Are there still people out there who house a crane hoist by actuating the
                                                      > two-block limit switch?
                                                      >
                                                      >
                                                      >
                                                      > Are there other examples of activities that challenge safety devices?
                                                      >
                                                      >
                                                      >
                                                      > Take care,
                                                      >
                                                      >
                                                      >
                                                      > Bill Corcoran
                                                      >
                                                      >
                                                      >
                                                      > W. R. Corcoran, Ph.D., P.E.
                                                      > Nuclear Safety Review Concepts
                                                      > 21 Broadleaf Circle
                                                      > Windsor, CT 06095-1634
                                                      > 860-285-8779
                                                      > Mission: Saving lives, pain, assets, and careers through thoughtful
                                                      inquiry.
                                                      >
                                                      > Check out our e-groups at
                                                      > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                      > where you will find the back issues of "The Firebird Forum" through 2003
                                                      and
                                                      > at
                                                      > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                      > where you will find a dialogue on the Davis-Besse near miss LOCA.,
                                                      including
                                                      > photos, polls, files, tables, and links.
                                                      >
                                                      >
                                                      >
                                                      > For a complimentary subscription to our e-newsletter on root cause,
                                                      > organizational learning, and safety send a message to
                                                      > firebird.one@...
                                                      >
                                                      > ----- Original Message -----
                                                      >
                                                      > From: Lawrence B. Durham <mailto:LBDurham@...>
                                                      >
                                                      > To: William Corcoran <mailto:williamcorcoran@...>
                                                      >
                                                      > Sent: Saturday, April 10, 2004 7:37 PM
                                                      >
                                                      > Subject: FW: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                      > Operational Purposes: I need your help
                                                      >
                                                      >
                                                      >
                                                      > Bill,
                                                      >
                                                      >
                                                      >
                                                      > For some reason, I can't mail out to the entire group as I tried to do.
                                                      You
                                                      > may forward this to whomever you wish if you wish.
                                                      >
                                                      >
                                                      >
                                                      > Best regards for a HAPPY EASTER!!!
                                                      >
                                                      >
                                                      >
                                                      > Larry
                                                      >
                                                      >
                                                      >
                                                      > -----Original Message-----
                                                      > From: Lawrence B. Durham [mailto:LBDurham@...]
                                                      > Sent: Saturday, April 10, 2004 6:03 PM
                                                      > To: Root_Cause_State_of_the_Practice@yahoogroups.com;
                                                      > 'Root_Cause_State_of_the_Practice_II'
                                                      > Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                      > Operational Purposes: I need your help
                                                      >
                                                      >
                                                      >
                                                      > Bill, bear in mind that I'm watching the Masters' Golf Tournament as I
                                                      think
                                                      > about your questions and write this response. I've seen some of the
                                                      world's
                                                      > best players muff shots like ones that they've made successfully literally
                                                      > thousands of times. To my knowledge, the PGA won't be kicking anyone out
                                                      of
                                                      > the organization for those errors. (Granted lives do not typically depend
                                                      > on golf shots.) Each golf professional is more eager than anyone else to
                                                      > maintain and improve his (or her) game. Hopefully, the operators are in
                                                      an
                                                      > organizational environment that also doesn't "go after" people who make
                                                      > mistakes and where individuals are self-motivated to constantly seek to
                                                      > improve and avoid mistakes.
                                                      >
                                                      >
                                                      >
                                                      > Nonetheless, an accident happened. My first thoughts ran toward checking
                                                      > if, how, and when the relevant evolutions were included in pre-briefings
                                                      > and/or training exercises. For years, I have shared with many folks the
                                                      > feeling that the nuclear industry is so attentive to the avoidance of
                                                      > abnormal conditions that it overlooks providing sufficient attention to
                                                      > reinforcing the proper execution of routine operating procedures. My
                                                      second
                                                      > wave of thought on this matter went to the realm of effective three-way
                                                      > communication. Back to golf, top players ask their caddies for advice and
                                                      > feedback - both before and after their shots. I don't see much of that
                                                      type
                                                      > of behavior among our nuclear workforce. How was the intra-team
                                                      > communication in this case?
                                                      >
                                                      >
                                                      >
                                                      > As for suggested corrective actions, your hardest job in this case may be
                                                      > persuading plant management that it may not be a training problem. Even
                                                      > though I have already suggested looking at the related training, please
                                                      > don't mistake that question for my having jumped to the same conclusion -
                                                      > insufficient (and, maybe, inadequate) training. Based on your sketch, it
                                                      > would seem that they had already demonstrated many times that they knew
                                                      what
                                                      > to do and how to do it. Thus, the question is why didn't they do it as
                                                      they
                                                      > had before? Though I sound like an echo of you, I have to remind even you
                                                      > to "just ask them". Frankly, this sounds very much like a complacency and
                                                      > operational attitude situation. I would respectfully suggest an
                                                      > environmental analysis of the organizational culture. I would make a
                                                      small
                                                      > wager that such an investigation would detect a number of other
                                                      less-visible
                                                      > errors that have stayed "below the radar". You taught me too well to get
                                                      me
                                                      > to "bite" on specific corrective action(s) absent further data.
                                                      >
                                                      > However, this one "feels" very much like a supervisory and, therefore,
                                                      > management problem that unfortunately manifested itself in a critical
                                                      > manner. I would suggest that after the company is comfortable that the
                                                      root
                                                      > causes have been identified that the cognizant manager and the
                                                      > directly-involved employee(s) should provide "lessons-learned" briefings
                                                      to
                                                      > their associates throughout the plant and develop a case study for INPO
                                                      > dissemination.
                                                      >
                                                      >
                                                      >
                                                      > The best examples that come to mind were reported in the airline cases
                                                      (poor
                                                      > communications and teamwork) reported out several years ago. I don't
                                                      > remember the specific reference, but I'll bet you know it and probably
                                                      have
                                                      > a copy. (If so, please send the reference back to me.) And, regrettably,
                                                      > it also has certain tones of the Davis-Besse inattention-to-detail,
                                                      > "business-as-usual" syndrome. On a matter that I polled this network
                                                      about
                                                      > last year, the realm of medical mistakes also offers all too many
                                                      potential
                                                      > comparisons - from mis-filled prescriptions to amputating the wrong limbs
                                                      to
                                                      > fatal anesthesia techniques. And, finally, to return to my golfing
                                                      analogy,
                                                      > rules and procedures that are typically followed so faithfully to avoid
                                                      > disqualification are, nonetheless, sometimes broken by top players who
                                                      make
                                                      > stupid mistakes like not signing their cards after a completed round or by
                                                      > inadvertently moving a ball by not walking carefully in the woods as one
                                                      > looks for it after an errant shot.
                                                      >
                                                      >
                                                      >
                                                      > I hope that this helps. As always, I would appreciate your assessment of
                                                      my
                                                      > critique and observations and suggestions. As more details are
                                                      releasable,
                                                      > please share them and the course of action that is followed by the
                                                      company.
                                                      >
                                                      >
                                                      >
                                                      > HAPPY EASTER!
                                                      >
                                                      >
                                                      >
                                                      > VR/LBD
                                                      >
                                                      >
                                                      >
                                                      >
                                                      >
                                                      > -----Original Message-----
                                                      > From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                      > Sent: Saturday, April 10, 2004 9:34 AM
                                                      > To: Root_Cause_State_of_the_Practice@yahoogroups.com;
                                                      > Root_Cause_State_of_the_Practice_II
                                                      > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                      > Operational Purposes: I need your help
                                                      >
                                                      >
                                                      >
                                                      > Colleague,
                                                      >
                                                      >
                                                      >
                                                      > I am investigating an event in which operators routinely used a safety
                                                      > device for operational purposes.
                                                      >
                                                      >
                                                      >
                                                      > After thousands of successful evolutions there was an evolution in which
                                                      the
                                                      > safety device was in a by-passed condition.
                                                      >
                                                      >
                                                      >
                                                      > Of course, an accident occurred.
                                                      >
                                                      >
                                                      >
                                                      > Would you be so kind as to
                                                      >
                                                      > 1. tell me your thoughts in this area,
                                                      >
                                                      > 2. let me know what corrective actions come to mind, and
                                                      >
                                                      > 3. give me any examples you can think of?
                                                      >
                                                      > Thanks ever so much.
                                                      >
                                                      >
                                                      >
                                                      > Take care,
                                                      >
                                                      >
                                                      >
                                                      > Bill Corcoran
                                                      >
                                                      >
                                                      >
                                                      > W. R. Corcoran, Ph.D., P.E.
                                                      > Nuclear Safety Review Concepts
                                                      > 21 Broadleaf Circle
                                                      > Windsor, CT 06095-1634
                                                      > 860-285-8779
                                                      > Mission: Saving lives, pain, assets, and careers through thoughtful
                                                      inquiry.
                                                      >
                                                      > Check out our e-groups at
                                                      > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                      > where you will find the back issues of "The Firebird Forum" through 2003
                                                      and
                                                      > at
                                                      > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                      > where you will find a dialogue on the Davis-Besse near miss LOCA.,
                                                      including
                                                      > photos, polls, files, tables, and links.
                                                      >
                                                      >
                                                      >
                                                      > For a complimentary subscription to our e-newsletter on root cause,
                                                      > organizational learning, and safety send a message to
                                                      > firebird.one@...
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                                                    • Dr. Bill Corcoran
                                                      Mr. Thomas, There s nothing wrong with zeal. The equipment involved in this event was a monorail hoist, but the principles must be the same. Can you site OSHA
                                                      Message 26 of 27 , Apr 16, 2004
                                                        Mr. Thomas,
                                                         
                                                        There's nothing wrong with zeal.
                                                         
                                                        The equipment involved in this event was a monorail hoist, but the principles must be the same.
                                                         
                                                        Can you site OSHA chapter and verse? The client subscribes to OSHA requirements.
                                                         
                                                        Take care,
                                                         
                                                        Bill Corcoran
                                                         
                                                        W. R. Corcoran, Ph.D., P.E.
                                                        Nuclear Safety Review Concepts
                                                        21 Broadleaf Circle
                                                        Windsor, CT 06095-1634
                                                        860-285-8779
                                                        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                                                         
                                                        Check out our e-groups  at
                                                        http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                        where you will find the back issues of "The Firebird Forum" through 2003 and at
                                                        http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                        where you will find a dialogue on the Davis-Besse near miss LOCA., including photos, polls, files, tables, and links.
                                                         
                                                        For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...
                                                        ----- Original Message -----
                                                        Sent: Friday, April 16, 2004 1:17 PM
                                                        Subject: [Root_Cause_State_of_the_Practice] Re: Using Safety Devices for Operational Purposes: I need your help

                                                        I was trained early in my career in the US Navy Nuclear Propulsion
                                                        program in the days when Admiral Rickover was at the helm. I was a
                                                        nuclear submarine officer. Our philosophy was that operations would
                                                        never deliberately rely on a safety device to terminate or take
                                                        control of the process. The safety devices are there to protect when
                                                        operations fail. An additional philosophy was to always believe our
                                                        indications and respond to them as specified in our plans and
                                                        procedures unless there was positive proof that the indicator had
                                                        failed.

                                                        Much of this philosophy was echoed many years later when two
                                                        different commissions invstigated the accident at Three mile Island
                                                        (I've spent 20 years of my career cleaning up the mess created by
                                                        someone else's failure to implement a positive safety culture)

                                                        My opinion as a professional with considerable experiance in the
                                                        operation of cranes is that deliberately hitting the rail stop as a
                                                        means of terminating trolley movement is dangerous, irresponsible,
                                                        and indicative of a total lack of familiarity with ANSI B-30 series
                                                        of standards, OSHA requirements, and an operational attitude that
                                                        allows things to be done wrong until someone gets killed.

                                                        I apologize if I took an overly zealous stance in this posting,
                                                        especially since it is my first post. I work in the nuclear
                                                        decommissioning field and this issue touched a raw nerve. I've seen
                                                        too many situations involving misoperation, misuse, abuse of cranes
                                                        and lifting and handling equipment during my career. I believe that
                                                        serendipity and the grace of the almighty is all that has prevented
                                                        more death and destruction resulting from very poor lifting and
                                                        handling programs.

                                                        -- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Dr. Bill
                                                        Corcoran" <firebird.one@a...> wrote:
                                                        > Colleague,
                                                        >
                                                        > I am investigating an event in which operators routinely used a
                                                        safety device for operational purposes.
                                                        >
                                                        > After thousands of successful evolutions there was an evolution in
                                                        which the safety device was in a by-passed condition.
                                                        >
                                                        > Of course, an accident occurred.
                                                        >
                                                        > Would you be so kind as to
                                                        >   1.. tell me your thoughts in this area,
                                                        >   2.. let me know what corrective actions come to mind, and
                                                        >   3.. give me any examples you can think of?
                                                        > Thanks ever so much.
                                                        >
                                                        > Take care,
                                                        >
                                                        > Bill Corcoran
                                                        >
                                                        > W. R. Corcoran, Ph.D., P.E.
                                                        > Nuclear Safety Review Concepts
                                                        > 21 Broadleaf Circle
                                                        > Windsor, CT 06095-1634
                                                        > 860-285-8779
                                                        > Mission: Saving lives, pain, assets, and careers through thoughtful
                                                        inquiry.

                                                        > Check out our e-groups  at
                                                        > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                        > where you will find the back issues of "The Firebird Forum" through
                                                        2003 and at
                                                        > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                        > where you will find a dialogue on the Davis-Besse near miss LOCA.,
                                                        including photos, polls, files, tables, and links.
                                                        >
                                                        > For a complimentary subscription to our e-newsletter on root cause,
                                                        organizational learning, and safety send a message to
                                                        firebird.one@a...

                                                      • Terry Herrmann
                                                        Dr. Bill, I agree. That would influence the part of the equation titled Perceived risk . If it s a practice where you see other people using it and there
                                                        Message 27 of 27 , Apr 17, 2004
                                                          Dr. Bill,

                                                          I agree. That would influence the part of the equation titled "Perceived
                                                          risk". If it's a practice where you see other people using it and there
                                                          hasn't been any penalty, what's the perceived risk?

                                                          Terry Herrmann


                                                          From: "Dr. Bill Corcoran" <firebird.one@...>
                                                          Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                          To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                                          Subject: Re: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                          Operational Purposes: I need your help
                                                          Date: Fri, 16 Apr 2004 13:36:03 -0400

                                                          Terry,

                                                          Although I love faux equations, I am suspicious of yours.

                                                          My work indicates suggests that the probability of violating a know rule is,
                                                          to first order dominated, by the probability that the same rule had been
                                                          previously violated by the workers themselves or their co-workers.

                                                          I have never investigated an adverse event involving rule violation in which
                                                          the rule violation was claimed to have been a first time infraction.

                                                          Take care,

                                                          Bill Corcoran

                                                          W. R. Corcoran, Ph.D., P.E.
                                                          Nuclear Safety Review Concepts
                                                          21 Broadleaf Circle
                                                          Windsor, CT 06095-1634
                                                          860-285-8779
                                                          Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.

                                                          Check out our e-groups at
                                                          http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                          where you will find the back issues of "The Firebird Forum" through 2003 and
                                                          at
                                                          http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                          where you will find a dialogue on the Davis-Besse near miss LOCA., including
                                                          photos, polls, files, tables, and links.

                                                          For a complimentary subscription to our e-newsletter on root cause,
                                                          organizational learning, and safety send a message to
                                                          firebird.one@...

                                                          ----- Original Message -----
                                                          From: "Terry Herrmann" <jherrmt@...>
                                                          To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                                          Sent: Friday, April 16, 2004 8:23 AM
                                                          Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                          Operational Purposes: I need your help


                                                          > While I agree that the front office contributes to the use of many poor
                                                          work
                                                          > practices, making the assumption that it started there may be premature
                                                          > without further investigation.
                                                          >
                                                          > I've worked on both ends of the job (field worker and office supervisor)
                                                          and
                                                          > I've seen many cases where the folks in the field inherited poor safety
                                                          > practices from other workers and made efforts to hide this from the
                                                          office
                                                          > folks because they perceived OSHA and other safety rules as being
                                                          "overkill"
                                                          > (their words, not mine).
                                                          >
                                                          > It all has to do with the PERCEIVED threat. If people have always done
                                                          > something that seems to help them get the job done and they don't
                                                          perceive
                                                          > the practice to be likely to hurt anything based on their personal
                                                          > experience, they will continue to do it.
                                                          >
                                                          > I like to use the following equation when explaining this to our folks:
                                                          >
                                                          > Likelihood of violating a known rule = Perceived burden / Perceived risk
                                                          >
                                                          > Terry Herrmann
                                                          >
                                                          >
                                                          > From: "Lawrence B. Durham" <LBDurham@...>
                                                          > Reply-To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                          > To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                                          > Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                          > Operational Purposes: I need your help
                                                          > Date: Tue, 13 Apr 2004 10:33:13 -0500
                                                          >
                                                          > That's why in my first response I suggested that the issue(s) transcended
                                                          > the manifestations of problems. The more I hear on this matter, the more
                                                          I
                                                          > suspect a lax safety attitude site-wide. And, of course, that has its
                                                          "root
                                                          > cause" in the front office not on the shop floor or in the site yard
                                                          spaces.
                                                          > Depending on the situation, this could even be a corporate culture
                                                          problem
                                                          > and, perhaps, related work scheduling pressure demands that could be
                                                          > emanating from marketing. I've seen marketing pressure quality control
                                                          > pressure production in a plant start-up of a chemical fiber plant. Our
                                                          > Process Assistance Group had to detect it and step in to mediate
                                                          solutions
                                                          > acceptable to all parties. That one was complicated by the construction
                                                          > group's wanting to turn the plant over to manufacturing before QC would
                                                          > agree that the product was within design specs. Fun!
                                                          >
                                                          >
                                                          >
                                                          > Am I too far afield? Maybe; maybe not.
                                                          >
                                                          >
                                                          >
                                                          > VR/ Larry
                                                          >
                                                          >
                                                          >
                                                          > -----Original Message-----
                                                          > From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                          > Sent: Tuesday, April 13, 2004 9:22 AM
                                                          > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                          > Subject: Re: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                          > Operational Purposes: I need your help
                                                          >
                                                          >
                                                          >
                                                          > Larry,
                                                          >
                                                          >
                                                          >
                                                          > It's a bigger problem than cranes.
                                                          >
                                                          >
                                                          >
                                                          > The problem is all on-site load movements.
                                                          >
                                                          >
                                                          >
                                                          > Take care,
                                                          >
                                                          >
                                                          >
                                                          > Bill Corcoran
                                                          >
                                                          >
                                                          >
                                                          > W. R. Corcoran, Ph.D., P.E.
                                                          > Nuclear Safety Review Concepts
                                                          > 21 Broadleaf Circle
                                                          > Windsor, CT 06095-1634
                                                          > 860-285-8779
                                                          > Mission: Saving lives, pain, assets, and careers through thoughtful
                                                          inquiry.
                                                          >
                                                          > Check out our e-groups at
                                                          > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                          > where you will find the back issues of "The Firebird Forum" through 2003
                                                          and
                                                          > at
                                                          > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                          > where you will find a dialogue on the Davis-Besse near miss LOCA.,
                                                          including
                                                          > photos, polls, files, tables, and links.
                                                          >
                                                          >
                                                          >
                                                          > For a complimentary subscription to our e-newsletter on root cause,
                                                          > organizational learning, and safety send a message to
                                                          > firebird.one@...
                                                          >
                                                          > ----- Original Message -----
                                                          >
                                                          > From: Lawrence B. <mailto:LBDurham@...> Durham
                                                          >
                                                          > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                          >
                                                          > Sent: Tuesday, April 13, 2004 9:37 AM
                                                          >
                                                          > Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                          > Operational Purposes: I need your help
                                                          >
                                                          >
                                                          >
                                                          > Based on further traffic on this issue, I will contribute that I have
                                                          found
                                                          > crane training to be among the least attended to topics in nuclear power
                                                          > plants' curricula. In spite of Tech Spec requirements, it comes to be
                                                          > assumed almost as a "skill of the craft" function - sometimes even by
                                                          > auditors who should know better. Your "incident" may yet have broader
                                                          and
                                                          > deeper ramifications even though it's not in a nuclear environment. What
                                                          > about OSHA and ISO standards and procedures?
                                                          >
                                                          >
                                                          >
                                                          > LBD
                                                          >
                                                          >
                                                          >
                                                          > -----Original Message-----
                                                          > From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                          > Sent: Sunday, April 11, 2004 4:33 AM
                                                          > To: Root_Cause_State_of_the_Practice@yahoogroups.com;
                                                          > Root_Cause_State_of_the_Practice_II
                                                          > Subject: Fw: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                          > Operational Purposes: I need your help
                                                          >
                                                          >
                                                          >
                                                          > Larry,
                                                          >
                                                          >
                                                          >
                                                          > Thanks for your insights. The airline accident you are referring to is
                                                          > probably ValuJet 592. I don't recall it as involving using a safety
                                                          device
                                                          > for operational purposes, but it did involve communications and it did
                                                          > involve safety devices.
                                                          >
                                                          >
                                                          >
                                                          > The venue for the safety device incident that prompted my request was not
                                                          a
                                                          > nuclear power plant, but that probably doesn't matter.
                                                          >
                                                          >
                                                          >
                                                          > I am still scratching my head over why all of the people who knew that
                                                          the
                                                          > safety device was being used for operational purposes didn't speak up.
                                                          This
                                                          > is a teamwork issue if they realized what they were seeing.
                                                          >
                                                          >
                                                          >
                                                          > How many of us never turn off our headlights until after we have opened
                                                          the
                                                          > driver's door and received the "headlights still on" warning light?
                                                          >
                                                          >
                                                          >
                                                          > Are there still people out there who house a crane hoist by actuating the
                                                          > two-block limit switch?
                                                          >
                                                          >
                                                          >
                                                          > Are there other examples of activities that challenge safety devices?
                                                          >
                                                          >
                                                          >
                                                          > Take care,
                                                          >
                                                          >
                                                          >
                                                          > Bill Corcoran
                                                          >
                                                          >
                                                          >
                                                          > W. R. Corcoran, Ph.D., P.E.
                                                          > Nuclear Safety Review Concepts
                                                          > 21 Broadleaf Circle
                                                          > Windsor, CT 06095-1634
                                                          > 860-285-8779
                                                          > Mission: Saving lives, pain, assets, and careers through thoughtful
                                                          inquiry.
                                                          >
                                                          > Check out our e-groups at
                                                          > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
                                                          > where you will find the back issues of "The Firebird Forum" through 2003
                                                          and
                                                          > at
                                                          > http://groups.yahoo.com/group/DBRVH_LTBL_II/
                                                          > where you will find a dialogue on the Davis-Besse near miss LOCA.,
                                                          including
                                                          > photos, polls, files, tables, and links.
                                                          >
                                                          >
                                                          >
                                                          > For a complimentary subscription to our e-newsletter on root cause,
                                                          > organizational learning, and safety send a message to
                                                          > firebird.one@...
                                                          >
                                                          > ----- Original Message -----
                                                          >
                                                          > From: Lawrence B. Durham <mailto:LBDurham@...>
                                                          >
                                                          > To: William Corcoran <mailto:williamcorcoran@...>
                                                          >
                                                          > Sent: Saturday, April 10, 2004 7:37 PM
                                                          >
                                                          > Subject: FW: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                          > Operational Purposes: I need your help
                                                          >
                                                          >
                                                          >
                                                          > Bill,
                                                          >
                                                          >
                                                          >
                                                          > For some reason, I can't mail out to the entire group as I tried to do.
                                                          You
                                                          > may forward this to whomever you wish if you wish.
                                                          >
                                                          >
                                                          >
                                                          > Best regards for a HAPPY EASTER!!!
                                                          >
                                                          >
                                                          >
                                                          > Larry
                                                          >
                                                          >
                                                          >
                                                          > -----Original Message-----
                                                          > From: Lawrence B. Durham [mailto:LBDurham@...]
                                                          > Sent: Saturday, April 10, 2004 6:03 PM
                                                          > To: Root_Cause_State_of_the_Practice@yahoogroups.com;
                                                          > 'Root_Cause_State_of_the_Practice_II'
                                                          > Subject: RE: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                          > Operational Purposes: I need your help
                                                          >
                                                          >
                                                          >
                                                          > Bill, bear in mind that I'm watching the Masters' Golf Tournament as I
                                                          think
                                                          > about your questions and write this response. I've seen some of the
                                                          world's
                                                          > best players muff shots like ones that they've made successfully
                                                          literally
                                                          > thousands of times. To my knowledge, the PGA won't be kicking anyone out
                                                          of
                                                          > the organization for those errors. (Granted lives do not typically
                                                          depend
                                                          > on golf shots.) Each golf professional is more eager than anyone else to
                                                          > maintain and improve his (or her) game. Hopefully, the operators are in
                                                          an
                                                          > organizational environment that also doesn't "go after" people who make
                                                          > mistakes and where individuals are self-motivated to constantly seek to
                                                          > improve and avoid mistakes.
                                                          >
                                                          >
                                                          >
                                                          > Nonetheless, an accident happened. My first thoughts ran toward checking
                                                          > if, how, and when the relevant evolutions were included in pre-briefings
                                                          > and/or training exercises. For years, I have shared with many folks the
                                                          > feeling that the nuclear industry is so attentive to the avoidance of
                                                          > abnormal conditions that it overlooks providing sufficient attention to
                                                          > reinforcing the proper execution of routine operating procedures. My
                                                          second
                                                          > wave of thought on this matter went to the realm of effective three-way
                                                          > communication. Back to golf, top players ask their caddies for advice
                                                          and
                                                          > feedback - both before and after their shots. I don't see much of that
                                                          type
                                                          > of behavior among our nuclear workforce. How was the intra-team
                                                          > communication in this case?
                                                          >
                                                          >
                                                          >
                                                          > As for suggested corrective actions, your hardest job in this case may be
                                                          > persuading plant management that it may not be a training problem. Even
                                                          > though I have already suggested looking at the related training, please
                                                          > don't mistake that question for my having jumped to the same conclusion -
                                                          > insufficient (and, maybe, inadequate) training. Based on your sketch, it
                                                          > would seem that they had already demonstrated many times that they knew
                                                          what
                                                          > to do and how to do it. Thus, the question is why didn't they do it as
                                                          they
                                                          > had before? Though I sound like an echo of you, I have to remind even
                                                          you
                                                          > to "just ask them". Frankly, this sounds very much like a complacency
                                                          and
                                                          > operational attitude situation. I would respectfully suggest an
                                                          > environmental analysis of the organizational culture. I would make a
                                                          small
                                                          > wager that such an investigation would detect a number of other
                                                          less-visible
                                                          > errors that have stayed "below the radar". You taught me too well to get
                                                          me
                                                          > to "bite" on specific corrective action(s) absent further data.
                                                          >
                                                          > However, this one "feels" very much like a supervisory and, therefore,
                                                          > management problem that unfortunately manifested itself in a critical
                                                          > manner. I would suggest that after the company is comfortable that the
                                                          root
                                                          > causes have been identified that the cognizant manager and the
                                                          > directly-involved employee(s) should provide "lessons-learned" briefings
                                                          to
                                                          > their associates throughout the plant and develop a case study for INPO
                                                          > dissemination.
                                                          >
                                                          >
                                                          >
                                                          > The best examples that come to mind were reported in the airline cases
                                                          (poor
                                                          > communications and teamwork) reported out several years ago. I don't
                                                          > remember the specific reference, but I'll bet you know it and probably
                                                          have
                                                          > a copy. (If so, please send the reference back to me.) And,
                                                          regrettably,
                                                          > it also has certain tones of the Davis-Besse inattention-to-detail,
                                                          > "business-as-usual" syndrome. On a matter that I polled this network
                                                          about
                                                          > last year, the realm of medical mistakes also offers all too many
                                                          potential
                                                          > comparisons - from mis-filled prescriptions to amputating the wrong limbs
                                                          to
                                                          > fatal anesthesia techniques. And, finally, to return to my golfing
                                                          analogy,
                                                          > rules and procedures that are typically followed so faithfully to avoid
                                                          > disqualification are, nonetheless, sometimes broken by top players who
                                                          make
                                                          > stupid mistakes like not signing their cards after a completed round or
                                                          by
                                                          > inadvertently moving a ball by not walking carefully in the woods as one
                                                          > looks for it after an errant shot.
                                                          >
                                                          >
                                                          >
                                                          > I hope that this helps. As always, I would appreciate your assessment of
                                                          my
                                                          > critique and observations and suggestions. As more details are
                                                          releasable,
                                                          > please share them and the course of action that is followed by the
                                                          company.
                                                          >
                                                          >
                                                          >
                                                          > HAPPY EASTER!
                                                          >
                                                          >
                                                          >
                                                          > VR/LBD
                                                          >
                                                          >
                                                          >
                                                          >
                                                          >
                                                          > -----Original Message-----
                                                          > From: Dr. Bill Corcoran [mailto:firebird.one@...]
                                                          > Sent: Saturday, April 10, 2004 9:34 AM
                                                          > To: Root_Cause_State_of_the_Practice@yahoogroups.com;
                                                          > Root_Cause_State_of_the_Practice_II
                                                          > Subject: [Root_Cause_State_of_the_Practice] Using Safety Devices for
                                                          > Operational Purposes: I need your help
                                                          >
                                                          >
                                                          >
                                                          > Colleague,
                                                          >
                                                          >
                                                          >
                                                          > I am investigating an event in which operators routinely used a safety
                                                          > device for operational purposes.
                                                          >
                                                          >
                                                          >
                                                          > After thousands of successful evolutions there was an evolution in which
                                                          the
                                                          > safety device was in a by-passed condition.
                                                          >
                                                          >
                                                          >
                                                          > Of course, an accident occurred.
                                                          >
                                                          >
                                                          >
                                                          > Would you be so kind as to
                                                          >
                                                          > 1. tell me your thoughts in this area,
                                                          >
                                                          > 2. let me know what corrective actions come to mind, and
                                                          >
                                                          > 3. give me any examples you can think of?
                                                          >
                                                          > Thanks ever so much.
                                                          >
                                                          >
                                                          >
                                                          > Take care,
                                                          >
                                                          >
                                                          >
                                                          > Bill Corcoran
                                                          >
                                                          >
                                                          >
                                                          > W. R. Corcoran, Ph.D., P.E.
                                                          > Nuclear Safety Review Concepts
                                                          > 21 Broadleaf Circle
                                                          > Windsor, CT 06095-1634
                                                          > 860-285-8779
                                                          > Mission: Saving lives, pain, assets, and careers through thoughtful
                                                          inquiry.
                                                          >
                                                          > Check out our e-groups at
                                                          > http://groups.yahoo.com/group/Root_Cause_State_of_the_Practice/
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