Re: [Root_Cause_State_of_the_Practice] Broader Ramifications, Extent of Condition, Generic Implications, etc.
- "Have a safe and skeptical New Year"? I love it, Bill!Be safe everyone and take care. Those of you in the Northeast US - stay home tonight! My speaking engagement tonight is cancelled due to the possible combination of snow and drunken drivers. Certainly not a good mix... Even lacking my own RCA qualifications, I certainly understand this!Jack Stanford, SRO/PE
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Haddam, CT 06438----- Original Message -----From: Dr. Bill CorcoranSent: Saturday, December 31, 2005 9:31 AMSubject: [Root_Cause_State_of_the_Practice] Broader Ramifications, Extent of Condition, Generic Implications, etc.Here is an attempt at a tabular presentation of this thorny topic.I await your thoughts.Have a safe and skeptical New Year.Take care,
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Name: Broader Ramifications, Extent of Condition, Generic Implications, etc.
Table Description: What does it mean when you find a problem? Well, it depends. There are lots of opinions as to what the terminology is and what the definitions are. Join the donnybrook and add your own two cents. Click on the "sorting number" column to rank the rows. If you receive this as a table someone has already sorted it. Issue Terminology Meaning Who says? Application or example Sources Caveats, downsides, and unintended consequences. Comments Exercises for readers Sorting number (click on this to sort) So you find a problem. It is probably not isolated. What do you need to look for? Given the existence of the problem what else could reasonably exist that your organization should know about? THE BROADER RAMIFICATIONS Given a) the existence of the problem and b) what is known about the context, then c) what else could reasonably exist that your organization should know about? Bill Corcoran. Who else? Send an e-mail to William.R.Corcoran@ 1959.USNA. com The containment air cooler repeatedly fouls at a nuclear power plant. See other items in this column. http://groups. yahoo.com/ group/DBRVH_ LTBL/ Clearly you don't want to go after world hunger when the cafeteria runs out of fries. If you are interested in the prompt identification of conditions adverse to quality (or safety) you will go after the broader ramifications. Write down at least four of the broader ramifications of the last problem you encountered in your living quarters. 0001 Given that "broader ramifications" is a set, what are the proper subsets? Set, proper subset Set: a collection of similar items. Proper subset: a collection of items, each of which belongs to the set. Bill Corcoran. Who else? Send an e-mail to William.R.Corcoran@ 1959.USNA. com The subsets of the set of broader ramifications of existing containment air cooler fouling include 1) what it could cause, 2) what is causing it, 3) what are the other effects of the foulant, and 4) what other foulants exist. Deductive reasoning. If you go this way you will alienate many fine people who know nothing about set theory. Possible tactic: Use the ideas, but express your results in small, simple, ordinary words. If the owners of the Davis-Besse Nuclear Plant had asked these questions they could have saved about $500million or so!! Do a Google search on "broader ramifications" and read a few of the hits. 0002 Is there any difference between "broader ramifications" and "generic implications" ? Generic implications (Plain English) The answer to: What else is implied by the existence of the problem? Bill Corcoran. Who else? Send an e-mail to William.R.Corcoran@ 1959.USNA. com The NRC generally uses "generic implications" to refer to the existence of a similar problem at other facilities. www.nrc.gov Anyone is free to attach their own meanings to English words and phrases, and many do. When you see the term "generic implications" note the context in which it is used. If you want to understand, find out what the other person means. If you want to be understood, say what you mean. Do a Google search on "generic implications" and read a few of the hits. 0003 Doesn't "extent of condition" cover it all? Extent of Condition Plain English: Given a defined "condition", the extent of the condition could include its extent in any one of a number of dimensions such as time, space, area, number, or the like. Bill Corcoran. Who else? Send an e-mail to William.R.Corcoran@ 1959.USNA. com A school nurse notices that a child has poison ivy rash on its hand. The extent of this condition could be: 1) where else on the child's body is the rash, 2) how long has the rash existed, 3) how many other children have the rash, 4) you pick it. The Firebird Forum, Volume 8, Number 2, Generic Implications/ Extent of Condition The term "extent of condition" can take on a variety of meanings in plain English. Listen carefully. If the behaviors and/or conditions happened before in your organization it tells you something about organizational learning. If they apply in other parts of your organization it tells you something about culture. Do a Google search on "extent of condition" and read a few of the hits. 0004 What are some narrow uses of the term "extent of condition". "extent of condition" Some organizations define "extent of condition" to mean "more of the same". Bill Corcoran. Who else? Send an e-mail to William.R.Corcoran@ 1959.USNA. com The extent of condition of containment air cooler fouling could include: 1) how many air coolers are fouled, 2) how long had they been fouled, 3) how bad is the fouling, 4) how many other containment components are fouled, .... If you have a non-plain English definition some people will think you are speaking plain English and be mislead. It is not a good idea to hijack plain English to restrict meaning. Discuss the extent of condition of the following: containment air cooler fouling at Davis-Besse, rad monitor filter clogging at Davis-Besse. 0004.1 What is transportability? transportability In plain English, "transportability" has to do with migration elsewhere. Many items are transportable (or have transportability) , including behaviors, conditions, causes, and effects, and oh, by the way, corrective actions. Bill Corcoran. Who else? Send an e-mail to William.R.Corcoran@ 1959.USNA. com Sand blast grit left in a heat exchanger will be transported throughout the system if the system is turned on before the grit is removed. Palo Verde NGS uses the term "transportability" more than other facilities. Transportability is one aspect of broader ramifications, not the only one. Do a Google search on "transportability" and read a few of the hits. 0005 How far should generic implications be taken? Residual risk Residual risk is that risk remaining when all cost-effective risk reduction measures have been deployed. Bill Corcoran. Who else? Send an e-mail to William.R.Corcoran@ 1959.USNA. com A business should take generic implications as far as the point of diminishing cost-effectiveness. Another way to say this is to the point at which additional risk factors will be expected to be residual risk. If the search for generic implications is too narrow latent adverse conditions and behaviors will be left concealed and lurking in the background to cause future harm. If the search for generic implications is taken beyond reason the searchers will lose credibility. Where should the search for the generic implications of the containment air cooler fouling have gone at Davis-Besse. 0006 What is an example of not going far enough? This is an isolated case. This usually means, "Going after extent is a career-limiting activity." Bill Corcoran. Who else? Send an e-mail to William.R.Corcoran@ 1959.USNA. com Extensive project rework was caused, in part, by a defect in the bid process. Investigators did not look for other bid process defects. The other bid process defects were later involved in a worse event. Whenever you find a process defect, ask what other defects there are in the same process. 0006.1 Why would one want to "low ball" extent of cause, extent of condition, generic implications, and/or broader ramifications? Commitment to the status quo. There are many forms of an many motivations for keeping things as they are. Bill Corcoran. Who else? Send an e-mail to William.R.Corcoran@ 1959.USNA. com Army Corps of Engineers management of New Orleans Levee System. Navy management of silver-brazed joints before the loss of USS Thresher (SSN-593). NASA management of foam strikes before loss of Columbia. Machiavelli, "The Prince" http://www.constitu tion.org/ mac/prince00. htm The problem you are now working on is not isolated. It is the natural and inevitable result of the way business is done. If the problem is unacceptable the search for generic implications, etc. will thoroughly disrupt the organization. Use Google to investigate the savings and loan debacle. 0007