Loading ...
Sorry, an error occurred while loading the content.

Root Cause: bad review / cures for the real causes

Expand Messages
  • Glen Mitchell
    The actual root causes were in the reward system, some unreasonable expectations, and the lack of tools to deal with the complexity of requirements. Our safety
    Message 1 of 1 , May 1, 2007
    • 0 Attachment
      The actual root causes were in the reward system, some unreasonable
      expectations, and the lack of tools to deal with the complexity of
      requirements.

      Our safety basis is extremely complex, coupled with an extremely
      complex and multi-headed customer, and unclear responsibility lines in
      our organization (unclear requirements at interfaces)

      The dependence on reviews for document quality is unreasonable, but
      understandable given the growth history here. Each change has a large
      number of potential impacts on different highly specialized
      organizations, each of which needs input on how the change is
      implemented to avoid conflicts and non-compliances with numerous
      oversight orgs and customers. (cures causing the next event)

      The challenge is getting all the impacts identified and input received
      from all these separate and often contradictory interests.

      I know there are Knowledge Management softwares out there that could
      help us to bring the specialist knowledge base to the change initiator
      at the start, but thought someone here might steer me to some that will
      do the following:
      Work from a change request document rather than the initiator having to
      build a search profile.
      Use AI to improve the profile engine over time
      Access any format document, including doing OCR on scanned documents.
      Work from windows machines and on multiple mainframe operating
      systems.


      glen
      -desk-806-477-4953
      -pager-806-345-9196
    Your message has been successfully submitted and would be delivered to recipients shortly.