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Re: [Root_Cause_State_of_the_Practice] potential wrong doing events

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  • Dr. Bill Corcoran
    Bill Leonard, Thanks for chiming in. I was involved in an event in which the wrongdoing was not a causal factor of the event, but it was a causal factor of the
    Message 1 of 3 , Jul 31, 2007
      Bill Leonard,
       
      Thanks for chiming in.
       
      I was involved in an event in which the wrongdoing was not a causal factor of the event, but it was a causal factor of the event's not being addressed earlier.
       
      Strangely enough the people involved in the cover-up probably would have faced no personal consequences for their roles in the original event, but they were canned over the cover-up.
       
      Because of special circumstances not involving the wrongdoing, the root cause team was working under the "supervision" of an outside lawyer. We informed him and he concurred with the team's recommendation to continue the investigation without pursuing the wrongdoing aspects. The lawyers took that part over.
       
      The whole thing went very smoothly with the lawyers and HR people handling the wrongdoing and the root cause analysis team handling everything else.
       
      It is important for rooticians to be clear about the difference between "wrongdoing" and the mere doing of wrong, i.e., fouling up.
       
       
      Take care,
       
      Bill Corcoran
       
      W. R. Corcoran, Ph.D., P.E.
      NSRC Corporation
      21 Broadleaf Circle
      Windsor, CT 06095-1634
      Voice and voice mail: 860-285-8779
       
      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
      Method: Mastering Investigative Technologies 
       
      Call or e-mail me to ask about the one-day Root Cause Analysis Training Workshop in Amelia Island, FL on August 9, 2007.
      It's open to all high hazard industry professionals. Register on-line at
      http://www.ans.org/meetings/calendar.cgi?d=8-5-2007 
       
       
      For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@...
      ----- Original Message -----
      Sent: Monday, July 30, 2007 12:28 PM
      Subject: RE: [Root_Cause_State_of_the_Practice] potential wrong doing events

      We have actually faced this situation and handled it in a variety of different ways depending on the event/condition being investigated.  If during the investigation, there is an appearance of illegality (sabotage comes to mind), we get our HR and Security departments involved and let them take over the investigation.  The primary reason for doing this is because the investigation will likely interrogate personnel involved and result in significant disciplinary action and possible criminal action.  It is extremely rare that these types of events happen so there are many occasions where the investigation gets turned over  
       
      We have also investigated events where obvious performance issues were involved.  For instance, we investigated a steam/water hammer event and discovered that it happened because a power operator intentionally violated the procedure to get the steam system back on line.  The reason he did this was because he was called in on overtime and knew that he was going to get paid for 4 hours, regardless of whether or not he was on site for 1 hour or 4 hours.  Although there were some management oversight issues associated with this, the facts were that the power operator was given a detailed prejob, told to follow the procedure (especially due to a recent fatality involving a steam/water hammer event) and then clearly demonstrated intent to violate the procedure.  He tried to cover it up by back dating (time) and initialing the datasheets, however the investigation revealed that it could not be done as was recorded and ultimately he came clean with what really happened and what his motivation was.
       
      Bill Leonard, Manager
      FH Corrective Action Management Project Support


      From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Dr. Bill Corcoran
      Sent: Friday, July 27, 2007 5:04 AM
      To: Undisclosed- Recipient: ;
      Subject: [Root_Cause_ State_of_ the_Practice] potential wrong doing events

      A colleague asked the following:

      I would like to understand how other organizations handle potential wrong doing events:

      1.      When an event occurs and a cause investigation starts AND it looks like potential wrong doing (willful violations, falsification, etc) >>may be<< involved, how does your organization respond?  I have noted that even the best >>cause<< investigators may not have the background  and skills or use techniques suitable for wrong doing situations when doing a cause investigation.

      2.      When a potential wrong doing case does come up (some may be obvious from the start and others may not), what part of the organization investigates?     (Line, ECP, Law, Regulatory Affairs, Corporate Security?)

      How does your organization do it?
       
      Take care,
       
      Bill Corcoran
       
      W. R. Corcoran, Ph.D., P.E.
      NSRC Corporation
      21 Broadleaf Circle
      Windsor, CT 06095-1634
      Voice and voice mail: 860-285-8779
       
      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
      Method: Mastering Investigative Technologies 
       
      Call or e-mail me to ask about the one-day Root Cause Analysis Training Workshop in Amelia Island, FL on August 9, 2007.
      It's open to all high hazard industry professionals. Register on-line at http://www.ans. org/meetings/ calendar. cgi?d=8-5- 2007 
       
       
      For a complimentary subscription to our e-newsletter on root cause, organizational learning, and safety send a message to firebird.one@ alum.MIT. edu

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