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

I have a dilemma: knowledge-based omission

Expand Messages
  • Glen Mitchell
    I have a knowledge-based task in which an omission was made. No decision logic was documented on how they selected the hazards and subsequent controls, and
    Message 1 of 4 , Sep 10, 2007
    • 0 Attachment
      I have a knowledge-based task in which an omission was made. No decision
      logic was documented on how they selected the hazards and subsequent
      controls, and those making the omission are no longer with us (moved on,
      not dead).
      I recognize that "knowledge-based" omission of a hazard is a category
      not a cause, but how do I get any deeper?

      We have noted other omissions and they generally point to a less-mature
      process, where descriptions and analysis were more general than
      specific, but we have no documentation of the decision logic for hazard
      selection, description or control.

      We are doing an number of things to improve the knowledge-base, LL from
      past uh-ohs, more detailed qualifications, more specific, hands on
      training, retention efforts to keep folks, etc. However, to
      specifically state that these things will prevent omissions? And how
      would we measure that anywho?

      enough rant, gotta go get confused at a higher level about more
      important things (Deal with the PAAA rep)

      glen
      -desk-806-477-4953
      -pager-806-345-9196
    • Bill Wightkin
      Would some type of independent peer review be applicable here? /bill ... ____________________________________________________________________________________
      Message 2 of 4 , Sep 10, 2007
      • 0 Attachment
        Would some type of independent peer review be
        applicable here?

        /bill
        --- Glen Mitchell <gmitchel@...> wrote:

        > I have a knowledge-based task in which an omission
        > was made. No decision
        > logic was documented on how they selected the
        > hazards and subsequent
        > controls, and those making the omission are no
        > longer with us (moved on,
        > not dead).
        > I recognize that "knowledge-based" omission of a
        > hazard is a category
        > not a cause, but how do I get any deeper?
        >
        > We have noted other omissions and they generally
        > point to a less-mature
        > process, where descriptions and analysis were more
        > general than
        > specific, but we have no documentation of the
        > decision logic for hazard
        > selection, description or control.
        >
        > We are doing an number of things to improve the
        > knowledge-base, LL from
        > past uh-ohs, more detailed qualifications, more
        > specific, hands on
        > training, retention efforts to keep folks, etc.
        > However, to
        > specifically state that these things will prevent
        > omissions? And how
        > would we measure that anywho?
        >
        > enough rant, gotta go get confused at a higher level
        > about more
        > important things (Deal with the PAAA rep)
        >
        > glen
        > -desk-806-477-4953
        > -pager-806-345-9196
        >
        >




        ____________________________________________________________________________________
        Sick sense of humor? Visit Yahoo! TV's
        Comedy with an Edge to see what's on, when.
        http://tv.yahoo.com/collections/222
      • Dr. Bill Corcoran
        Glen, One of the factors of every knowledge-based error is that the person was shifted into a knowledge-based mode. You could ask, What were the factors that
        Message 3 of 4 , Sep 10, 2007
        • 0 Attachment
          Glen,
           
          One of the factors of every knowledge-based error is that the person was shifted into a knowledge-based mode.
           
          You could ask, "What were the factors that resulted in having the person in the knowledge-based mode?"
           
          Often it is easy to change the situation to keep the person rule-based.
           
          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 
           
          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, September 10, 2007 3:15 PM
          Subject: [Root_Cause_State_of_the_Practice] I have a dilemma: knowledge-based omission

          I have a knowledge-based task in which an omission was made. No decision
          logic was documented on how they selected the hazards and subsequent
          controls, and those making the omission are no longer with us (moved on,
          not dead).
          I recognize that "knowledge-based" omission of a hazard is a category
          not a cause, but how do I get any deeper?

          We have noted other omissions and they generally point to a less-mature
          process, where descriptions and analysis were more general than
          specific, but we have no documentation of the decision logic for hazard
          selection, description or control.

          We are doing an number of things to improve the knowledge-base, LL from
          past uh-ohs, more detailed qualifications, more specific, hands on
          training, retention efforts to keep folks, etc. However, to
          specifically state that these things will prevent omissions? And how
          would we measure that anywho?

          enough rant, gotta go get confused at a higher level about more
          important things (Deal with the PAAA rep)

          glen
          -desk-806-477- 4953
          -pager-806-345- 9196

        • Terry Herrmann
          Glen, Omissions in knowledge-based activities are not unexpected. This is why those types of activities are typically designed to have redundant barriers to
          Message 4 of 4 , Sep 10, 2007
          • 0 Attachment

            Glen,

            Omissions in knowledge-based activities are not unexpected. This is why those types of activities are typically designed to have redundant barriers to omissions or errors through the use of independent reviews.

            I'd suggest using a barrier analysis approach to identify barriers that were intended to prevent the omission that were ineffective and any barriers that could reasonably helped to prevent the omission that were missing.  I'd also look at the earlier events to see what similarities there are to this omission and what other distinctions there are between this omission and the others you describe as "lesse mature processes".  If this was more mature, what other factors were involved that led to the omission?

            Hope this helps.

            Terry Herrmann



             


            From: "Glen Mitchell" <gmitchel@...>
            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] I have a dilemma: knowledge-based omission
            Date: Mon, 10 Sep 2007 14:15:15 -0500

            I have a knowledge-based task in which an omission was made. No decision
            logic was documented on how they selected the hazards and subsequent
            controls, and those making the omission are no longer with us (moved on,
            not dead).
            I recognize that "knowledge-based" omission of a hazard is a category
            not a cause, but how do I get any deeper?

            We have noted other omissions and they generally point to a less-mature
            process, where descriptions and analysis were more general than
            specific, but we have no documentation of the decision logic for hazard
            selection, description or control.

            We are doing an number of things to improve the knowledge-base, LL from
            past uh-ohs, more detailed qualifications, more specific, hands on
            training, retention efforts to keep folks, etc. However, to
            specifically state that these things will prevent omissions? And how
            would we measure that anywho?

            enough rant, gotta go get confused at a higher level about more
            important things (Deal with the PAAA rep)

            glen
            -desk-806-477- 4953
            -pager-806-345- 9196




            Discover sweet stuff waiting for you at the Messenger Cafe.� Claim your treat today!
          Your message has been successfully submitted and would be delivered to recipients shortly.