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All Accidents are Like the Following:

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  • DR WILLIAM CORCORAN
    All Accidents are Like One or More of the Following:   Russian Roulette, i.e., performing a known hazardous activity time and time again until the round is in
    Message 1 of 6 , Feb 2, 2009
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      All Accidents are Like One or More of the Following:
       
      • Russian Roulette, i.e., performing a known hazardous activity time and time again until the round is in the chanber: Example: U.S. Airways Flight 1549, The Peanut Butter Salmonella Outbreak
      • Cancer: Ignoring the early warning signs until the situation progresses beyond simple remedial action: Example: Davis-Besse 2002, The Sub-prime Mortgage Crisis
      • Heart Attack: Continuing a known dysfunctional life style until the causal factors pile up to overwhelm the system: Example: BP Texas City
       
      What fraction of consequentials fall in one or more of those categories?
      What additional categories are needed to catch 99% of consequentials?


      Take care,
       
      Bill Corcoran
      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.
       
      W. R. Corcoran, Ph.D., P.E.
      NSRC Corporation
      21 Broadleaf Circle
      Windsor, CT 06095-1634
      860-285-8779
       
      Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
      Join the group advancing the practice of root cause analysis  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
    • Paul Oortman Gerlings
      Bonjour mr. Bill (and others), Thanks for sharing these sharp observations. They tickle the fantasy and challenge the brain. However, before being able to
      Message 2 of 6 , Feb 3, 2009
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        Bonjour mr. Bill (and others),

         

        Thanks for sharing these sharp observations. They tickle the fantasy and challenge the brain.

         

        However, before being able to answer the questions, there are other issues that have to be resolved.

        (1)   Can all accidents be assigned only to one of these categories? Or is it possible that one accident

        has characteristics of two or even three categories? How should such cases be classified?

        (assuming we feel they should to add up to 99 or 100%)

        (2)   Do all players agree with the classification of an accident? Or can it be that various (groups of)

        players come to a different classification than others? What should be done in such cases?

        Who has the ultimate power to define the situation?

         

        Some thoughts after coffee from sunny Geneva,

         

        Paul.

         

         

        00000000000000000000000000000000000000000000000000000000000000000000

        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
        Sent: lundi, 2. février 2009 17:06
        To: root_cause_state_of_the_practice@yahoogroups.com
        Subject: [Root_Cause_State_of_the_Practice] All Accidents are Like the Following:

         

        All Accidents are Like One or More of the Following:

         

        • Russian Roulette, i.e., performing a known hazardous activity time and time again until the round is in the chanber: Example: U.S. Airways Flight 1549, The Peanut Butter Salmonella Outbreak
        • Cancer: Ignoring the early warning signs until the situation progresses beyond simple remedial action: Example: Davis-Besse 2002, The Sub-prime Mortgage Crisis
        • Heart Attack: Continuing a known dysfunctional life style until the causal factors pile up to overwhelm the system: Example: BP Texas City

         

        What fraction of consequentials fall in one or more of those categories?

        What additional categories are needed to catch 99% of consequentials?

         

      • Lawrence B. Durham
        Bill, My mathematics background causes me to have to respectfully disagree with your semantic restriction of all accidents into these three categories. In the
        Message 3 of 6 , Feb 3, 2009
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          Bill,

           

          My mathematics background causes me to have to respectfully disagree with your semantic restriction of all accidents into these three categories. In the first place, mathematicians are very reluctant to say "always" or "never" without a rigorous proof of the postulated theorem. Secondly, a single counter-example can disprove a theorem. In that regard, I contend that the following two examples would not fit into any one of the three postulated categories:

           

          1.   Falling on "black ice" on an asphalt parking lot when one had never before been in such conditions or even known what "black ice" was.

          2.   Falling off the back of a lift-gate truck when the lift-gate was lowered without notice to the worker removing material from the lift-gate into the truck. Again, the worker had never even been around such equipment before the incident.

           

          Your categories pre-suppose malfunctions after related preceding activities over time. I respectfully contend that some accidents happen absent earlier relevant activity. Incidentally, as you might have suspected, I was the accident "victim" in each of the above-stated examples. Am I missing something? Or, would you classify either of my accidents into one or more of your three categories?

           

          As for an additional category, I would suggest "Sudden Occurrence" because my intent is to communicate an absence of the continuation factor suggested by each of your three categories. Maybe you or others will be able to suggest a better label - if, indeed, you even accept my line of thinking. As for proportions falling into the various classifications, I have no data on which to base a guess. However, intuitively, I would conjecture that about half of "all" accidents might fall into your three categories - combined - and the remainder into the category that I am suggesting.

           

          Respectfully,

           

          Larry

           

          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
          Sent: Monday, February 02, 2009 10:06 AM
          To: root_cause_state_of_the_practice@yahoogroups.com
          Subject: [Root_Cause_State_of_the_Practice] All Accidents are Like the Following:

           

          All Accidents are Like One or More of the Following:

           

          • Russian Roulette, i.e., performing a known hazardous activity time and time again until the round is in the chanber: Example: U.S. Airways Flight 1549, The Peanut Butter Salmonella Outbreak
          • Cancer: Ignoring the early warning signs until the situation progresses beyond simple remedial action: Example: Davis-Besse 2002, The Sub-prime Mortgage Crisis
          • Heart Attack: Continuing a known dysfunctional life style until the causal factors pile up to overwhelm the system: Example: BP Texas City

           

          What fraction of consequentials fall in one or more of those categories?

          What additional categories are needed to catch 99% of consequentials?

           

          Take care,
           
          Bill Corcoran
          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.
           
          W. R. Corcoran, Ph.D., P.E.
          NSRC Corporation
          21 Broadleaf Circle
          Windsor, CT 06095-1634
          860-285-8779

           

          Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com

          Join the group advancing the practice of root cause analysis  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com

        • Salot, William
          Larry D and Bill C, I would call Larry s new category land mines . If you are unaware of them, or even if you are aware and try to avoid them, you can still
          Message 4 of 6 , Feb 3, 2009
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            Larry D and Bill C,

             

            I would call Larry’s new category “land mines”.  If you are unaware of them, or even if you are aware and try to avoid them, you can still step on one.

             

            Bill Salot


            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto: Root_Cause_State_of_the_Practice@yahoogroups.com ] On Behalf Of Lawrence B. Durham
            Sent: Tuesday, February 03, 2009 1:59 PM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: RE: [Root_Cause_State_of_the_Practice] All Accidents are Like the Following:

             

            Bill,

             

            My mathematics background causes me to have to respectfully disagree with your semantic restriction of all accidents into these three categories. In the first place, mathematicians are very reluctant to say "always" or "never" without a rigorous proof of the postulated theorem. Secondly, a single counter-example can disprove a theorem. In that regard, I contend that the following two examples would not fit into any one of the three postulated categories:

             

            1.   Falling on "black ice" on an asphalt parking lot when one had never before been in such conditions or even known what "black ice" was.

            2.   Falling off the back of a lift-gate truck when the lift-gate was lowered without notice to the worker removing material from the lift-gate into the truck. Again, the worker had never even been around such equipment before the incident.

             

            Your categories pre-suppose malfunctions after related preceding activities over time. I respectfully contend that some accidents happen absent earlier relevant activity. Incidentally, as you might have suspected, I was the accident "victim" in each of the above-stated examples. Am I missing something? Or, would you classify either of my accidents into one or more of your three categories?

             

            As for an additional category, I would suggest "Sudden Occurrence" because my intent is to communicate an absence of the continuation factor suggested by each of your three categories. Maybe you or others will be able to suggest a better label - if, indeed, you even accept my line of thinking. As for proportions falling into the various classifications, I have no data on which to base a guess. However, intuitively, I would conjecture that about half of "all" accidents might fall into your three categories - combined - and the remainder into the category that I am suggesting.

             

            Respectfully,

             

            Larry

             

            From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto: Root_ Cause_State_ of_the_Practice@ yahoogroups. com ] On Behalf Of DR WILLIAM CORCORAN
            Sent: Monday, February 02, 2009 10:06 AM
            To: root_cause_state_ of_the_practice@ yahoogroups. com
            Subject: [Root_Cause_ State_of_ the_Practice] All Accidents are Like the Following:

             

            All Accidents are Like One or More of the Following:

             

            • Russian Roulette, i.e., performing a known hazardous activity time and time again until the round is in the chanber: Example: U.S. Airways Flight 1549, The Peanut Butter Salmonella Outbreak
            • Cancer: Ignoring the early warning signs until the situation progresses beyond simple remedial action: Example: Davis-Besse 2002, The Sub-prime Mortgage Crisis
            • Heart Attack: Continuing a known dysfunctional life style until the causal factors pile up to overwhelm the system: Example: BP Texas City

             

            What fraction of consequentials fall in one or more of those categories?

            What additional categories are needed to catch 99% of consequentials?

             

            Take care,
             
            Bill Corcoran

             

             

          • William R. Corcoran, Ph.D.,P.E.
            Is the FAA tolerating Russian Roulette? FAA: bird strikes more than double at big airports http://news.yahoo.com/s/ap/20090424/ap_on_go_ot/us_faa_bird_strikes
            Message 5 of 6 , Apr 24 10:24 AM
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              Is the FAA tolerating Russian Roulette?

              FAA: bird strikes more than double at big airports

              http://news.yahoo.com/s/ap/20090424/ap_on_go_ot/us_faa_bird_strikes


              --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Salot, William" <william.salot@...> wrote:
              >
              > Larry D and Bill C,
              >
              >
              >
              > I would call Larry's new category "land mines". If you are unaware of
              > them, or even if you are aware and try to avoid them, you can still step
              > on one.
              >
              >
              >
              > Bill Salot
              >
              > ________________________________
              >
              > From: Root_Cause_State_of_the_Practice@yahoogroups.com
              > [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of
              > Lawrence B. Durham
              > Sent: Tuesday, February 03, 2009 1:59 PM
              > To: Root_Cause_State_of_the_Practice@yahoogroups.com
              > Subject: RE: [Root_Cause_State_of_the_Practice] All Accidents are Like
              > the Following:
              >
              >
              >
              > Bill,
              >
              >
              >
              > My mathematics background causes me to have to respectfully disagree
              > with your semantic restriction of all accidents into these three
              > categories. In the first place, mathematicians are very reluctant to say
              > "always" or "never" without a rigorous proof of the postulated theorem.
              > Secondly, a single counter-example can disprove a theorem. In that
              > regard, I contend that the following two examples would not fit into any
              > one of the three postulated categories:
              >
              >
              >
              > 1. Falling on "black ice" on an asphalt parking lot when one had never
              > before been in such conditions or even known what "black ice" was.
              >
              > 2. Falling off the back of a lift-gate truck when the lift-gate was
              > lowered without notice to the worker removing material from the
              > lift-gate into the truck. Again, the worker had never even been around
              > such equipment before the incident.
              >
              >
              >
              > Your categories pre-suppose malfunctions after related preceding
              > activities over time. I respectfully contend that some accidents happen
              > absent earlier relevant activity. Incidentally, as you might have
              > suspected, I was the accident "victim" in each of the above-stated
              > examples. Am I missing something? Or, would you classify either of my
              > accidents into one or more of your three categories?
              >
              >
              >
              > As for an additional category, I would suggest "Sudden Occurrence"
              > because my intent is to communicate an absence of the continuation
              > factor suggested by each of your three categories. Maybe you or others
              > will be able to suggest a better label - if, indeed, you even accept my
              > line of thinking. As for proportions falling into the various
              > classifications, I have no data on which to base a guess. However,
              > intuitively, I would conjecture that about half of "all" accidents might
              > fall into your three categories - combined - and the remainder into the
              > category that I am suggesting.
              >
              >
              >
              > Respectfully,
              >
              >
              >
              > Larry
              >
              >
              >
              > From: Root_Cause_State_of_the_Practice@yahoogroups.com
              > [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of
              > DR WILLIAM CORCORAN
              > Sent: Monday, February 02, 2009 10:06 AM
              > To: root_cause_state_of_the_practice@yahoogroups.com
              > Subject: [Root_Cause_State_of_the_Practice] All Accidents are Like the
              > Following:
              >
              >
              >
              > All Accidents are Like One or More of the Following:
              >
              >
              >
              > * Russian Roulette, i.e., performing a known hazardous activity
              > time and time again until the round is in the chanber: Example: U.S.
              > Airways Flight 1549, The Peanut Butter Salmonella Outbreak
              > * Cancer: Ignoring the early warning signs until the situation
              > progresses beyond simple remedial action: Example: Davis-Besse 2002, The
              > Sub-prime Mortgage Crisis
              > * Heart Attack: Continuing a known dysfunctional life style until
              > the causal factors pile up to overwhelm the system: Example: BP Texas
              > City
              >
              >
              >
              > What fraction of consequentials fall in one or more of those categories?
              >
              > What additional categories are needed to catch 99% of consequentials?
              >
              >
              >
              > Take care,
              >
              > Bill Corcoran
              >
            • William R. Corcoran, Ph.D.,P.E.
              What is the extent? How many more government agencies are hiding safety data? http://www.nytimes.com/2009/04/25/us/25birds.html?th&emc=th The DOT Secretary
              Message 6 of 6 , Apr 25 3:56 AM
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                What is the extent?

                How many more government agencies are hiding safety data?

                http://www.nytimes.com/2009/04/25/us/25birds.html?th&emc=th


                The DOT Secretary LaHood said, "Public disclosure is our job."

                There's always some XXX that doesn't get the word?

                Do you see concealment of safety data in your industry?


                --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "William R. Corcoran, Ph.D.,P.E." <William.R.Corcoran@...> wrote:
                >
                > Is the FAA tolerating Russian Roulette?
                >
                > FAA: bird strikes more than double at big airports
                >
                > http://news.yahoo.com/s/ap/20090424/ap_on_go_ot/us_faa_bird_strikes
                >
                >
                > --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Salot, William" <william.salot@> wrote:
                > >
                > > Larry D and Bill C,
                > >
                > >
                > >
                > > I would call Larry's new category "land mines". If you are unaware of
                > > them, or even if you are aware and try to avoid them, you can still step
                > > on one.
                > >
                > >
                > >
                > > Bill Salot
                > >
                > > ________________________________
                > >
                > > From: Root_Cause_State_of_the_Practice@yahoogroups.com
                > > [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of
                > > Lawrence B. Durham
                > > Sent: Tuesday, February 03, 2009 1:59 PM
                > > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                > > Subject: RE: [Root_Cause_State_of_the_Practice] All Accidents are Like
                > > the Following:
                > >
                > >
                > >
                > > Bill,
                > >
                > >
                > >
                > > My mathematics background causes me to have to respectfully disagree
                > > with your semantic restriction of all accidents into these three
                > > categories. In the first place, mathematicians are very reluctant to say
                > > "always" or "never" without a rigorous proof of the postulated theorem.
                > > Secondly, a single counter-example can disprove a theorem. In that
                > > regard, I contend that the following two examples would not fit into any
                > > one of the three postulated categories:
                > >
                > >
                > >
                > > 1. Falling on "black ice" on an asphalt parking lot when one had never
                > > before been in such conditions or even known what "black ice" was.
                > >
                > > 2. Falling off the back of a lift-gate truck when the lift-gate was
                > > lowered without notice to the worker removing material from the
                > > lift-gate into the truck. Again, the worker had never even been around
                > > such equipment before the incident.
                > >
                > >
                > >
                > > Your categories pre-suppose malfunctions after related preceding
                > > activities over time. I respectfully contend that some accidents happen
                > > absent earlier relevant activity. Incidentally, as you might have
                > > suspected, I was the accident "victim" in each of the above-stated
                > > examples. Am I missing something? Or, would you classify either of my
                > > accidents into one or more of your three categories?
                > >
                > >
                > >
                > > As for an additional category, I would suggest "Sudden Occurrence"
                > > because my intent is to communicate an absence of the continuation
                > > factor suggested by each of your three categories. Maybe you or others
                > > will be able to suggest a better label - if, indeed, you even accept my
                > > line of thinking. As for proportions falling into the various
                > > classifications, I have no data on which to base a guess. However,
                > > intuitively, I would conjecture that about half of "all" accidents might
                > > fall into your three categories - combined - and the remainder into the
                > > category that I am suggesting.
                > >
                > >
                > >
                > > Respectfully,
                > >
                > >
                > >
                > > Larry
                > >
                > >
                > >
                > > From: Root_Cause_State_of_the_Practice@yahoogroups.com
                > > [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of
                > > DR WILLIAM CORCORAN
                > > Sent: Monday, February 02, 2009 10:06 AM
                > > To: root_cause_state_of_the_practice@yahoogroups.com
                > > Subject: [Root_Cause_State_of_the_Practice] All Accidents are Like the
                > > Following:
                > >
                > >
                > >
                > > All Accidents are Like One or More of the Following:
                > >
                > >
                > >
                > > * Russian Roulette, i.e., performing a known hazardous activity
                > > time and time again until the round is in the chanber: Example: U.S.
                > > Airways Flight 1549, The Peanut Butter Salmonella Outbreak
                > > * Cancer: Ignoring the early warning signs until the situation
                > > progresses beyond simple remedial action: Example: Davis-Besse 2002, The
                > > Sub-prime Mortgage Crisis
                > > * Heart Attack: Continuing a known dysfunctional life style until
                > > the causal factors pile up to overwhelm the system: Example: BP Texas
                > > City
                > >
                > >
                > >
                > > What fraction of consequentials fall in one or more of those categories?
                > >
                > > What additional categories are needed to catch 99% of consequentials?
                > >
                > >
                > >
                > > Take care,
                > >
                > > Bill Corcoran
                > >
                >
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