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Re: [Root_Cause_State_of_the_Practice] New Wave of Corrective Actions?

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  • DR WILLIAM CORCORAN
    According to the article, even if the inspection had been done and done properly the event would still have happened.   Thus if you draw a factor tree for any
    Message 1 of 30 , Sep 1, 2009
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      According to the article, even if the inspection had been done and done properly the event would still have happened.
       
      Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

      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.
      Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
       
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      --- On Mon, 8/31/09, fforck@... <fforck@...> wrote:

      From: fforck@... <fforck@...>
      Subject: Re: [Root_Cause_State_of_the_Practice] New Wave of Corrective Actions?
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Date: Monday, August 31, 2009, 12:08 PM

       
      I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?
      Sent via BlackBerry by AT&T

      From: DR WILLIAM CORCORAN
      Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
      To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
      Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
       
      Fred,
       
      If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

      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.
      Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
       
      ****Internet Email Confidentiality Footer****
       
      Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


      --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:

      From: fforck@yahoo. com <fforck@yahoo. com>
      Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
      Date: Saturday, August 29, 2009, 9:02 AM

       
      Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

      Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
      I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
      Fred
      Sent via BlackBerry by AT&T

      From: "drbillcorcoran"
      Date: Sat, 29 Aug 2009 09:31:13 -0000
      To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
      Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
       
      The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).
      What do you get out of this article?
      August 29, 2009

      Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

      Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.
      The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.
      The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.
      "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.
      The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.
      A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.
      Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."
      But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."
      Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.
      The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.
      "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."
      Colin Moynihan contributed reporting.
       
    • fforck@yahoo.com
      I missed the quote in the article that said, even if the inspection had been done and done properly the event would still have happened . The only related
      Message 2 of 30 , Sep 1, 2009
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        I missed the quote in the article that said, 'even if the inspection had been done and done properly the event would still have happened'. The only related quote I saw was "Officials have said it was unlikely that the missed inspection had any relation to the accident". To me, "unlikely" is not the same as 'would still have happened'.

        Sent via BlackBerry by AT&T


        From: DR WILLIAM CORCORAN
        Date: Tue, 1 Sep 2009 06:18:29 -0700 (PDT)
        To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
        Subject: Re: [Root_Cause_State_of_the_Practice] New Wave of Corrective Actions?

         

        According to the article, even if the inspection had been done and done properly the event would still have happened.
         
        Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

        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.
        Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
         
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        Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


        --- On Mon, 8/31/09, fforck@yahoo. com <fforck@yahoo. com> wrote:

        From: fforck@yahoo. com <fforck@yahoo. com>
        Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
        To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
        Date: Monday, August 31, 2009, 12:08 PM

         
        I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?
        Sent via BlackBerry by AT&T

        From: DR WILLIAM CORCORAN
        Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
        To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
        Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
         
        Fred,
         
        If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

        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.
        Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
         
        ****Internet Email Confidentiality Footer****
         
        Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


        --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:

        From: fforck@yahoo. com <fforck@yahoo. com>
        Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
        To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
        Date: Saturday, August 29, 2009, 9:02 AM

         
        Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

        Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
        I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
        Fred
        Sent via BlackBerry by AT&T

        From: "drbillcorcoran"
        Date: Sat, 29 Aug 2009 09:31:13 -0000
        To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
        Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
         
        The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).
        What do you get out of this article?
        August 29, 2009

        Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

        Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.
        The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.
        The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.
        "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.
        The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.
        A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.
        Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."
        But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."
        Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.
        The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.
        "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."
        Colin Moynihan contributed reporting.
         

      • jack.stanford@att.net
        The NYC govt. should simply fire Edward Marquette. The guy has apparently falsified at least three crane inspection reports. Why do you think that he
        Message 3 of 30 , Sep 1, 2009
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          The NYC govt. should simply fire Edward Marquette.  The guy has apparently falsified at least three crane inspection reports.  Why do you think that he believes that falsified reports are what he is being paid to do?  The man does not have integrity and should be terminated because of that, whether or not the fact that he did not perform a crane inspection is relevant to the big accident.  The accident that killed seven people happened 11 days after the inspection that never took place last year.  Anyone who reported false documentation intentionally, if they worked for me, would have been fired pronto.  I remain unconvinced that the missed inspection is just an extraneous factor.
           
          Jack 
           
          -------------- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@...>: --------------

           

          According to the article, even if the inspection had been done and done properly the event would still have happened.
           
          Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

          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.
          Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
           
          ****Internet Email Confidentiality Footer****
           
          Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


          --- On Mon, 8/31/09, fforck@yahoo. com <fforck@yahoo. com> wrote:

          From: fforck@yahoo. com <fforck@yahoo. com>
          Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
          To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
          Date: Monday, August 31, 2009, 12:08 PM

           
          I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?
          Sent via BlackBerry by AT&T

          From: DR WILLIAM CORCORAN
          Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
          To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
          Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
           
          Fred,
           
          If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

          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.
          Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
           
          ****Internet Email Confidentiality Footer****
           
          Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


          --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:

          From: fforck@yahoo. com <fforck@yahoo. com>
          Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
          To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
          Date: Saturday, August 29, 2009, 9:02 AM

           
          Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

          Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
          I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
          Fred
          Sent via BlackBerry by AT&T

          From: "drbillcorcoran"
          Date: Sat, 29 Aug 2009 09:31:13 -0000
          To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
          Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
           
          The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).
          What do you get out of this article?
          August 29, 2009

          Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

          Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.
          The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.
          The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.
          "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.
          The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.
          A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.
          Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."
          But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."
          Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.
          The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.
          "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."
          Colin Moynihan contributed reporting.
           

        • DR WILLIAM CORCORAN
          Jack,   The article said, Officials have said it was unlikely that the missed inspection had any relation to the accident.   If that is true the failure to
          Message 4 of 30 , Sep 1, 2009
          • 0 Attachment
            Jack,
             
            The article said, "Officials have said it was unlikely that the missed inspection had any relation to the accident."
             
            If that is true the failure to do the inspection and the falsification were not harmful factors of the accident.
             
            They are bad.
             
            They are hateful.
             
            They are heinous.
             
            But they are extraneous to the factors that resulted in the consequences.

            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.
            Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
             
            ****Internet Email Confidentiality Footer****
             
            Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


            --- On Tue, 9/1/09, jack.stanford@... <jack.stanford@...> wrote:

            From: jack.stanford@... <jack.stanford@...>
            Subject: Re: [Root_Cause_State_of_the_Practice] New Wave of Corrective Actions?
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Date: Tuesday, September 1, 2009, 10:21 AM

            The NYC govt. should simply fire Edward Marquette.  The guy has apparently falsified at least three crane inspection reports.  Why do you think that he believes that falsified reports are what he is being paid to do?  The man does not have integrity and should be terminated because of that, whether or not the fact that he did not perform a crane inspection is relevant to the big accident.  The accident that killed seven people happened 11 days after the inspection that never took place last year.  Anyone who reported false documentation intentionally, if they worked for me, would have been fired pronto.  I remain unconvinced that the missed inspection is just an extraneous factor.
             
            Jack 
             
            -------------- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@...>: --------------

             
            According to the article, even if the inspection had been done and done properly the event would still have happened.
             
            Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

            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.
            Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
             
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            --- On Mon, 8/31/09, fforck@yahoo. com <fforck@yahoo. com> wrote:

            From: fforck@yahoo. com <fforck@yahoo. com>
            Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
            To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
            Date: Monday, August 31, 2009, 12:08 PM

             
            I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?
            Sent via BlackBerry by AT&T

            From: DR WILLIAM CORCORAN
            Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
            To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
            Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
             
            Fred,
             
            If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

            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.
            Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
             
            ****Internet Email Confidentiality Footer****
             
            Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


            --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:

            From: fforck@yahoo. com <fforck@yahoo. com>
            Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
            To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
            Date: Saturday, August 29, 2009, 9:02 AM

             
            Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

            Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
            I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
            Fred
            Sent via BlackBerry by AT&T

            From: "drbillcorcoran"
            Date: Sat, 29 Aug 2009 09:31:13 -0000
            To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
            Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
             
            The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).
            What do you get out of this article?
            August 29, 2009

            Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

            Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.
            The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.
            The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.
            "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.
            The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.
            A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.
            Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."
            But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."
            Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.
            The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.
            "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."
            Colin Moynihan contributed reporting.
             
          • Van Leuken, Mike
            In other words, the missed inspection was a factor, potentially, in the prevention of this but not a factor in creating the incident in the first place. Mike
            Message 5 of 30 , Sep 1, 2009
            • 0 Attachment

              In other words, the missed inspection was a factor, potentially, in the prevention of this but not a factor in creating the incident in the first place.

               

              Mike van Leuken      Product Release Team

              ISC: Protected

               

              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: 2009 September 01 9:09 AM
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Subject: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality

               

               

              Jack,

               

              The article said, "Officials have said it was unlikely that the missed inspection had any relation to the accident."

               

              If that is true the failure to do the inspection and the falsification were not harmful factors of the accident.

               

              They are bad.

               

              They are hateful.

               

              They are heinous.

               

              But they are extraneous to the factors that resulted in the consequences.

              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.
              Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com

               

              ****Internet Email Confidentiality Footer****

               

              Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



              --- On Tue, 9/1/09, jack.stanford@... <jack.stanford@...> wrote:


              From: jack.stanford@... <jack.stanford@...>
              Subject: Re: [Root_Cause_State_of_the_Practice] New Wave of Corrective Actions?
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Date: Tuesday, September 1, 2009, 10:21 AM

              The NYC govt. should simply fire Edward Marquette.  The guy has apparently falsified at least three crane inspection reports.  Why do you think that he believes that falsified reports are what he is being paid to do?  The man does not have integrity and should be terminated because of that, whether or not the fact that he did not perform a crane inspection is relevant to the big accident.  The accident that killed seven people happened 11 days after the inspection that never took place last year.  Anyone who reported false documentation intentionally, if they worked for me, would have been fired pronto.  I remain unconvinced that the missed inspection is just an extraneous factor.

               

              Jack 

               

              -------------- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@...>: --------------

               

              According to the article, even if the inspection had been done and done properly the event would still have happened.

               

              Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

              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.
              Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

               

              ****Internet Email Confidentiality Footer****

               

              Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



              --- On Mon, 8/31/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


              From: fforck@yahoo. com <fforck@yahoo. com>
              Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
              To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
              Date: Monday, August 31, 2009, 12:08 PM

               

              I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?

              Sent via BlackBerry by AT&T


              From: DR WILLIAM CORCORAN
              Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
              To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
              Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

               

              Fred,

               

              If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

              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.
              Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

               

              ****Internet Email Confidentiality Footer****

               

              Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



              --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


              From: fforck@yahoo. com <fforck@yahoo. com>
              Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
              To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
              Date: Saturday, August 29, 2009, 9:02 AM

               

              Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

              Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
              I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
              Fred

              Sent via BlackBerry by AT&T


              From: "drbillcorcoran"
              Date: Sat, 29 Aug 2009 09:31:13 -0000
              To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
              Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

               

              The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).

              What do you get out of this article?

              August 29, 2009

              Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

              Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.

              The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.

              The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.

              "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.

              The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.

              A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.

              Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."

              But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."

              Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.

              The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.

              "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."

              Colin Moynihan contributed reporting.

               



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            • DR WILLIAM CORCORAN
              Mike,   My understanding of what went on is that the inspection process was flawed in that it would not have surfaced the harmful factors that resulted in the
              Message 6 of 30 , Sep 1, 2009
              • 0 Attachment
                Mike,
                 
                My understanding of what went on is that the inspection process was flawed in that it would not have surfaced the harmful factors that resulted in the consequence even if it had been carried out as required.
                 
                Thus, not doing it did not matter.
                 
                Is it right that people be fired for not doing what doesn't matter?

                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.
                Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                 
                ****Internet Email Confidentiality Footer****
                 
                Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


                --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@...> wrote:

                From: Van Leuken, Mike <mike.van.leuken@...>
                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                To: "'Root_Cause_State_of_the_Practice@yahoogroups.com'" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                Date: Tuesday, September 1, 2009, 11:28 AM

                 

                In other words, the missed inspection was a factor, potentially, in the prevention of this but not a factor in creating the incident in the first place.

                 

                Mike van Leuken      Product Release Team

                ISC: Protected

                 

                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: 2009 September 01 9:09 AM
                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                 

                 

                 

                The article said, "Officials have said it was unlikely that the missed inspection had any relation to the accident."

                 

                If that is true the failure to do the inspection and the falsification were not harmful factors of the accident.

                 

                They are bad.

                 

                They are hateful.

                 

                They are heinous.

                 

                But they are extraneous to the factors that resulted in the consequences.

                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.
                Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                 

                ****Internet Email Confidentiality Footer****

                 

                Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                --- On Tue, 9/1/09, jack.stanford@ att.net <jack.stanford@ att.net> wrote:


                From: jack.stanford@ att.net <jack.stanford@ att.net>
                Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                Date: Tuesday, September 1, 2009, 10:21 AM

                The NYC govt. should simply fire Edward Marquette.  The guy has apparently falsified at least three crane inspection reports.  Why do you think that he believes that falsified reports are what he is being paid to do?  The man does not have integrity and should be terminated because of that, whether or not the fact that he did not perform a crane inspection is relevant to the big accident.  The accident that killed seven people happened 11 days after the inspection that never took place last year.  Anyone who reported false documentation intentionally, if they worked for me, would have been fired pronto.  I remain unconvinced that the missed inspection is just an extraneous factor.

                 

                Jack 

                 

                ------------ -- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>: ------------ --

                 

                Jack,

                 

                Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

                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.
                Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                 

                ****Internet Email Confidentiality Footer****

                 

                Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                --- On Mon, 8/31/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                From: fforck@yahoo. com <fforck@yahoo. com>
                Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                Date: Monday, August 31, 2009, 12:08 PM

                 

                I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?

                Sent via BlackBerry by AT&T


                From: DR WILLIAM CORCORAN
                Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                 

                According to the article, even if the inspection had been done and done properly the event would still have happened.

                 

                If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

                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.
                Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                 

                ****Internet Email Confidentiality Footer****

                 

                Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                From: fforck@yahoo. com <fforck@yahoo. com>
                Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                Date: Saturday, August 29, 2009, 9:02 AM

                 

                Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

                Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
                I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
                Fred

                Sent via BlackBerry by AT&T


                From: "drbillcorcoran"
                Date: Sat, 29 Aug 2009 09:31:13 -0000
                To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                 

                The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).

                What do you get out of this article?

                August 29, 2009

                Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

                Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.

                The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.

                The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.

                "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.

                The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.

                A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.

                Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."

                But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."

                Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.

                The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.

                "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."

                Colin Moynihan contributed reporting.

                 

                Fred,



                NOTICE -
                This communication is intended ONLY for the use of the person or entity named above and may contain information that is confidential or legally privileged. If you are not the intended recipient named above or a person responsible for delivering messages or communications to the intended recipient, YOU ARE HEREBY NOTIFIED that any use, distribution, or copying of this communication or any of the information contained in it is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and then destroy or delete this communication, or return it to us by mail if requested by us. The City of Calgary thanks you for your attention and co-operation.
              • Van Leuken, Mike
                So, in other words, every inspector is just doing busy work and accomplishing nothing beyond drawing a pay-cheque. That sure opens up a whole bunch of lines of
                Message 7 of 30 , Sep 1, 2009
                • 0 Attachment

                  So, in other words, every inspector is just doing busy work and accomplishing nothing beyond drawing a pay-cheque. That sure opens up a whole bunch of lines of inquiry then.  Is it right that people be fired for not doing what doesn’t matter? I don’t know. So many things to consider before answering that question including how much did the inspector know about the uselessness of the inspection process.

                   

                  Mike van Leuken      Product Release Team

                  ISC: Protected

                   

                  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: 2009 September 01 9:49 AM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: RE: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality

                   

                   

                  Mike,

                   

                  My understanding of what went on is that the inspection process was flawed in that it would not have surfaced the harmful factors that resulted in the consequence even if it had been carried out as required.

                   

                  Thus, not doing it did not matter.

                   

                  Is it right that people be fired for not doing what doesn't matter?

                  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.
                  Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com

                   

                  ****Internet Email Confidentiality Footer****

                   

                  Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                  --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@...> wrote:


                  From: Van Leuken, Mike <mike.van.leuken@...>
                  Subject: RE: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                  To: "'Root_Cause_State_of_the_Practice@yahoogroups.com'" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                  Date: Tuesday, September 1, 2009, 11:28 AM

                   

                  In other words, the missed inspection was a factor, potentially, in the prevention of this but not a factor in creating the incident in the first place.

                   

                  Mike van Leuken      Product Release Team

                  ISC: Protected

                   

                  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: 2009 September 01 9:09 AM
                  To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                  Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                   

                   

                  Jack,

                   

                  The article said, "Officials have said it was unlikely that the missed inspection had any relation to the accident."

                   

                  If that is true the failure to do the inspection and the falsification were not harmful factors of the accident.

                   

                  They are bad.

                   

                  They are hateful.

                   

                  They are heinous.

                   

                  But they are extraneous to the factors that resulted in the consequences.

                  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.
                  Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                   

                  ****Internet Email Confidentiality Footer****

                   

                  Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                  --- On Tue, 9/1/09, jack.stanford@ att.net <jack.stanford@ att.net> wrote:


                  From: jack.stanford@ att.net <jack.stanford@ att.net>
                  Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                  To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                  Date: Tuesday, September 1, 2009, 10:21 AM

                  The NYC govt. should simply fire Edward Marquette.  The guy has apparently falsified at least three crane inspection reports.  Why do you think that he believes that falsified reports are what he is being paid to do?  The man does not have integrity and should be terminated because of that, whether or not the fact that he did not perform a crane inspection is relevant to the big accident.  The accident that killed seven people happened 11 days after the inspection that never took place last year.  Anyone who reported false documentation intentionally, if they worked for me, would have been fired pronto.  I remain unconvinced that the missed inspection is just an extraneous factor.

                   

                  Jack 

                   

                  ------------ -- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>: ------------ --

                   

                  According to the article, even if the inspection had been done and done properly the event would still have happened.

                   

                  Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

                  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.
                  Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                   

                  ****Internet Email Confidentiality Footer****

                   

                  Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                  --- On Mon, 8/31/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                  From: fforck@yahoo. com <fforck@yahoo. com>
                  Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                  To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                  Date: Monday, August 31, 2009, 12:08 PM

                   

                  I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?

                  Sent via BlackBerry by AT&T


                  From: DR WILLIAM CORCORAN
                  Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                  To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                  Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                   

                  Fred,

                   

                  If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

                  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.
                  Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                   

                  ****Internet Email Confidentiality Footer****

                   

                  Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                  --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                  From: fforck@yahoo. com <fforck@yahoo. com>
                  Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                  To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                  Date: Saturday, August 29, 2009, 9:02 AM

                   

                  Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

                  Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
                  I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
                  Fred

                  Sent via BlackBerry by AT&T


                  From: "drbillcorcoran"
                  Date: Sat, 29 Aug 2009 09:31:13 -0000
                  To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                  Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                   

                  The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).

                  What do you get out of this article?

                  August 29, 2009

                  Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

                  Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.

                  The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.

                  The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.

                  "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.

                  The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.

                  A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.

                  Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."

                  But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."

                  Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.

                  The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.

                  "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."

                  Colin Moynihan contributed reporting.

                   

                   


                  NOTICE -
                  This communication is intended ONLY for the use of the person or entity named above and may contain information that is confidential or legally privileged. If you are not the intended recipient named above or a person responsible for delivering messages or communications to the intended recipient, YOU ARE HEREBY NOTIFIED that any use, distribution, or copying of this communication or any of the information contained in it is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and then destroy or delete this communication, or return it to us by mail if requested by us. The City of Calgary thanks you for your attention and co-operation.

                • jack.stanford@att.net
                  If someone does refuse to do the job that they were hired to do, and then lies about what they should have done but did not do, for me, that is a matter of
                  Message 8 of 30 , Sep 1, 2009
                  • 0 Attachment
                    If someone does refuse to do the job that they were hired to do, and then lies about what they should have done but did not do, for me, that is a matter of moral integrity. Let such a person go so that they can clean streets or bag groceries.  They have no business inspecting cranes that could endanger people, and then lie about an inspection that they did not perform.
                     
                    I firmly stand my ground on this issue.
                     
                    Jack
                     
                    -------------- Original message from "Van Leuken, Mike" <mike.van.leuken@...>: --------------

                     

                    So, in other words, every inspector is just doing busy work and accomplishing nothing beyond drawing a pay-cheque. That sure opens up a whole bunch of lines of inquiry then.  Is it right that people be fired for not doing what doesn’t matter? I don’t know. So many things to consider before answering that question including how much did the inspector know about the uselessness of the inspection process.

                    Mike van Leuken      Product Release Team

                    ISC: Protected

                    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: 2009 September 01 9:49 AM
                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                    Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                     

                    Mike,

                    My understanding of what went on is that the inspection process was flawed in that it would not have surfaced the harmful factors that resulted in the consequence even if it had been carried out as required.

                    Thus, not doing it did not matter.

                    Is it right that people be fired for not doing what doesn't matter?

                    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.
                    Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                    ****Internet Email Confidentiality Footer****

                    Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                    --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@ calgary.ca> wrote:


                    From: Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                    Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                    To: "'Root_Cause_ State_of_ the_Practice@ yahoogroups. com'" <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                    Date: Tuesday, September 1, 2009, 11:28 AM

                     

                    In other words, the missed inspection was a factor, potentially, in the prevention of this but not a factor in creating the incident in the first place.

                    Mike van Leuken      Product Release Team

                    ISC: Protected

                     

                    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: 2009 September 01 9:09 AM
                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                    Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                     

                     

                    Jack,

                    The article said, "Officials have said it was unlikely that the missed inspection had any relation to the accident."

                    If that is true the failure to do the inspection and the falsification were not harmful factors of the accident.

                    They are bad.

                    They are hateful.

                    They are heinous.

                    But they are extraneous to the factors that resulted in the consequences.

                    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.
                    Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                    ****Internet Email Confidentiality Footer****

                    Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                    --- On Tue, 9/1/09, jack.stanford@ att.net <jack.stanford@ att.net> wrote:


                    From: jack.stanford@ att.net <jack.stanford@ att.net>
                    Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                    Date: Tuesday, September 1, 2009, 10:21 AM

                    The NYC govt. should simply fire Edward Marquette.  The guy has apparently falsified at least three crane inspection reports.  Why do you think that he believes that falsified reports are what he is being paid to do?  The man does not have integrity and should be terminated because of that, whether or not the fact that he did not perform a crane inspection is relevant to the big accident.  The accident that killed seven people happened 11 days after the inspection that never took place last year.  Anyone who reported false documentation intentionally, if they worked for me, would have been fired pronto.  I remain unconvinced that the missed inspection is just an extraneous factor.

                    Jack 

                    ------------ -- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>: ------------ --

                     

                    According to the article, even if the inspection had been done and done properly the event would still have happened.

                    Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

                    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.
                    Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                    ****Internet Email Confidentiality Footer****

                    Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                    --- On Mon, 8/31/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                    From: fforck@yahoo. com <fforck@yahoo. com>
                    Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                    Date: Monday, August 31, 2009, 12:08 PM

                     

                    I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?

                    Sent via BlackBerry by AT&T


                    From: DR WILLIAM CORCORAN
                    Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                    To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                    Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                     

                    Fred,

                    If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

                    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.
                    Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                    ****Internet Email Confidentiality Footer****

                    Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                    --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                    From: fforck@yahoo. com <fforck@yahoo. com>
                    Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                    Date: Saturday, August 29, 2009, 9:02 AM

                     

                    Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

                    Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
                    I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
                    Fred

                    Sent via BlackBerry by AT&T


                    From: "drbillcorcoran"
                    Date: Sat, 29 Aug 2009 09:31:13 -0000
                    To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                    Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                     

                    The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).

                    What do you get out of this article?

                    August 29, 2009

                    Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

                    Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.

                    The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.

                    The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.

                    "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.

                    The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.

                    A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.

                    Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."

                    But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."

                    Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.

                    The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.

                    "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."

                    Colin Moynihan contributed reporting.


                    NOTICE -
                    This communication is intended ONLY for the use of the person or entity named above and may contain information that is confidential or legally privileged. If you are not the intended recipient named above or a person responsible for delivering messages or communications to the intended recipient, YOU ARE HEREBY NOTIFIED that any use, distribution, or copying of this communication or any of the information contained in it is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and then destroy or delete this communication, or return it to us by mail if requested by us. The City of Calgary thanks you for your attention and co-operation.

                  • DR WILLIAM CORCORAN
                    When an employee does not do what was ordered to be done one needs to determine what the factors were that resulted in the employee s inaction?   Was it the
                    Message 9 of 30 , Sep 1, 2009
                    • 0 Attachment
                      When an employee does not do what was ordered to be done one needs to determine what the factors were that resulted in the employee's inaction?
                       
                      Was it the first time?
                       
                      Was it allowed by custom?
                       
                      Etc.
                       
                      In the Navy a CPO told me, "Mr. Corcoran, you get what you inspect, not what you expect!"

                      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.
                      Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                       
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                      --- On Tue, 9/1/09, DR WILLIAM CORCORAN <William.R.Corcoran@...> wrote:

                      From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                      Subject: RE: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                      To: Root_Cause_State_of_the_Practice@yahoogroups.com
                      Date: Tuesday, September 1, 2009, 11:48 AM

                       

                      ISC: Protected

                       

                      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: 2009 September 01 9:09 AM
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                       

                       

                      Mike,
                       
                      My understanding of what went on is that the inspection process was flawed in that it would not have surfaced the harmful factors that resulted in the consequence even if it had been carried out as required.
                       
                      Thus, not doing it did not matter.
                       
                      Is it right that people be fired for not doing what doesn't matter?

                      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.
                      Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                       
                      ****Internet Email Confidentiality Footer****
                       
                      Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


                      --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@ calgary.ca> wrote:

                      From: Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                      Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                      To: "'Root_Cause_ State_of_ the_Practice@ yahoogroups. com'" <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                      Date: Tuesday, September 1, 2009, 11:28 AM

                       

                      In other words, the missed inspection was a factor, potentially, in the prevention of this but not a factor in creating the incident in the first place.

                       

                      Mike van Leuken      Product Release Team

                       

                      The article said, "Officials have said it was unlikely that the missed inspection had any relation to the accident."

                       

                      If that is true the failure to do the inspection and the falsification were not harmful factors of the accident.

                       

                      They are bad.

                       

                      They are hateful.

                       

                      They are heinous.

                       

                      But they are extraneous to the factors that resulted in the consequences.

                      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.
                      Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                       

                      ****Internet Email Confidentiality Footer****

                       

                      Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                      --- On Tue, 9/1/09, jack.stanford@ att.net <jack.stanford@ att.net> wrote:


                      From: jack.stanford@ att.net <jack.stanford@ att.net>
                      Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Date: Tuesday, September 1, 2009, 10:21 AM

                      The NYC govt. should simply fire Edward Marquette.  The guy has apparently falsified at least three crane inspection reports.  Why do you think that he believes that falsified reports are what he is being paid to do?  The man does not have integrity and should be terminated because of that, whether or not the fact that he did not perform a crane inspection is relevant to the big accident.  The accident that killed seven people happened 11 days after the inspection that never took place last year.  Anyone who reported false documentation intentionally, if they worked for me, would have been fired pronto.  I remain unconvinced that the missed inspection is just an extraneous factor.

                       

                      Jack 

                       

                      ------------ -- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>: ------------ --

                       

                      Jack,

                       

                      Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

                      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.
                      Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                       

                      ****Internet Email Confidentiality Footer****

                       

                      Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                      --- On Mon, 8/31/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                      From: fforck@yahoo. com <fforck@yahoo. com>
                      Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Date: Monday, August 31, 2009, 12:08 PM

                       

                      I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?

                      Sent via BlackBerry by AT&T


                      From: DR WILLIAM CORCORAN
                      Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                      To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                      Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                       

                      According to the article, even if the inspection had been done and done properly the event would still have happened.

                       

                      If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

                      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.
                      Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                       

                      ****Internet Email Confidentiality Footer****

                       

                      Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                      --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                      From: fforck@yahoo. com <fforck@yahoo. com>
                      Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Date: Saturday, August 29, 2009, 9:02 AM

                       

                      Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

                      Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
                      I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
                      Fred

                      Sent via BlackBerry by AT&T


                      From: "drbillcorcoran"
                      Date: Sat, 29 Aug 2009 09:31:13 -0000
                      To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                      Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                       

                      The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).

                      What do you get out of this article?

                      August 29, 2009

                      Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

                      Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.

                      The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.

                      The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.

                      "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.

                      The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.

                      A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.

                      Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."

                      But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."

                      Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.

                      The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.

                      "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."

                      Colin Moynihan contributed reporting.

                       

                      Fred,



                      NOTICE -
                      This communication is intended ONLY for the use of the person or entity named above and may contain information that is confidential or legally privileged. If you are not the intended recipient named above or a person responsible for delivering messages or communications to the intended recipient, YOU ARE HEREBY NOTIFIED that any use, distribution, or copying of this communication or any of the information contained in it is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and then destroy or delete this communication, or return it to us by mail if requested by us. The City of Calgary thanks you for your attention and co-operation.
                    • fforck@yahoo.com
                      Where are you getting the information you reported in the first paragraph? Is there something else we should read that would help us reach your conclusion?
                      Message 10 of 30 , Sep 1, 2009
                      • 0 Attachment
                        Where are you getting the information you reported in the first paragraph? Is there something else we should read that would help us reach your conclusion?

                        Sent via BlackBerry by AT&T


                        From: DR WILLIAM CORCORAN
                        Date: Tue, 1 Sep 2009 08:48:55 -0700 (PDT)
                        To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                        Subject: RE: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality

                         

                        Mike,
                         
                        My understanding of what went on is that the inspection process was flawed in that it would not have surfaced the harmful factors that resulted in the consequence even if it had been carried out as required.
                         
                        Thus, not doing it did not matter.
                         
                        Is it right that people be fired for not doing what doesn't matter?

                        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.
                        Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                         
                        ****Internet Email Confidentiality Footer****
                         
                        Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


                        --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@ calgary.ca> wrote:

                        From: Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                        Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                        To: "'Root_Cause_ State_of_ the_Practice@ yahoogroups. com'" <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                        Date: Tuesday, September 1, 2009, 11:28 AM

                         

                        In other words, the missed inspection was a factor, potentially, in the prevention of this but not a factor in creating the incident in the first place.

                         

                        Mike van Leuken      Product Release Team

                        ISC: Protected

                         

                        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: 2009 September 01 9:09 AM
                        To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                        Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                         

                         

                         

                        The article said, "Officials have said it was unlikely that the missed inspection had any relation to the accident."

                         

                        If that is true the failure to do the inspection and the falsification were not harmful factors of the accident.

                         

                        They are bad.

                         

                        They are hateful.

                         

                        They are heinous.

                         

                        But they are extraneous to the factors that resulted in the consequences.

                        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.
                        Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                         

                        ****Internet Email Confidentiality Footer****

                         

                        Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                        --- On Tue, 9/1/09, jack.stanford@ att.net <jack.stanford@ att.net> wrote:


                        From: jack.stanford@ att.net <jack.stanford@ att.net>
                        Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                        To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                        Date: Tuesday, September 1, 2009, 10:21 AM

                        The NYC govt. should simply fire Edward Marquette.  The guy has apparently falsified at least three crane inspection reports.  Why do you think that he believes that falsified reports are what he is being paid to do?  The man does not have integrity and should be terminated because of that, whether or not the fact that he did not perform a crane inspection is relevant to the big accident.  The accident that killed seven people happened 11 days after the inspection that never took place last year.  Anyone who reported false documentation intentionally, if they worked for me, would have been fired pronto.  I remain unconvinced that the missed inspection is just an extraneous factor.

                         

                        Jack 

                         

                        ------------ -- Original message from DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>: ------------ --

                         

                        Jack,

                         

                        Thus if you draw a factor tree for any of the consequences the missed inspections will not be on it.

                        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.
                        Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com

                         

                        ****Internet Email Confidentiality Footer****

                         

                        Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.



                        --- On Mon, 8/31/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                        From: fforck@yahoo. com <fforck@yahoo. com>
                        Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                        To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                        Date: Monday, August 31, 2009, 12:08 PM

                         

                        I understand. I think the missed inspection is a flawed defense and deserves a place on the factor tree because it is related to the event. It seems you are saying the missed inspection is unrelated (extraneous) and does not deserve a place on the factor tree. Am I receiving your message correctly?

                        Sent via BlackBerry by AT&T


                        From: DR WILLIAM CORCORAN
                        Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                        To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                        Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                         

                        According to the article, even if the inspection had been done and done properly the event would still have happened.

                         

                        If the item has no place on the factor tree it would be appropriate to call it "extraneous. "

                        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.
                        Nuclear Safety Review Concepts Corporation
                        21 Broadleaf Circle
                        Windsor, CT 06095-1634
                        860-285-8779

                         

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

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                        --- On Sat, 8/29/09, fforck@yahoo. com <fforck@yahoo. com> wrote:


                        From: fforck@yahoo. com <fforck@yahoo. com>
                        Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?
                        To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                        Date: Saturday, August 29, 2009, 9:02 AM

                         

                        Seems to be a flawed organizational defense/control (i.e. the inspection). Inspections are built into a system to provide a layer of assurance work happens successfully.

                        Just because "Officials have said it was unlikely that the missed inspection had any relation to the accident" doesn't mean the missed inspection was an unrelated factor or "extraneous" .
                        I wonder if the officials reaching this conclusion have a concept of "defense-in- depth"?
                        Fred

                        Sent via BlackBerry by AT&T


                        From: "drbillcorcoran"
                        Date: Sat, 29 Aug 2009 09:31:13 -0000
                        To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                        Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective Actions?

                         

                        The item, not factor, being corrected was not a harmful factor of the adverse consequence, but was rather an Extraneous Condition Adverse to Quality (ECAQ).

                        What do you get out of this article?

                        August 29, 2009

                        Buildings Dept. to Track Inspectors via Cellphone and GPS Technology

                        Seeking to better manage its resources and increase the supervision of its inspectors, New York City's Department of Buildings will begin tracking their whereabouts using GPS technology in their department-issued cellphones.

                        The new tracking system, which has upset some inspectors, will begin monitoring the first group of 10 inspectors on Monday. By the end of next month, all of the agency's 379 inspectors — including crane and elevator inspectors — will be tracked through their cellphones, agency officials announced Friday.

                        The new tracking system is being put in place in part because of the case of Edward J. Marquette, an inspector who was charged last year with faking a report that he inspected a tower crane on the East Side of Manhattan in response to a complaint. He never visited the crane, the authorities said, and 11 days later, it toppled and killed seven people. Officials have said it was unlikely that the missed inspection had any relation to the accident. Prosecutors said that Mr. Marquette, who pleaded not guilty to the charges, also filed false inspection reports for cranes at two other sites.

                        "This new GPS tracking system is a simple, innovative way to ensure inspectors reach their assigned locations and are held accountable for their important work," Buildings Commissioner Robert D. LiMandri said in a statement.

                        The management of the Buildings Department has long been criticized. The two tower-crane accidents last year in Manhattan that left a total of nine people dead led to the resignation of Patricia J. Lancaster, Mr. LiMandri's predecessor as commissioner, and spurred several investigations that uncovered corruption within the agency's Cranes and Derricks Division.

                        A department official said the agency did not believe there was a widespread problem of inspectors misusing their time while on duty, and described the new system as one way to improve the accountability of the department and its inspectors. Supervisors will also be able to identify the closest inspector to a building-related emergency and pinpoint the location of inspectors who lose contact with their superiors while working in hazardous conditions.

                        Joseph M. Corso, the president of Local 211 of the Allied Building Inspectors Union, which represents most Buildings Department inspectors, said the initial response from members employed by the agency was one of disappointment. "Just like the Justice Department monitors parolees and those under house arrest, they'll have a tracking device," he said of the inspectors. "We're going to do all we can to ensure the rights of the membership are covered."

                        But one inspector who did not want to give his name said, "If you are where you're supposed to be, you've got nothing to fear."

                        Department officials said the heads of inspection units would be able to monitor the movements of inspectors in real time from any computer, using a confidential log-in and password. The daily routes the inspectors travel will also be electronically recorded and stored. The union was given few details about how the system would work, Mr. Corso said, but one concern is that inspectors usually have their department-issued cellphones with them even when off duty.

                        The Buildings Department's chief spokesman, Tony Sclafani, said the agency would monitor the inspectors only while on duty.

                        "The software enables the tracking system to be fixed to the work schedule of each inspector," Mr. Sclafani said. "When the shift ends, the tracking system will turn off."

                        Colin Moynihan contributed reporting.

                         

                        Fred,



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                      • wlrigot
                        Dr. Bill, I really hate to bring this up, because it always generates (unintended) controversy, but this relates to what Sydney Dekker and others call
                        Message 11 of 30 , Sep 1, 2009
                        • 0 Attachment
                          Dr. Bill,



                          I really hate to bring this up, because it always generates (unintended)
                          controversy, but this relates to what Sydney Dekker and others call
                          "counterfactuals". They are behaviors that never happened, that
                          management wished with all their little hearts would have happened.
                          They are certainly extraneous conditions adverse to quality and should
                          be investigated, but have nothing to do with the nature, magitude,
                          timing and location of factors leading to the event.



                          Unfortunately, when bad things happen and people end up dead, hordes of
                          people in the "uh oh" squad descend on you and will always find bad
                          things that had been buried for a long time. Unintended consequences
                          almost always ensue. This appears to be what happened here. While some
                          will feel good about punishing some poor soul who got caught not doing
                          an inspection, they are no nearer determining what actually led to the
                          event. And they are thus no nearer determining effective corrective
                          actions that would prevent recurrence.



                          Bill Rigot
                          --- In Root_Cause_State_of_the_Practice@yahoogroups.com, DR WILLIAM
                          CORCORAN <William.R.Corcoran@...> wrote:
                          >
                          > When an employee does not do what was ordered to be done one needs to
                          determine what the factors were that resulted in the employee's
                          inaction?
                          > Â
                          > Was it the first time?
                          > Â
                          > Was it allowed by custom?
                          > Â
                          > Etc.
                          > Â
                          > In the Navy a CPO told me, "Mr. Corcoran, you get what you inspect,
                          not what you expect!"
                          >
                          >
                          >
                          > Take care,
                          > Â
                          > 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.
                          > Â
                          > W. R. Corcoran, Ph.D., P.E.
                          > Nuclear Safety Review Concepts Corporation
                          > 21 Broadleaf Circle
                          > Windsor, CT 06095-1634
                          > 860-285-8779
                          >
                          > Â
                          > Subscribe to "The Firebird Forum" Â
                          TheFirebirdForum-subscribe@yahoogroups.com
                          > Join the group advancing the practice of root cause analysis/
                          evaluation Â
                          Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                          > Â
                          > ****Internet Email Confidentiality Footer****
                          > Â
                          > Privileged/Confidential Information may be contained in this message.
                          If you are not the addressee indicated in this message (or responsible
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                          understood as neither given nor endorsed by it.
                          >
                          > --- On Tue, 9/1/09, DR WILLIAM CORCORAN William.R.Corcoran@... wrote:
                          >
                          >
                          > From: DR WILLIAM CORCORAN William.R.Corcoran@...
                          > Subject: RE: [Root_Cause_State_of_the_Practice] Re: Extraneous
                          Conditions Adverse to Quality
                          > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                          > Date: Tuesday, September 1, 2009, 11:48 AM
                          >
                          >
                          > Â
                          >
                          >
                          >
                          >
                          >
                          >
                          >
                          >
                          > Mike,
                          > Â
                          > My understanding of what went on is that the inspection process was
                          flawed in that it would not have surfaced the harmful factors that
                          resulted in the consequence even if it had been carried out as required.
                          > Â
                          > Thus, not doing it did not matter.
                          > Â
                          > Is it right that people be fired for not doing what doesn't matter?
                          >
                          >
                          >
                          > Take care,
                          > Â
                          > 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.
                          > Â
                          > W. R. Corcoran, Ph.D., P.E.
                          > Nuclear Safety Review Concepts Corporation
                          > 21 Broadleaf Circle
                          > Windsor, CT 06095-1634
                          > 860-285-8779
                          >
                          > Â
                          > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                          yahoogroups. com
                          > Join the group advancing the practice of root cause analysis/
                          evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                          yahoogroups. com
                          > Â
                          > ****Internet Email Confidentiality Footer****
                          > Â
                          > Privileged/Confiden tial Information may be contained in this message.
                          If you are not the addressee indicated in this message (or responsible
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                          this message to anyone. In such case, you should destroy this message
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                          or your employer do not consent to Internet email for messages of this
                          kind. Opinions, conclusions and other information in this message that
                          do not relate to the official business of NSRC Corp. shall be
                          understood as neither given nor endorsed by it.
                          >
                          > --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                          wrote:
                          >
                          >
                          > From: Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                          > Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                          Conditions Adverse to Quality
                          > To: "'Root_Cause_ State_of_ the_Practice@ yahoogroups. com'"
                          <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                          > Date: Tuesday, September 1, 2009, 11:28 AM
                          >
                          >
                          > Â
                          >
                          >
                          >
                          > In other words, the missed inspection was a factor, potentially, in
                          the prevention of this but not a factor in creating the incident in the
                          first place.
                          > Â
                          >
                          > Mike van Leuken     Product Release Team
                          > ISC: Protected
                          > Â
                          >
                          >
                          > 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: 2009 September 01 9:09 AM
                          > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                          > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                          Conditions Adverse to Quality
                          > Â
                          > Â
                          >
                          >
                          >
                          >
                          >
                          >
                          >
                          >
                          > Jack,
                          >
                          >
                          > Â
                          >
                          >
                          > The article said, "Officials have said it was unlikely that the missed
                          inspection had any relation to the accident."
                          >
                          >
                          > Â
                          >
                          > If that is true the failure to do the inspection and the falsification
                          were not harmful factors of the accident.
                          >
                          > Â
                          >
                          > They are bad.
                          >
                          > Â
                          >
                          > They are hateful.
                          >
                          > Â
                          >
                          > They are heinous.
                          >
                          > Â
                          >
                          > But they are extraneous to the factors that resulted in the
                          consequences.
                          >
                          >
                          > Take care,
                          > Â
                          > 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.
                          > Â
                          > W. R. Corcoran, Ph.D., P.E.
                          > Nuclear Safety Review Concepts Corporation
                          > 21 Broadleaf Circle
                          > Windsor, CT 06095-1634
                          > 860-285-8779
                          >
                          >
                          > Â
                          >
                          > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                          yahoogroups. com
                          >
                          > Join the group advancing the practice of root cause analysis/
                          evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                          yahoogroups. com
                          >
                          > Â
                          >
                          > ****Internet Email Confidentiality Footer****
                          >
                          > Â
                          >
                          > Privileged/Confiden tial Information may be contained in this message.
                          If you are not the addressee indicated in this message (or responsible
                          for delivery of the message to such person), you may not copy or deliver
                          this message to anyone. In such case, you should destroy this message
                          and notify the sender by reply email. Please advise immediately if you
                          or your employer do not consent to Internet email for messages of this
                          kind. Opinions, conclusions and other information in this message that
                          do not relate to the official business of NSRC Corp. shall be
                          understood as neither given nor endorsed by it.
                          >
                          >
                          > --- On Tue, 9/1/09, jack.stanford@ att.net <jack.stanford@ att.net>
                          wrote:
                          >
                          > From: jack.stanford@ att.net <jack.stanford@ att.net>
                          > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                          Corrective Actions?
                          > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                          > Date: Tuesday, September 1, 2009, 10:21 AM
                          >
                          >
                          > The NYC govt. should simply fire Edward Marquette. The guy has
                          apparently falsified at least three crane inspection reports. Why
                          do you think that he believes that falsified reports are what he is
                          being paid to do? The man does not have integrity and should be
                          terminated because of that, whether or not the fact that he did not
                          perform a crane inspection is relevant to the big accident. The
                          accident that killed seven people happened 11 days after the inspection
                          that never took place last year. Anyone who reported false
                          documentation intentionally, if they worked for me, would have been
                          fired pronto. I remain unconvinced that the missed inspection is
                          just an extraneous factor.
                          >
                          > Â
                          >
                          > JackÂ
                          >
                          > Â
                          >
                          > ------------ -- Original message from DR WILLIAM CORCORAN
                          <William.R.Corcoran@ 1959.USNA. com>: ------------ --
                          >
                          > Â
                          >
                          >
                          >
                          >
                          >
                          >
                          >
                          > According to the article, even if the inspection had been done and
                          done properly the event would still have happened.
                          >
                          >
                          > Â
                          >
                          >
                          > Thus if you draw a factor tree for any of the consequences the missed
                          inspections will not be on it.
                          >
                          >
                          > Take care,
                          > Â
                          > 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.
                          > Â
                          > W. R. Corcoran, Ph.D., P.E.
                          > Nuclear Safety Review Concepts Corporation
                          > 21 Broadleaf Circle
                          > Windsor, CT 06095-1634
                          > 860-285-8779
                          >
                          >
                          > Â
                          >
                          > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                          yahoogroups. com
                          >
                          > Join the group advancing the practice of root cause analysis/
                          evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                          yahoogroups. com
                          >
                          > Â
                          >
                          > ****Internet Email Confidentiality Footer****
                          >
                          > Â
                          >
                          > Privileged/Confiden tial Information may be contained in this message.
                          If you are not the addressee indicated in this message (or responsible
                          for delivery of the message to such person), you may not copy or deliver
                          this message to anyone. In such case, you should destroy this message
                          and notify the sender by reply email. Please advise immediately if you
                          or your employer do not consent to Internet email for messages of this
                          kind. Opinions, conclusions and other information in this message that
                          do not relate to the official business of NSRC Corp. shall be
                          understood as neither given nor endorsed by it.
                          >
                          >
                          > --- On Mon, 8/31/09, fforck@yahoo. com fforck@yahoo. com> wrote:
                          >
                          > From: fforck@yahoo. com fforck@yahoo. com>
                          > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                          Corrective Actions?
                          > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                          > Date: Monday, August 31, 2009, 12:08 PM
                          >
                          > Â
                          >
                          >
                          > I understand. I think the missed inspection is a flawed defense and
                          deserves a place on the factor tree because it is related to the event.
                          It seems you are saying the missed inspection is unrelated (extraneous)
                          and does not deserve a place on the factor tree. Am I receiving your
                          message correctly?
                          >
                          > Sent via BlackBerry by AT&T
                          >
                          >
                          >
                          >
                          > From: DR WILLIAM CORCORAN
                          > Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                          > To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                          > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                          Corrective Actions?
                          > Â
                          >
                          >
                          >
                          >
                          >
                          >
                          >
                          > Fred,
                          >
                          >
                          > Â
                          >
                          >
                          > If the item has no place on the factor tree it would be appropriate to
                          call it "extraneous. "
                          >
                          >
                          > Take care,
                          > Â
                          > 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.
                          > Â
                          > W. R. Corcoran, Ph.D., P.E.
                          > Nuclear Safety Review Concepts Corporation
                          > 21 Broadleaf Circle
                          > Windsor, CT 06095-1634
                          > 860-285-8779
                          >
                          >
                          > Â
                          >
                          > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                          yahoogroups. com
                          >
                          > Join the group advancing the practice of root cause analysis/
                          evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                          yahoogroups. com
                          >
                          > Â
                          >
                          > ****Internet Email Confidentiality Footer****
                          >
                          > Â
                          >
                          > Privileged/Confiden tial Information may be contained in this message.
                          If you are not the addressee indicated in this message (or responsible
                          for delivery of the message to such person), you may not copy or deliver
                          this message to anyone. In such case, you should destroy this message
                          and notify the sender by reply email. Please advise immediately if you
                          or your employer do not consent to Internet email for messages of this
                          kind. Opinions, conclusions and other information in this message that
                          do not relate to the official business of NSRC Corp. shall be
                          understood as neither given nor endorsed by it.
                          >
                          >
                          > --- On Sat, 8/29/09, fforck@yahoo. com fforck@yahoo. com> wrote:
                          >
                          > From: fforck@yahoo. com fforck@yahoo. com>
                          > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                          Corrective Actions?
                          > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                          > Date: Saturday, August 29, 2009, 9:02 AM
                          >
                          > Â
                          >
                          >
                          > Seems to be a flawed organizational defense/control (i.e. the
                          inspection). Inspections are built into a system to provide a layer of
                          assurance work happens successfully.
                          >
                          > Just because "Officials have said it was unlikely that the missed
                          inspection had any relation to the accident" doesn't mean the missed
                          inspection was an unrelated factor or "extraneous" .
                          > I wonder if the officials reaching this conclusion have a concept of
                          "defense-in- depth"?
                          > Fred
                          >
                          > Sent via BlackBerry by AT&T
                          >
                          >
                          >
                          >
                          > From: "drbillcorcoran"
                          > Date: Sat, 29 Aug 2009 09:31:13 -0000
                          > To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                          > Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective
                          Actions?
                          > Â
                          >
                          >
                          >
                          > http://www.nytimes com/2009/ 08/29/nyregion/ 29inspectors. html?emc=
                          tnt&tntemail1=y
                          >
                          > The item, not factor, being corrected was not a harmful factor of the
                          adverse consequence, but was rather an Extraneous Condition Adverse to
                          Quality (ECAQ).
                          >
                          > What do you get out of this article?
                          >
                          > August 29, 2009
                          > Buildings Dept. to Track Inspectors via Cellphone and GPS Technology
                          >
                          > By MANNY FERNANDEZ
                          >
                          >
                          > Seeking to better manage its resources and increase the supervision of
                          its inspectors, New York City's Department of Buildings will begin
                          tracking their whereabouts using GPS technology in their
                          department-issued cellphones.
                          >
                          > The new tracking system, which has upset some inspectors, will begin
                          monitoring the first group of 10 inspectors on Monday. By the end of
                          next month, all of the agency's 379 inspectors â€" including crane
                          and elevator inspectors â€" will be tracked through their
                          cellphones, agency officials announced Friday.
                          >
                          > The new tracking system is being put in place in part because of the
                          case of Edward J. Marquette, an inspector who was charged last year with
                          faking a report that he inspected a tower crane on the East Side of
                          Manhattan in response to a complaint. He never visited the crane, the
                          authorities said, and 11 days later, it toppled and killed seven people.
                          Officials have said it was unlikely that the missed inspection had any
                          relation to the accident. Prosecutors said that Mr. Marquette, who
                          pleaded not guilty to the charges, also filed false inspection reports
                          for cranes at two other sites.
                          >
                          > "This new GPS tracking system is a simple, innovative way to ensure
                          inspectors reach their assigned locations and are held accountable for
                          their important work," Buildings Commissioner Robert D. LiMandri said in
                          a statement.
                          >
                          > The management of the Buildings Department has long been criticized.
                          The two tower-crane accidents last year in Manhattan that left a total
                          of nine people dead led to the resignation of Patricia J. Lancaster, Mr.
                          LiMandri's predecessor as commissioner, and spurred several
                          investigations that uncovered corruption within the agency's Cranes and
                          Derricks Division.
                          >
                          > A department official said the agency did not believe there was a
                          widespread problem of inspectors misusing their time while on duty, and
                          described the new system as one way to improve the accountability of the
                          department and its inspectors. Supervisors will also be able to identify
                          the closest inspector to a building-related emergency and pinpoint the
                          location of inspectors who lose contact with their superiors while
                          working in hazardous conditions.
                          >
                          > Joseph M. Corso, the president of Local 211 of the Allied Building
                          Inspectors Union, which represents most Buildings Department inspectors,
                          said the initial response from members employed by the agency was one of
                          disappointment. "Just like the Justice Department monitors parolees and
                          those under house arrest, they'll have a tracking device," he said of
                          the inspectors. "We're going to do all we can to ensure the rights of
                          the membership are covered."
                          >
                          > But one inspector who did not want to give his name said, "If you are
                          where you're supposed to be, you've got nothing to fear."
                          >
                          > Department officials said the heads of inspection units would be able
                          to monitor the movements of inspectors in real time from any computer,
                          using a confidential log-in and password. The daily routes the
                          inspectors travel will also be electronically recorded and stored. The
                          union was given few details about how the system would work, Mr. Corso
                          said, but one concern is that inspectors usually have their
                          department-issued cellphones with them even when off duty.
                          >
                          > The Buildings Department's chief spokesman, Tony Sclafani, said the
                          agency would monitor the inspectors only while on duty.
                          >
                          > "The software enables the tracking system to be fixed to the work
                          schedule of each inspector," Mr. Sclafani said. "When the shift ends,
                          the tracking system will turn off."
                          >
                          >
                          > Colin Moynihan contributed reporting.
                          >
                          > Â
                          >
                          >
                          >
                          >
                          > NOTICE -
                          > This communication is intended ONLY for the use of the person or
                          entity named above and may contain information that is confidential or
                          legally privileged. If you are not the intended recipient named above or
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                          >
                        • fforck@yahoo.com
                          So missed opportunities are pertinent to investigations, but missed inspections are extraneous . Interesting Sent via BlackBerry by AT&T ... From: wlrigot
                          Message 12 of 30 , Sep 1, 2009
                          • 0 Attachment
                            So "missed opportunities" are pertinent to investigations, but missed inspections are "extraneous". Interesting

                            Sent via BlackBerry by AT&T


                            From: "wlrigot"
                            Date: Tue, 01 Sep 2009 21:13:08 -0000
                            To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                            Subject: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality

                             


                            Dr. Bill,

                            I really hate to bring this up, because it always generates (unintended)
                            controversy, but this relates to what Sydney Dekker and others call
                            "counterfactuals" . They are behaviors that never happened, that
                            management wished with all their little hearts would have happened.
                            They are certainly extraneous conditions adverse to quality and should
                            be investigated, but have nothing to do with the nature, magitude,
                            timing and location of factors leading to the event.

                            Unfortunately, when bad things happen and people end up dead, hordes of
                            people in the "uh oh" squad descend on you and will always find bad
                            things that had been buried for a long time. Unintended consequences
                            almost always ensue. This appears to be what happened here. While some
                            will feel good about punishing some poor soul who got caught not doing
                            an inspection, they are no nearer determining what actually led to the
                            event. And they are thus no nearer determining effective corrective
                            actions that would prevent recurrence.

                            Bill Rigot
                            --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM
                            CORCORAN <William.R.Corcoran @...> wrote:

                            >
                            > When an employee does not do what was ordered to be done one needs to
                            determine what the factors were that resulted in the employee's
                            inaction?
                            > Â
                            > Was it the first time?
                            > Â
                            > Was it allowed by custom?
                            > Â
                            > Etc.
                            > Â
                            > In the Navy a CPO told me, "Mr. Corcoran, you get what you inspect,
                            not what you expect!"
                            >
                            >
                            >
                            > Take care,
                            > Â
                            > 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.
                            > Â
                            > W. R. Corcoran, Ph.D., P.E.
                            > Nuclear Safety Review Concepts Corporation
                            > 21 Broadleaf Circle
                            > Windsor, CT 06095-1634
                            > 860-285-8779
                            >
                            > Â
                            > Subscribe to "The Firebird Forum" Â
                            TheFirebirdForum- subscribe@ yahoogroups. com
                            > Join the group advancing the practice of root cause analysis/
                            evaluation Â
                            Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                            > Â
                            > ****Internet Email Confidentiality Footer****
                            > Â
                            > Privileged/Confiden tial Information may be contained in this message.
                            If you are not the addressee indicated in this message (or responsible
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                            this message to anyone. In such case, you should destroy this message
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                            understood as neither given nor endorsed by it.
                            >
                            > --- On Tue, 9/1/09, DR WILLIAM CORCORAN William.R.Corcoran@ ... wrote:
                            >
                            >
                            > From: DR WILLIAM CORCORAN William.R.Corcoran@ ...
                            > Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                            Conditions Adverse to Quality
                            > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                            > Date: Tuesday, September 1, 2009, 11:48 AM
                            >
                            >
                            > Â
                            >
                            >
                            >
                            >
                            >
                            >
                            >
                            >
                            > Mike,
                            > Â
                            > My understanding of what went on is that the inspection process was
                            flawed in that it would not have surfaced the harmful factors that
                            resulted in the consequence even if it had been carried out as required.
                            > Â
                            > Thus, not doing it did not matter.
                            > Â
                            > Is it right that people be fired for not doing what doesn't matter?
                            >
                            >
                            >
                            > Take care,
                            > Â
                            > 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.
                            > Â
                            > W. R. Corcoran, Ph.D., P.E.
                            > Nuclear Safety Review Concepts Corporation
                            > 21 Broadleaf Circle
                            > Windsor, CT 06095-1634
                            > 860-285-8779
                            >
                            > Â
                            > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                            yahoogroups. com
                            > Join the group advancing the practice of root cause analysis/
                            evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                            yahoogroups. com
                            > Â
                            > ****Internet Email Confidentiality Footer****
                            > Â
                            > Privileged/Confiden tial Information may be contained in this message.
                            If you are not the addressee indicated in this message (or responsible
                            for delivery of the message to such person), you may not copy or deliver
                            this message to anyone. In such case, you should destroy this message
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                            or your employer do not consent to Internet email for messages of this
                            kind. Opinions, conclusions and other information in this message that
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                            understood as neither given nor endorsed by it.
                            >
                            > --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                            wrote:
                            >
                            >
                            > From: Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                            > Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                            Conditions Adverse to Quality
                            > To: "'Root_Cause_ State_of_ the_Practice@ yahoogroups. com'"
                            <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                            > Date: Tuesday, September 1, 2009, 11:28 AM
                            >
                            >
                            > Â
                            >
                            >
                            >
                            > In other words, the missed inspection was a factor, potentially, in
                            the prevention of this but not a factor in creating the incident in the
                            first place.
                            > Â
                            >
                            > Mike van Leuken     Product Release Team
                            > ISC: Protected
                            > Â
                            >
                            >
                            > 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: 2009 September 01 9:09 AM
                            > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                            > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                            Conditions Adverse to Quality
                            > Â
                            > Â
                            >
                            >
                            >
                            >
                            >
                            >
                            >
                            >
                            > Jack,
                            >
                            >
                            > Â
                            >
                            >
                            > The article said, "Officials have said it was unlikely that the missed
                            inspection had any relation to the accident."
                            >
                            >
                            > Â
                            >
                            > If that is true the failure to do the inspection and the falsification
                            were not harmful factors of the accident.
                            >
                            > Â
                            >
                            > They are bad.
                            >
                            > Â
                            >
                            > They are hateful.
                            >
                            > Â
                            >
                            > They are heinous.
                            >
                            > Â
                            >
                            > But they are extraneous to the factors that resulted in the
                            consequences.
                            >
                            >
                            > Take care,
                            > Â
                            > 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.
                            > Â
                            > W. R. Corcoran, Ph.D., P.E.
                            > Nuclear Safety Review Concepts Corporation
                            > 21 Broadleaf Circle
                            > Windsor, CT 06095-1634
                            > 860-285-8779
                            >
                            >
                            > Â
                            >
                            > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                            yahoogroups. com
                            >
                            > Join the group advancing the practice of root cause analysis/
                            evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                            yahoogroups. com
                            >
                            > Â
                            >
                            > ****Internet Email Confidentiality Footer****
                            >
                            > Â
                            >
                            > Privileged/Confiden tial Information may be contained in this message.
                            If you are not the addressee indicated in this message (or responsible
                            for delivery of the message to such person), you may not copy or deliver
                            this message to anyone. In such case, you should destroy this message
                            and notify the sender by reply email. Please advise immediately if you
                            or your employer do not consent to Internet email for messages of this
                            kind. Opinions, conclusions and other information in this message that
                            do not relate to the official business of NSRC Corp. shall be
                            understood as neither given nor endorsed by it.
                            >
                            >
                            > --- On Tue, 9/1/09, jack.stanford@ att.net <jack.stanford@ att.net>
                            wrote:
                            >
                            > From: jack.stanford@ att.net <jack.stanford@ att.net>
                            > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                            Corrective Actions?
                            > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                            > Date: Tuesday, September 1, 2009, 10:21 AM
                            >
                            >
                            > The NYC govt. should simply fire Edward Marquette. The guy has
                            apparently falsified at least three crane inspection reports. Why
                            do you think that he believes that falsified reports are what he is
                            being paid to do? The man does not have integrity and should be
                            terminated because of that, whether or not the fact that he did not
                            perform a crane inspection is relevant to the big accident. The
                            accident that killed seven people happened 11 days after the inspection
                            that never took place last year. Anyone who reported false
                            documentation intentionally, if they worked for me, would have been
                            fired pronto. I remain unconvinced that the missed inspection is
                            just an extraneous factor.
                            >
                            > Â
                            >
                            > JackÂ
                            >
                            > Â
                            >
                            > ------------ -- Original message from DR WILLIAM CORCORAN
                            <William.R.Corcoran @ 1959.USNA. com>: ------------ --
                            >
                            > Â
                            >
                            >
                            >
                            >
                            >
                            >
                            >
                            > According to the article, even if the inspection had been done and
                            done properly the event would still have happened.
                            >
                            >
                            > Â
                            >
                            >
                            > Thus if you draw a factor tree for any of the consequences the missed
                            inspections will not be on it.
                            >
                            >
                            > Take care,
                            > Â
                            > 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.
                            > Â
                            > W. R. Corcoran, Ph.D., P.E.
                            > Nuclear Safety Review Concepts Corporation
                            > 21 Broadleaf Circle
                            > Windsor, CT 06095-1634
                            > 860-285-8779
                            >
                            >
                            > Â
                            >
                            > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                            yahoogroups. com
                            >
                            > Join the group advancing the practice of root cause analysis/
                            evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                            yahoogroups. com
                            >
                            > Â
                            >
                            > ****Internet Email Confidentiality Footer****
                            >
                            > Â
                            >
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                            If you are not the addressee indicated in this message (or responsible
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                            kind. Opinions, conclusions and other information in this message that
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                            understood as neither given nor endorsed by it.
                            >
                            >
                            > --- On Mon, 8/31/09, fforck@yahoo. com fforck@yahoo. com> wrote:
                            >
                            > From: fforck@yahoo. com fforck@yahoo. com>
                            > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                            Corrective Actions?
                            > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                            > Date: Monday, August 31, 2009, 12:08 PM
                            >
                            > Â
                            >
                            >
                            > I understand. I think the missed inspection is a flawed defense and
                            deserves a place on the factor tree because it is related to the event.
                            It seems you are saying the missed inspection is unrelated (extraneous)
                            and does not deserve a place on the factor tree. Am I receiving your
                            message correctly?
                            >
                            > Sent via BlackBerry by AT&T
                            >
                            >
                            >
                            >
                            > From: DR WILLIAM CORCORAN
                            > Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                            > To: <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                            > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                            Corrective Actions?
                            > Â
                            >
                            >
                            >
                            >
                            >
                            >
                            >
                            > Fred,
                            >
                            >
                            > Â
                            >
                            >
                            > If the item has no place on the factor tree it would be appropriate to
                            call it "extraneous. "
                            >
                            >
                            > Take care,
                            > Â
                            > 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.
                            > Â
                            > W. R. Corcoran, Ph.D., P.E.
                            > Nuclear Safety Review Concepts Corporation
                            > 21 Broadleaf Circle
                            > Windsor, CT 06095-1634
                            > 860-285-8779
                            >
                            >
                            > Â
                            >
                            > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                            yahoogroups. com
                            >
                            > Join the group advancing the practice of root cause analysis/
                            evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                            yahoogroups. com
                            >
                            > Â
                            >
                            > ****Internet Email Confidentiality Footer****
                            >
                            > Â
                            >
                            > Privileged/Confiden tial Information may be contained in this message.
                            If you are not the addressee indicated in this message (or responsible
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                            kind. Opinions, conclusions and other information in this message that
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                            understood as neither given nor endorsed by it.
                            >
                            >
                            > --- On Sat, 8/29/09, fforck@yahoo. com fforck@yahoo. com> wrote:
                            >
                            > From: fforck@yahoo. com fforck@yahoo. com>
                            > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                            Corrective Actions?
                            > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                            > Date: Saturday, August 29, 2009, 9:02 AM
                            >
                            > Â
                            >
                            >
                            > Seems to be a flawed organizational defense/control (i.e. the
                            inspection). Inspections are built into a system to provide a layer of
                            assurance work happens successfully.
                            >
                            > Just because "Officials have said it was unlikely that the missed
                            inspection had any relation to the accident" doesn't mean the missed
                            inspection was an unrelated factor or "extraneous" .
                            > I wonder if the officials reaching this conclusion have a concept of
                            "defense-in- depth"?
                            > Fred
                            >
                            > Sent via BlackBerry by AT&T
                            >
                            >
                            >
                            >
                            > From: "drbillcorcoran"
                            > Date: Sat, 29 Aug 2009 09:31:13 -0000
                            > To: <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                            > Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective
                            Actions?
                            > Â
                            >
                            >
                            >
                            > http://www.nytimes. com/2009/ 08/29/nyregion/ 29inspectors. html?emc=
                            tnt&tntemail1= y
                            >
                            > The item, not factor, being corrected was not a harmful factor of the
                            adverse consequence, but was rather an Extraneous Condition Adverse to
                            Quality (ECAQ).
                            >
                            > What do you get out of this article?
                            >
                            > August 29, 2009
                            > Buildings Dept. to Track Inspectors via Cellphone and GPS Technology
                            >
                            > By MANNY FERNANDEZ
                            >
                            >
                            > Seeking to better manage its resources and increase the supervision of
                            its inspectors, New York City's Department of Buildings will begin
                            tracking their whereabouts using GPS technology in their
                            department-issued cellphones.
                            >
                            > The new tracking system, which has upset some inspectors, will begin
                            monitoring the first group of 10 inspectors on Monday. By the end of
                            next month, all of the agency's 379 inspectors â€" including crane
                            and elevator inspectors â€" will be tracked through their
                            cellphones, agency officials announced Friday.
                            >
                            > The new tracking system is being put in place in part because of the
                            case of Edward J. Marquette, an inspector who was charged last year with
                            faking a report that he inspected a tower crane on the East Side of
                            Manhattan in response to a complaint. He never visited the crane, the
                            authorities said, and 11 days later, it toppled and killed seven people.
                            Officials have said it was unlikely that the missed inspection had any
                            relation to the accident. Prosecutors said that Mr. Marquette, who
                            pleaded not guilty to the charges, also filed false inspection reports
                            for cranes at two other sites.
                            >
                            > "This new GPS tracking system is a simple, innovative way to ensure
                            inspectors reach their assigned locations and are held accountable for
                            their important work," Buildings Commissioner Robert D. LiMandri said in
                            a statement.
                            >
                            > The management of the Buildings Department has long been criticized.
                            The two tower-crane accidents last year in Manhattan that left a total
                            of nine people dead led to the resignation of Patricia J. Lancaster, Mr.
                            LiMandri's predecessor as commissioner, and spurred several
                            investigations that uncovered corruption within the agency's Cranes and
                            Derricks Division.
                            >
                            > A department official said the agency did not believe there was a
                            widespread problem of inspectors misusing their time while on duty, and
                            described the new system as one way to improve the accountability of the
                            department and its inspectors. Supervisors will also be able to identify
                            the closest inspector to a building-related emergency and pinpoint the
                            location of inspectors who lose contact with their superiors while
                            working in hazardous conditions.
                            >
                            > Joseph M. Corso, the president of Local 211 of the Allied Building
                            Inspectors Union, which represents most Buildings Department inspectors,
                            said the initial response from members employed by the agency was one of
                            disappointment. "Just like the Justice Department monitors parolees and
                            those under house arrest, they'll have a tracking device," he said of
                            the inspectors. "We're going to do all we can to ensure the rights of
                            the membership are covered."
                            >
                            > But one inspector who did not want to give his name said, "If you are
                            where you're supposed to be, you've got nothing to fear."
                            >
                            > Department officials said the heads of inspection units would be able
                            to monitor the movements of inspectors in real time from any computer,
                            using a confidential log-in and password. The daily routes the
                            inspectors travel will also be electronically recorded and stored. The
                            union was given few details about how the system would work, Mr. Corso
                            said, but one concern is that inspectors usually have their
                            department-issued cellphones with them even when off duty.
                            >
                            > The Buildings Department's chief spokesman, Tony Sclafani, said the
                            agency would monitor the inspectors only while on duty.
                            >
                            > "The software enables the tracking system to be fixed to the work
                            schedule of each inspector," Mr. Sclafani said. "When the shift ends,
                            the tracking system will turn off."
                            >
                            >
                            > Colin Moynihan contributed reporting.
                            >
                            > Â
                            >
                            >
                            >
                            >
                            > NOTICE -
                            > This communication is intended ONLY for the use of the person or
                            entity named above and may contain information that is confidential or
                            legally privileged. If you are not the intended recipient named above or
                            a person responsible for delivering messages or communications to the
                            intended recipient, YOU ARE HEREBY NOTIFIED that any use, distribution,
                            or copying of this communication or any of the information contained in
                            it is strictly prohibited. If you have received this communication in
                            error, please notify us immediately by telephone and then destroy or
                            delete this communication, or return it to us by mail if requested by
                            us. The City of Calgary thanks you for your attention and co-operation.
                            >

                          • Dillard, Tedd A (E S SF RNA FS 11E)
                            Gentle Persons, I happened to be working at Indian Point when this event occurred. It was much in the local papers. As I recall the most significant factor
                            Message 13 of 30 , Sep 1, 2009
                            • 0 Attachment
                              
                              Gentle Persons,
                              I happened to be working at Indian Point when this event occurred.
                              It was much in the local papers.
                              As I recall the most significant factor that resulted in the crane falling was a structural brace was not properly installed.
                              This was a tower crane that is raised section by section as the building gets taller.
                              As each section is added it is braced back to the building structure.
                              The event occurred during one of the raising task called "jacking".
                              Apparently one of the braces at the top of the last section was not properly connected to the building and as they raised the crane it became unstable and fell.
                              As Dr. Bill stated, apparently the inspection that was not done was a some what superficial inspection and would not have actually looked at the structure of the crane.
                              So I believe it is true that that inspection would not have found the defect even if performed.
                              But as also pointed out when something goes wrong there is always multiple things identified that are not correct.
                              Apparently falsified inspection reports were some what common, not just for the inspector involved, but others.
                              This raises the question of the culture in the inspection department and the construction industry and also suggest that inspections are not robust enough even if performed.
                              The real issue is did the missed inspection and the resulting activity prevent the identification and corrective action of the real cause?
                              An interesting side issue is a retired construction superintendent lived in a building next to the job site and he had seen the crane moving several days prior to the event and had tried to get someone to pay attention.
                              Tedd
                               


                              From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of fforck@...
                              Sent: Tuesday, September 01, 2009 6:13 PM
                              To: Root_Cause_State_of_the_Practice@yahoogroups.com
                              Subject: Re: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality

                               

                              So "missed opportunities" are pertinent to investigations, but missed inspections are "extraneous" . Interesting

                              Sent via BlackBerry by AT&T


                              From: "wlrigot"
                              Date: Tue, 01 Sep 2009 21:13:08 -0000
                              To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                              Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                               


                              Dr. Bill,

                              I really hate to bring this up, because it always generates (unintended)
                              controversy, but this relates to what Sydney Dekker and others call
                              "counterfactuals" . They are behaviors that never happened, that
                              management wished with all their little hearts would have happened.
                              They are certainly extraneous conditions adverse to quality and should
                              be investigated, but have nothing to do with the nature, magitude,
                              timing and location of factors leading to the event.

                              Unfortunately, when bad things happen and people end up dead, hordes of
                              people in the "uh oh" squad descend on you and will always find bad
                              things that had been buried for a long time. Unintended consequences
                              almost always ensue. This appears to be what happened here. While some
                              will feel good about punishing some poor soul who got caught not doing
                              an inspection, they are no nearer determining what actually led to the
                              event. And they are thus no nearer determining effective corrective
                              actions that would prevent recurrence.

                              Bill Rigot
                              --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM
                              CORCORAN <William.R.Corcoran @...> wrote:

                              >
                              > When an employee does not do what was ordered to be done
                              one needs to
                              determine what the factors were that resulted in the employee's
                              inaction?
                              > Â
                              > Was it the first time?
                              >
                              Â
                              > Was it allowed by custom?
                              > Â
                              > Etc.
                              > Â
                              > In
                              the Navy a CPO told me, "Mr. Corcoran, you get what you inspect,
                              not what you expect!"
                              >
                              >
                              >
                              > Take care,
                              > Â
                              > 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.
                              > Â
                              > W.
                              R. Corcoran, Ph.D., P.E.
                              > Nuclear Safety Review Concepts
                              Corporation
                              > 21 Broadleaf Circle
                              > Windsor, CT 06095-1634
                              >
                              860-285-8779
                              >
                              > Â
                              > Subscribe to "The Firebird Forum" Â
                              TheFirebirdForum- subscribe@ yahoogroups. com
                              >
                              Join the group advancing the practice of root cause analysis/
                              evaluation Â
                              Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                              >
                              Â
                              > ****Internet Email Confidentiality Footer****
                              > Â
                              >
                              Privileged/Confiden tial Information may be contained in this message.
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                              >
                              > --- On Tue, 9/1/09, DR WILLIAM CORCORAN
                              William.R.Corcoran@ ... wrote:
                              >
                              >
                              > From: DR WILLIAM
                              CORCORAN William.R.Corcoran@ ...
                              > Subject: RE:
                              [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                              Conditions Adverse to Quality
                              > To:
                              href="mailto:Root_Cause_State_of_the_Practice%40yahoogroups.com">Root_Cause_State_ of_the_Practice@ yahoogroups. com
                              >
                              Date: Tuesday, September 1, 2009, 11:48 AM
                              >
                              >
                              >
                              Â
                              >
                              >
                              >
                              >
                              >
                              >
                              >
                              >
                              >
                              Mike,
                              > Â
                              > My understanding of what went on is that the inspection
                              process was
                              flawed in that it would not have surfaced the harmful factors that
                              resulted in the consequence even if it had been carried out as required.
                              > Â
                              > Thus, not doing it did not matter.
                              > Â
                              >
                              Is it right that people be fired for not doing what doesn't matter?
                              >
                              >
                              >
                              > Take care,
                              > Â
                              > 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.
                              > Â
                              > W.
                              R. Corcoran, Ph.D., P.E.
                              > Nuclear Safety Review Concepts
                              Corporation
                              > 21 Broadleaf Circle
                              > Windsor, CT 06095-1634
                              >
                              860-285-8779
                              >
                              > Â
                              > Subscribe to "The Firebird Forum" Â
                              TheFirebirdForum- subscribe@
                              yahoogroups. com
                              > Join the group
                              advancing the practice of root cause analysis/
                              evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                              yahoogroups. com
                              >
                              Â
                              > ****Internet Email Confidentiality Footer****
                              > Â
                              >
                              Privileged/Confiden tial Information may be contained in this message.
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                              understood as neither given nor endorsed by it.
                              >
                              > --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@
                              calgary.ca>
                              wrote:
                              >
                              >
                              > From: Van Leuken, Mike
                              <mike.van.leuken@ calgary.ca>
                              > Subject: RE: [Root_Cause_ State_of_
                              the_Practice] Re: Extraneous
                              Conditions Adverse to Quality
                              > To:
                              "'Root_Cause_ State_of_ the_Practice@ yahoogroups. com'"
                              <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                              > Date: Tuesday, September 1, 2009, 11:28
                              AM
                              >
                              >
                              > Â
                              >
                              >
                              >
                              > In other words, the
                              missed inspection was a factor, potentially, in
                              the prevention of this but not a factor in creating the incident in the
                              first place.
                              >
                              Â
                              >
                              > Mike van Leuken     Product Release Team
                              > ISC:
                              Protected
                              > Â
                              >
                              >
                              > 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: 2009
                              September 01 9:09 AM
                              > To: Root_Cause_State_ of_the_Practice@ yahoogroups.
                              com
                              > Subject: [Root_Cause_ State_of_ the_Practice] Re:
                              Extraneous
                              Conditions Adverse to Quality
                              > Â
                              >
                              Â
                              >
                              >
                              >
                              >
                              >
                              >
                              >
                              >
                              >
                              Jack,
                              >
                              >
                              > Â
                              >
                              >
                              > The article said,
                              "Officials have said it was unlikely that the missed
                              inspection had any relation to the accident."
                              >
                              >
                              > Â
                              >
                              > If that is
                              true the failure to do the inspection and the falsification
                              were not harmful factors of the accident.
                              >
                              > Â
                              >
                              > They are
                              bad.
                              >
                              > Â
                              >
                              > They are hateful.
                              >
                              >
                              Â
                              >
                              > They are heinous.
                              >
                              > Â
                              >
                              > But they
                              are extraneous to the factors that resulted in the
                              consequences.
                              >
                              >
                              > Take care,
                              > Â
                              > 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.
                              > Â
                              > W.
                              R. Corcoran, Ph.D., P.E.
                              > Nuclear Safety Review Concepts
                              Corporation
                              > 21 Broadleaf Circle
                              > Windsor, CT 06095-1634
                              >
                              860-285-8779
                              >
                              >
                              > Â
                              >
                              > Subscribe to "The
                              Firebird Forum" Â TheFirebirdForum- subscribe@
                              yahoogroups. com
                              >
                              > Join the group advancing the practice of root cause
                              analysis/
                              evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                              yahoogroups. com
                              >
                              > Â
                              >
                              > ****Internet
                              Email Confidentiality Footer****
                              >
                              > Â
                              >
                              >
                              Privileged/Confiden tial Information may be contained in this message.
                              If you are not the addressee indicated in this message (or responsible
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                              >
                              >
                              > --- On Tue, 9/1/09, jack.stanford@ att.net
                              <jack.stanford@ att.net>
                              wrote:
                              >
                              > From: jack.stanford@
                              att.net <jack.stanford@ att.net>
                              > Subject: Re: [Root_Cause_
                              State_of_ the_Practice] New Wave of
                              Corrective Actions?
                              > To:
                              Root_Cause_State_ of_the_Practice@ yahoogroups. com
                              > Date: Tuesday,
                              September 1, 2009, 10:21 AM
                              >
                              >
                              > The NYC govt. should simply
                              fire Edward Marquette. The guy has
                              apparently falsified at least three crane inspection reports. Why
                              do you think that he believes that falsified reports are what he is
                              being paid to do? The man does not have integrity and should be
                              terminated because of that, whether or not the fact that he did not
                              perform a crane inspection is relevant to the big accident. The
                              accident that killed seven people happened 11 days after the inspection
                              that never took place last year. Anyone who reported false
                              documentation intentionally, if they worked for me, would have been
                              fired pronto. I remain unconvinced that the missed inspection is
                              just an extraneous factor.
                              >
                              > Â
                              >
                              >
                              JackÂ
                              >
                              > Â
                              >
                              > ------------ -- Original message from DR
                              WILLIAM CORCORAN
                              <William.R.Corcoran @ 1959.USNA. com>: ------------ --
                              >
                              >
                              Â
                              >
                              >
                              >
                              >
                              >
                              >
                              >
                              > According to
                              the article, even if the inspection had been done and
                              done properly the event would still have happened.
                              >
                              >
                              > Â
                              >
                              >
                              >
                              Thus if you draw a factor tree for any of the consequences the missed
                              inspections will not be on it.
                              >
                              >
                              > Take
                              care,
                              > Â
                              > 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.
                              > Â
                              > W. R. Corcoran, Ph.D., P.E.
                              > Nuclear
                              Safety Review Concepts Corporation
                              > 21 Broadleaf Circle
                              > Windsor,
                              CT 06095-1634
                              > 860-285-8779
                              >
                              >
                              > Â
                              >
                              >
                              Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                              yahoogroups. com
                              >
                              > Join the group advancing the practice of root cause
                              analysis/
                              evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                              yahoogroups. com
                              >
                              > Â
                              >
                              > ****Internet
                              Email Confidentiality Footer****
                              >
                              > Â
                              >
                              >
                              Privileged/Confiden tial Information may be contained in this message.
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                              for delivery of the message to such person), you may not copy or deliver
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                              understood as neither given nor endorsed by it.
                              >
                              >
                              > --- On Mon, 8/31/09, fforck@yahoo. com fforck@yahoo.
                              com> wrote:
                              >
                              > From: fforck@yahoo. com fforck@yahoo.
                              com>
                              > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave
                              of
                              Corrective Actions?
                              > To: Root_Cause_State_ of_the_Practice@
                              yahoogroups. com
                              > Date: Monday, August 31, 2009, 12:08 PM
                              >
                              >
                              Â
                              >
                              >
                              > I understand. I think the missed inspection is a
                              flawed defense and
                              deserves a place on the factor tree because it is related to the event.
                              It seems you are saying the missed inspection is unrelated (extraneous)
                              and does not deserve a place on the factor tree. Am I receiving your
                              message correctly?
                              >
                              > Sent via BlackBerry by
                              AT&T
                              >
                              >
                              >
                              >
                              > From: DR WILLIAM
                              CORCORAN
                              > Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                              > To:
                              <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                              >
                              Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                              Corrective Actions?
                              >
                              Â
                              >
                              >
                              >
                              >
                              >
                              >
                              >
                              >
                              Fred,
                              >
                              >
                              > Â
                              >
                              >
                              > If the item has no place
                              on the factor tree it would be appropriate to
                              call it "extraneous. "
                              >
                              >
                              > Take care,
                              > Â
                              > 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.
                              > Â
                              > W.
                              R. Corcoran, Ph.D., P.E.
                              > Nuclear Safety Review Concepts
                              Corporation
                              > 21 Broadleaf Circle
                              > Windsor, CT 06095-1634
                              >
                              860-285-8779
                              >
                              >
                              > Â
                              >
                              > Subscribe to "The
                              Firebird Forum" Â TheFirebirdForum- subscribe@
                              yahoogroups. com
                              >
                              > Join the group advancing the practice of root cause
                              analysis/
                              evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                              yahoogroups. com
                              >
                              > Â
                              >
                              > ****Internet
                              Email Confidentiality Footer****
                              >
                              > Â
                              >
                              >
                              Privileged/Confiden tial Information may be contained in this message.
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                              >
                              >
                              > --- On Sat, 8/29/09, fforck@yahoo. com fforck@yahoo.
                              com> wrote:
                              >
                              > From: fforck@yahoo. com fforck@yahoo.
                              com>
                              > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave
                              of
                              Corrective Actions?
                              > To: Root_Cause_State_ of_the_Practice@
                              yahoogroups. com
                              > Date: Saturday, August 29, 2009, 9:02
                              AM
                              >
                              > Â
                              >
                              >
                              > Seems to be a flawed organizational
                              defense/control (i.e. the
                              inspection). Inspections are built into a system to provide a layer of
                              assurance work happens successfully.
                              >
                              > Just
                              because "Officials have said it was unlikely that the missed
                              inspection had any relation to the accident" doesn't mean the missed
                              inspection was an unrelated factor or "extraneous" .
                              > I wonder if the officials reaching
                              this conclusion have a concept of
                              "defense-in- depth"?
                              >
                              Fred
                              >
                              > Sent via BlackBerry by
                              AT&T
                              >
                              >
                              >
                              >
                              > From: "drbillcorcoran"
                              >
                              Date: Sat, 29 Aug 2009 09:31:13 -0000
                              > To: <Root_Cause_ State_
                              of_the_Practice@ yahoogroups. com>
                              > Subject: [Root_Cause_ State_of_
                              the_Practice] New Wave of Corrective
                              Actions?
                              >
                              Â
                              >
                              >
                              >
                              >
                              href="http://www.nytimes.">http://www.nytimes. com/2009/ 08/29/nyregion/ 29inspectors. html?emc=
                              tnt&tntemail1= y
                              >
                              > The item,
                              not factor, being corrected was not a harmful factor of the
                              adverse consequence, but was rather an Extraneous Condition Adverse to
                              Quality (ECAQ).
                              >
                              > What do you get out of this article?
                              >
                              >
                              August 29, 2009
                              > Buildings Dept. to Track Inspectors via Cellphone and
                              GPS Technology
                              >
                              > By MANNY FERNANDEZ
                              >
                              >
                              >
                              Seeking to better manage its resources and increase the supervision of
                              its inspectors, New York City's Department of Buildings will begin
                              tracking their whereabouts using GPS technology in their
                              department-issued cellphones.
                              >
                              > The new tracking system, which has upset some
                              inspectors, will begin
                              monitoring the first group of 10 inspectors on Monday. By the end of
                              next month, all of the agency's 379 inspectors â€" including crane
                              and elevator inspectors â€" will be tracked through their
                              cellphones, agency officials announced Friday.
                              >
                              > The new
                              tracking system is being put in place in part because of the
                              case of Edward J. Marquette, an inspector who was charged last year with
                              faking a report that he inspected a tower crane on the East Side of
                              Manhattan in response to a complaint. He never visited the crane, the
                              authorities said, and 11 days later, it toppled and killed seven people.
                              Officials have said it was unlikely that the missed inspection had any
                              relation to the accident. Prosecutors said that Mr. Marquette, who
                              pleaded not guilty to the charges, also filed false inspection reports
                              for cranes at two other sites.
                              >
                              > "This new GPS tracking system is a simple, innovative way
                              to ensure
                              inspectors reach their assigned locations and are held accountable for
                              their important work," Buildings Commissioner Robert D. LiMandri said in
                              a statement.
                              >
                              > The management of the Buildings Department
                              has long been criticized.
                              The two tower-crane accidents last year in Manhattan that left a total
                              of nine people dead led to the resignation of Patricia J. Lancaster, Mr.
                              LiMandri's predecessor as commissioner, and spurred several
                              investigations that uncovered corruption within the agency's Cranes and
                              Derricks Division.
                              >
                              > A department official said the
                              agency did not believe there was a
                              widespread problem of inspectors misusing their time while on duty, and
                              described the new system as one way to improve the accountability of the
                              department and its inspectors. Supervisors will also be able to identify
                              the closest inspector to a building-related emergency and pinpoint the
                              location of inspectors who lose contact with their superiors while
                              working in hazardous conditions.
                              >
                              > Joseph M.
                              Corso, the president of Local 211 of the Allied Building
                              Inspectors Union, which represents most Buildings Department inspectors,
                              said the initial response from members employed by the agency was one of
                              disappointment. "Just like the Justice Department monitors parolees and
                              those under house arrest, they'll have a tracking device," he said of
                              the inspectors. "We're going to do all we can to ensure the rights of
                              the membership are covered."
                              >
                              > But one inspector who did not want to give his name
                              said, "If you are
                              where you're supposed to be, you've got nothing to fear."
                              >
                              > Department officials said the heads of inspection units
                              would be able
                              to monitor the movements of inspectors in real time from any computer,
                              using a confidential log-in and password. The daily routes the
                              inspectors travel will also be electronically recorded and stored. The
                              union was given few details about how the system would work, Mr. Corso
                              said, but one concern is that inspectors usually have their
                              department-issued cellphones with them even when off duty.
                              >
                              > The Buildings Department's chief spokesman, Tony Sclafani,
                              said the
                              agency would monitor the inspectors only while on duty.
                              >
                              > "The software enables the tracking system to be fixed to
                              the work
                              schedule of each inspector," Mr. Sclafani said. "When the shift ends,
                              the tracking system will turn off."
                              >
                              >
                              > Colin
                              Moynihan contributed reporting.
                              >
                              >
                              Â
                              >
                              >
                              >
                              >
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                            • DR WILLIAM CORCORAN
                              Tedd,   Thanks for the very helpful posting.   For orientation: A factor is something that affects an effect. (In this case, the effect under discussion is
                              Message 14 of 30 , Sep 2, 2009
                              • 0 Attachment
                                Tedd,
                                 
                                Thanks for the very helpful posting.
                                 
                                For orientation: A factor is something that affects an effect. (In this case, the effect under discussion is the multiple deaths, a consequence.)
                                 
                                When we do a good investigation we find lots of things wrong. (This is a property of the universe.)
                                 
                                The things we find wrong that adversely contributed to the consequence under discussion are called harmful factors of that consequence.
                                 
                                The ones that did not contribute to the nature, the magnitude, the location, or the timing of the consequence ARE NOT FACTORS of that consequence.
                                 
                                OK
                                 
                                Then what are they?
                                 
                                Some people, including me, call them "Extraneous Conditions Adverse to Quality" (ECAQ) because they are adverse, but are extraneous to the consequence.(This is plain English.)
                                 
                                Example: Heater Drain System pipe break at MP 2.  After the event investigators determined that the failed pipe had been left out of the erorsion-corrosion program. Was this a harmful factor of the pipe failure? No. Structural analysis showed that the forces needed to distort the pipe to its as-found condition would have failed a brand new pipe. The flawed erosion-corrosion program was an ECAQ, not a harmful factor.
                                 
                                Hit the reply button and tell us your favorite ECAQ.
                                OBTW: How angry an item makes you is not a reliable indicator of its importance to the consequence. You need to use some investigation tools, e.g., a Factor Tree and a Factors-Consequences Matrix.
                                 
                                OBTW: The failure of the construction management to respond to the retired construction superintendent's warning was a harmful factor.
                                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.
                                Nuclear Safety Review Concepts Corporation
                                21 Broadleaf Circle
                                Windsor, CT 06095-1634
                                860-285-8779
                                 
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                                --- On Tue, 9/1/09, Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@...> wrote:

                                From: Dillard, Tedd A (E S SF RNA FS 11E) <tedd.dillard@...>
                                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                Date: Tuesday, September 1, 2009, 9:10 PM

                                 
                                
                                Gentle Persons,
                                I happened to be working at Indian Point when this event occurred.
                                It was much in the local papers.
                                As I recall the most significant factor that resulted in the crane falling was a structural brace was not properly installed.
                                This was a tower crane that is raised section by section as the building gets taller.
                                As each section is added it is braced back to the building structure.
                                The event occurred during one of the raising task called "jacking".
                                Apparently one of the braces at the top of the last section was not properly connected to the building and as they raised the crane it became unstable and fell.
                                As Dr. Bill stated, apparently the inspection that was not done was a some what superficial inspection and would not have actually looked at the structure of the crane.
                                So I believe it is true that that inspection would not have found the defect even if performed.
                                But as also pointed out when something goes wrong there is always multiple things identified that are not correct.
                                Apparently falsified inspection reports were some what common, not just for the inspector involved, but others.
                                This raises the question of the culture in the inspection department and the construction industry and also suggest that inspections are not robust enough even if performed.
                                The real issue is did the missed inspection and the resulting activity prevent the identification and corrective action of the real cause?
                                An interesting side issue is a retired construction superintendent lived in a building next to the job site and he had seen the crane moving several days prior to the event and had tried to get someone to pay attention.
                                Tedd
                                 


                                From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of fforck@yahoo. com
                                Sent: Tuesday, September 01, 2009 6:13 PM
                                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                                 
                                So "missed opportunities" are pertinent to investigations, but missed inspections are "extraneous" . Interesting
                                Sent via BlackBerry by AT&T

                                From: "wlrigot"
                                Date: Tue, 01 Sep 2009 21:13:08 -0000
                                To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                                Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                                 

                                Dr. Bill,

                                I really hate to bring this up, because it always generates (unintended)
                                controversy, but this relates to what Sydney Dekker and others call
                                "counterfactuals" . They are behaviors that never happened, that
                                management wished with all their little hearts would have happened.
                                They are certainly extraneous conditions adverse to quality and should
                                be investigated, but have nothing to do with the nature, magitude,
                                timing and location of factors leading to the event.

                                Unfortunately, when bad things happen and people end up dead, hordes of
                                people in the "uh oh" squad descend on you and will always find bad
                                things that had been buried for a long time. Unintended consequences
                                almost always ensue. This appears to be what happened here. While some
                                will feel good about punishing some poor soul who got caught not doing
                                an inspection, they are no nearer determining what actually led to the
                                event. And they are thus no nearer determining effective corrective
                                actions that would prevent recurrence.

                                Bill Rigot
                                --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM
                                CORCORAN <William.R.Corcoran @...> wrote:
                                >
                                > When an employee does not do what was ordered to be done one needs to
                                determine what the factors were that resulted in the employee's
                                inaction?
                                > Â
                                > Was it the first time?
                                > Â
                                > Was it allowed by custom?
                                > Â
                                > Etc.
                                > Â
                                > In the Navy a CPO told me, "Mr. Corcoran, you get what you inspect,
                                not what you expect!"
                                >
                                >
                                >
                                > Take care,
                                > Â
                                > 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.
                                > Â
                                > W. R. Corcoran, Ph.D., P.E.
                                > Nuclear Safety Review Concepts Corporation
                                > 21 Broadleaf Circle
                                > Windsor, CT 06095-1634
                                > 860-285-8779
                                >
                                > Â
                                > Subscribe to "The Firebird Forum" Â
                                TheFirebirdForum- subscribe@ yahoogroups. com
                                > Join the group advancing the practice of root cause analysis/
                                evaluation Â
                                Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                                > Â
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                                > Â
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                                >
                                > --- On Tue, 9/1/09, DR WILLIAM CORCORAN William.R.Corcoran@ ... wrote:
                                >
                                >
                                > From: DR WILLIAM CORCORAN William.R.Corcoran@ ...
                                > Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                Conditions Adverse to Quality
                                > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                > Date: Tuesday, September 1, 2009, 11:48 AM
                                >
                                >
                                > Â
                                >
                                >
                                >
                                >
                                >
                                >
                                >
                                >
                                > Mike,
                                > Â
                                > My understanding of what went on is that the inspection process was
                                flawed in that it would not have surfaced the harmful factors that
                                resulted in the consequence even if it had been carried out as required.
                                > Â
                                > Thus, not doing it did not matter.
                                > Â
                                > Is it right that people be fired for not doing what doesn't matter?
                                >
                                >
                                >
                                > Take care,
                                > Â
                                > 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.
                                > Â
                                > W. R. Corcoran, Ph.D., P.E.
                                > Nuclear Safety Review Concepts Corporation
                                > 21 Broadleaf Circle
                                > Windsor, CT 06095-1634
                                > 860-285-8779
                                >
                                > Â
                                > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                                yahoogroups. com
                                > Join the group advancing the practice of root cause analysis/
                                evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                                yahoogroups. com
                                > Â
                                > ****Internet Email Confidentiality Footer****
                                > Â
                                > Privileged/Confiden tial Information may be contained in this message.
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                                >
                                > --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                                wrote:
                                >
                                >
                                > From: Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                                > Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                Conditions Adverse to Quality
                                > To: "'Root_Cause_ State_of_ the_Practice@ yahoogroups. com'"
                                <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                                > Date: Tuesday, September 1, 2009, 11:28 AM
                                >
                                >
                                > Â
                                >
                                >
                                >
                                > In other words, the missed inspection was a factor, potentially, in
                                the prevention of this but not a factor in creating the incident in the
                                first place.
                                > Â
                                >
                                > Mike van Leuken     Product Release Team
                                > ISC: Protected
                                > Â
                                >
                                >
                                > 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: 2009 September 01 9:09 AM
                                > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                Conditions Adverse to Quality
                                > Â
                                > Â
                                >
                                >
                                >
                                >
                                >
                                >
                                >
                                >
                                > Jack,
                                >
                                >
                                > Â
                                >
                                >
                                > The article said, "Officials have said it was unlikely that the missed
                                inspection had any relation to the accident."
                                >
                                >
                                > Â
                                >
                                > If that is true the failure to do the inspection and the falsification
                                were not harmful factors of the accident.
                                >
                                > Â
                                >
                                > They are bad.
                                >
                                > Â
                                >
                                > They are hateful.
                                >
                                > Â
                                >
                                > They are heinous.
                                >
                                > Â
                                >
                                > But they are extraneous to the factors that resulted in the
                                consequences.
                                >
                                >
                                > Take care,
                                > Â
                                > 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.
                                > Â
                                > W. R. Corcoran, Ph.D., P.E.
                                > Nuclear Safety Review Concepts Corporation
                                > 21 Broadleaf Circle
                                > Windsor, CT 06095-1634
                                > 860-285-8779
                                >
                                >
                                > Â
                                >
                                > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                                yahoogroups. com
                                >
                                > Join the group advancing the practice of root cause analysis/
                                evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                                yahoogroups. com
                                >
                                > Â
                                >
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                                >
                                > Â
                                >
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                                understood as neither given nor endorsed by it.
                                >
                                >
                                > --- On Tue, 9/1/09, jack.stanford@ att.net <jack.stanford@ att.net>
                                wrote:
                                >
                                > From: jack.stanford@ att.net <jack.stanford@ att.net>
                                > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                                Corrective Actions?
                                > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                > Date: Tuesday, September 1, 2009, 10:21 AM
                                >
                                >
                                > The NYC govt. should simply fire Edward Marquette. The guy has
                                apparently falsified at least three crane inspection reports. Why
                                do you think that he believes that falsified reports are what he is
                                being paid to do? The man does not have integrity and should be
                                terminated because of that, whether or not the fact that he did not
                                perform a crane inspection is relevant to the big accident. The
                                accident that killed seven people happened 11 days after the inspection
                                that never took place last year. Anyone who reported false
                                documentation intentionally, if they worked for me, would have been
                                fired pronto. I remain unconvinced that the missed inspection is
                                just an extraneous factor.
                                >
                                > Â
                                >
                                > JackÂ
                                >
                                > Â
                                >
                                > ------------ -- Original message from DR WILLIAM CORCORAN
                                <William.R.Corcoran @ 1959.USNA. com>: ------------ --
                                >
                                > Â
                                >
                                >
                                >
                                >
                                >
                                >
                                >
                                > According to the article, even if the inspection had been done and
                                done properly the event would still have happened.
                                >
                                >
                                > Â
                                >
                                >
                                > Thus if you draw a factor tree for any of the consequences the missed
                                inspections will not be on it.
                                >
                                >
                                > Take care,
                                > Â
                                > 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.
                                > Â
                                > W. R. Corcoran, Ph.D., P.E.
                                > Nuclear Safety Review Concepts Corporation
                                > 21 Broadleaf Circle
                                > Windsor, CT 06095-1634
                                > 860-285-8779
                                >
                                >
                                > Â
                                >
                                > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                                yahoogroups. com
                                >
                                > Join the group advancing the practice of root cause analysis/
                                evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                                yahoogroups. com
                                >
                                > Â
                                >
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                                >
                                > Â
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                                understood as neither given nor endorsed by it.
                                >
                                >
                                > --- On Mon, 8/31/09, fforck@yahoo. com fforck@yahoo. com> wrote:
                                >
                                > From: fforck@yahoo. com fforck@yahoo. com>
                                > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                                Corrective Actions?
                                > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                > Date: Monday, August 31, 2009, 12:08 PM
                                >
                                > Â
                                >
                                >
                                > I understand. I think the missed inspection is a flawed defense and
                                deserves a place on the factor tree because it is related to the event.
                                It seems you are saying the missed inspection is unrelated (extraneous)
                                and does not deserve a place on the factor tree. Am I receiving your
                                message correctly?
                                >
                                > Sent via BlackBerry by AT&T
                                >
                                >
                                >
                                >
                                > From: DR WILLIAM CORCORAN
                                > Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                                > To: <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                                > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                                Corrective Actions?
                                > Â
                                >
                                >
                                >
                                >
                                >
                                >
                                >
                                > Fred,
                                >
                                >
                                > Â
                                >
                                >
                                > If the item has no place on the factor tree it would be appropriate to
                                call it "extraneous. "
                                >
                                >
                                > Take care,
                                > Â
                                > 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.
                                > Â
                                > W. R. Corcoran, Ph.D., P.E.
                                > Nuclear Safety Review Concepts Corporation
                                > 21 Broadleaf Circle
                                > Windsor, CT 06095-1634
                                > 860-285-8779
                                >
                                >
                                > Â
                                >
                                > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                                yahoogroups. com
                                >
                                > Join the group advancing the practice of root cause analysis/
                                evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                                yahoogroups. com
                                >
                                > Â
                                >
                                > ****Internet Email Confidentiality Footer****
                                >
                                > Â
                                >
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                                understood as neither given nor endorsed by it.
                                >
                                >
                                > --- On Sat, 8/29/09, fforck@yahoo. com fforck@yahoo. com> wrote:
                                >
                                > From: fforck@yahoo. com fforck@yahoo. com>
                                > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                                Corrective Actions?
                                > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                > Date: Saturday, August 29, 2009, 9:02 AM
                                >
                                > Â
                                >
                                >
                                > Seems to be a flawed organizational defense/control (i.e. the
                                inspection). Inspections are built into a system to provide a layer of
                                assurance work happens successfully.
                                >
                                > Just because "Officials have said it was unlikely that the missed
                                inspection had any relation to the accident" doesn't mean the missed
                                inspection was an unrelated factor or "extraneous" .
                                > I wonder if the officials reaching this conclusion have a concept of
                                "defense-in- depth"?
                                > Fred
                                >
                                > Sent via BlackBerry by AT&T
                                >
                                >
                                >
                                >
                                > From: "drbillcorcoran"
                                > Date: Sat, 29 Aug 2009 09:31:13 -0000
                                > To: <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                                > Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective
                                Actions?
                                > Â
                                >
                                >
                                >
                                > http://www.nytimes. com/2009/ 08/29/nyregion/ 29inspectors. html?emc=
                                tnt&tntemail1= y
                                >
                                > The item, not factor, being corrected was not a harmful factor of the
                                adverse consequence, but was rather an Extraneous Condition Adverse to
                                Quality (ECAQ).
                                >
                                > What do you get out of this article?
                                >
                                > August 29, 2009
                                > Buildings Dept. to Track Inspectors via Cellphone and GPS Technology
                                >
                                > By MANNY FERNANDEZ
                                >
                                >
                                > Seeking to better manage its resources and increase the supervision of
                                its inspectors, New York City's Department of Buildings will begin
                                tracking their whereabouts using GPS technology in their
                                department-issued cellphones.
                                >
                                > The new tracking system, which has upset some inspectors, will begin
                                monitoring the first group of 10 inspectors on Monday. By the end of
                                next month, all of the agency's 379 inspectors â€" including crane
                                and elevator inspectors â€" will be tracked through their
                                cellphones, agency officials announced Friday.
                                >
                                > The new tracking system is being put in place in part because of the
                                case of Edward J. Marquette, an inspector who was charged last year with
                                faking a report that he inspected a tower crane on the East Side of
                                Manhattan in response to a complaint. He never visited the crane, the
                                authorities said, and 11 days later, it toppled and killed seven people.
                                Officials have said it was unlikely that the missed inspection had any
                                relation to the accident. Prosecutors said that Mr. Marquette, who
                                pleaded not guilty to the charges, also filed false inspection reports
                                for cranes at two other sites.
                                >
                                > "This new GPS tracking system is a simple, innovative way to ensure
                                inspectors reach their assigned locations and are held accountable for
                                their important work," Buildings Commissioner Robert D. LiMandri said in
                                a statement.
                                >
                                > The management of the Buildings Department has long been criticized.
                                The two tower-crane accidents last year in Manhattan that left a total
                                of nine people dead led to the resignation of Patricia J. Lancaster, Mr.
                                LiMandri's predecessor as commissioner, and spurred several
                                investigations that uncovered corruption within the agency's Cranes and
                                Derricks Division.
                                >
                                > A department official said the agency did not believe there was a
                                widespread problem of inspectors misusing their time while on duty, and
                                described the new system as one way to improve the accountability of the
                                department and its inspectors. Supervisors will also be able to identify
                                the closest inspector to a building-related emergency and pinpoint the
                                location of inspectors who lose contact with their superiors while
                                working in hazardous conditions.
                                >
                                > Joseph M. Corso, the president of Local 211 of the Allied Building
                                Inspectors Union, which represents most Buildings Department inspectors,
                                said the initial response from members employed by the agency was one of
                                disappointment. "Just like the Justice Department monitors parolees and
                                those under house arrest, they'll have a tracking device," he said of
                                the inspectors. "We're going to do all we can to ensure the rights of
                                the membership are covered."
                                >
                                > But one inspector who did not want to give his name said, "If you are
                                where you're supposed to be, you've got nothing to fear."
                                >
                                > Department officials said the heads of inspection units would be able
                                to monitor the movements of inspectors in real time from any computer,
                                using a confidential log-in and password. The daily routes the
                                inspectors travel will also be electronically recorded and stored. The
                                union was given few details about how the system would work, Mr. Corso
                                said, but one concern is that inspectors usually have their
                                department-issued cellphones with them even when off duty.
                                >
                                > The Buildings Department's chief spokesman, Tony Sclafani, said the
                                agency would monitor the inspectors only while on duty.
                                >
                                > "The software enables the tracking system to be fixed to the work
                                schedule of each inspector," Mr. Sclafani said. "When the shift ends,
                                the tracking system will turn off."
                                >
                                >
                                > Colin Moynihan contributed reporting.
                                >
                                > Â
                                >
                                >
                                >
                                >
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                              • bruce.hart@srs.gov
                                I have found that at different levels of management there are varying perspectives as to what should have prevented an event. So I try to catch all those
                                Message 15 of 30 , Sep 2, 2009
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                                  I have found that at different levels of management there are varying perspectives as to what should have prevented an event.  So I try to catch all those perspectives and address them in a barrier analysis.  For instance I had one senior engineering manager upset that his "Memo" had not been effective in preventing an event.  It turned out that not one involved engineer or involved engineering manager remembered seeing his memo (when all had signed the "Read and Initial" log as having read it.

                                  Below is a sanitized excerpt from an RCA I'm working on currently.  It precedes the table where I've listed 12 "barriers/defenses."
                                  --------------------------
                                  "The Table below provides a summary of what could be perceived as barriers or defenses having some potential to prevent these noncompliances.  There are several ways that processes or systems that are perceived by some to be a defense can lose effectiveness.

                                  "1) The process is not designed to be a barrier; however some may think of it as having some function in that area., e.g., the EFCOG.  It has no charter to define or enforce uniform implementation across the DOE Complex.  
                                  2) The process is used, but not effective for some reason.   For example: The site self-assessment process and site independent assessments identified documents which had deficiencies.  However the individual deficiencies were not rolled up and understood as a site deficiency.
                                  3) The process was not used; for instance, not all "...Authorities" were reviewing the documents as required by the procedure. "
                                  --------------------------

                                  I do include barriers that mitigated the event in the table.  
                                  All that lacked effectiveness, however, are included in our cause and effect chart with branches for the causes of their lack of effectiveness.

                                  Thanks,
                                  B.




                                  "Dillard, Tedd A (E S SF RNA FS 11E)" <tedd.dillard@...>
                                  Sent by: Root_Cause_State_of_the_Practice@yahoogroups.com

                                  09/01/2009 09:10 PM

                                  Please respond to
                                  Root_Cause_State_of_the_Practice@yahoogroups.com

                                  To
                                  <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                  cc
                                  Subject
                                  RE: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality





                                   

                                  
                                  Gentle Persons,

                                  I happened to be working at Indian Point when this event occurred.
                                  It was much in the local papers.
                                  As I recall the most significant factor that resulted in the crane falling was a structural brace was not properly installed.
                                  This was a tower crane that is raised section by section as the building gets taller.
                                  As each section is added it is braced back to the building structure.
                                  The event occurred during one of the raising task called "jacking".
                                  Apparently one of the braces at the top of the last section was not properly connected to the building and as they raised the crane it became unstable and fell.
                                  As Dr. Bill stated, apparently the inspection that was not done was a some what superficial inspection and would not have actually looked at the structure of the crane.
                                  So I believe it is true that that inspection would not have found the defect even if performed.
                                  But as also pointed out when something goes wrong there is always multiple things identified that are not correct.
                                  Apparently falsified inspection reports were some what common, not just for the inspector involved, but others.
                                  This raises the question of the culture in the inspection department and the construction industry and also suggest that inspections are not robust enough even if performed.
                                  The real issue is did the missed inspection and the resulting activity prevent the identification and corrective action of the real cause?
                                  An interesting side issue is a retired construction superintendent lived in a building next to the job site and he had seen the crane moving several days prior to the event and had tried to get someone to pay attention.
                                  Tedd
                                   


                                  From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of fforck@...
                                  Sent:
                                  Tuesday, September 01, 2009 6:13 PM
                                  To:
                                  Root_Cause_State_of_the_Practice@yahoogroups.com
                                  Subject:
                                  Re: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality


                                   

                                  So "missed opportunities" are pertinent to investigations, but missed inspections are "extraneous". Interesting

                                  Sent via BlackBerry by AT&T


                                  From: "wlrigot"
                                  Date
                                  : Tue, 01 Sep 2009 21:13:08 -0000
                                  To
                                  : <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                  Subject
                                  : [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality

                                   


                                  Dr. Bill,

                                  I really hate to bring this up, because it always generates (unintended)
                                  controversy, but this relates to what Sydney Dekker and others call
                                  "counterfactuals". They are behaviors that never happened, that
                                  management wished with all their little hearts would have happened.
                                  They are certainly extraneous conditions adverse to quality and should
                                  be investigated, but have nothing to do with the nature, magitude,
                                  timing and location of factors leading to the event.

                                  Unfortunately, when bad things happen and people end up dead, hordes of
                                  people in the "uh oh" squad descend on you and will always find bad
                                  things that had been buried for a long time. Unintended consequences
                                  almost always ensue. This appears to be what happened here. While some
                                  will feel good about punishing some poor soul who got caught not doing
                                  an inspection, they are no nearer determining what actually led to the
                                  event. And they are thus no nearer determining effective corrective
                                  actions that would prevent recurrence.

                                  Bill Rigot
                                  --- In
                                  Root_Cause_State_of_the_Practice@yahoogroups.com, DR WILLIAM
                                  CORCORAN <William.R.Corcoran@...> wrote:

                                  >
                                  > When an employee does not do what was ordered to be done one needs
                                  to
                                  determine what the factors were that resulted in the employee's
                                  inaction?
                                  > Â
                                  > Was it the first time?
                                  > Â
                                  > Was it allowed by custom?
                                  > Â
                                  > Etc.
                                  > Â
                                  > In the Navy a CPO told me, "Mr. Corcoran, you get what you inspect,
                                  not what you expect!"
                                  >
                                  >
                                  >
                                  > Take care,
                                  > Â
                                  > 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.
                                  > Â
                                  > W. R. Corcoran, Ph.D., P.E.
                                  > Nuclear Safety Review Concepts Corporation
                                  > 21 Broadleaf Circle
                                  > Windsor, CT 06095-1634
                                  > 860-285-8779
                                  >
                                  > Â
                                  > Subscribe to "The Firebird Forum" Â

                                  TheFirebirdForum-subscribe@yahoogroups.com
                                  > Join the group advancing the practice of root cause analysis/
                                  evaluation Â

                                  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                                  > Â
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                                  > Privileged/Confidential Information may be contained in this message.
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                                  > --- On Tue, 9/1/09, DR WILLIAM CORCORAN William.R.Corcoran@... wrote:
                                  >
                                  >
                                  > From: DR WILLIAM CORCORAN William.R.Corcoran@...
                                  > Subject: RE: [Root_Cause_State_of_the_Practice] Re: Extraneous
                                  Conditions Adverse to Quality
                                  > To:
                                  Root_Cause_State_of_the_Practice@yahoogroups.com
                                  > Date: Tuesday, September 1, 2009, 11:48 AM
                                  >
                                  >
                                  > Â
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  > Mike,
                                  > Â
                                  > My understanding of what went on is that the inspection process was
                                  flawed in that it would not have surfaced the harmful factors that
                                  resulted in the consequence even if it had been carried out as required.
                                  > Â
                                  > Thus, not doing it did not matter.
                                  > Â
                                  > Is it right that people be fired for not doing what doesn't matter?
                                  >
                                  >
                                  >
                                  > Take care,
                                  > Â
                                  > 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.
                                  > Â
                                  > W. R. Corcoran, Ph.D., P.E.
                                  > Nuclear Safety Review Concepts Corporation
                                  > 21 Broadleaf Circle
                                  > Windsor, CT 06095-1634
                                  > 860-285-8779
                                  >
                                  > Â
                                  > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                                  yahoogroups. com
                                  > Join the group advancing the practice of root cause analysis/
                                  evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                                  yahoogroups. com
                                  > Â
                                  > ****Internet Email Confidentiality Footer****
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                                  >
                                  > --- On Tue, 9/1/09, Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                                  wrote:
                                  >
                                  >
                                  > From: Van Leuken, Mike <mike.van.leuken@ calgary.ca>
                                  > Subject: RE: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                  Conditions Adverse to Quality
                                  > To: "'Root_Cause_ State_of_ the_Practice@ yahoogroups. com'"
                                  <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                                  > Date: Tuesday, September 1, 2009, 11:28 AM
                                  >
                                  >
                                  > Â
                                  >
                                  >
                                  >
                                  > In other words, the missed inspection was a factor, potentially, in
                                  the prevention of this but not a factor in creating the incident in the
                                  first place.
                                  > Â
                                  >
                                  > Mike van Leuken     Product Release Team
                                  > ISC: Protected
                                  > Â
                                  >
                                  >
                                  > 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: 2009 September 01 9:09 AM
                                  > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                  > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                  Conditions Adverse to Quality
                                  > Â
                                  > Â
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  > Jack,
                                  >
                                  >
                                  > Â
                                  >
                                  >
                                  > The article said, "Officials have said it was unlikely that the
                                  missed
                                  inspection had any relation to the accident."
                                  >
                                  >
                                  > Â
                                  >
                                  > If that is true the failure to do the inspection and the falsification
                                  were not harmful factors of the accident.
                                  >
                                  > Â
                                  >
                                  > They are bad.
                                  >
                                  > Â
                                  >
                                  > They are hateful.
                                  >
                                  > Â
                                  >
                                  > They are heinous.
                                  >
                                  > Â
                                  >
                                  > But they are extraneous to the factors that resulted in the
                                  consequences.
                                  >
                                  >
                                  > Take care,
                                  > Â
                                  > 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.
                                  > Â
                                  > W. R. Corcoran, Ph.D., P.E.
                                  > Nuclear Safety Review Concepts Corporation
                                  > 21 Broadleaf Circle
                                  > Windsor, CT 06095-1634
                                  > 860-285-8779
                                  >
                                  >
                                  > Â
                                  >
                                  > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                                  yahoogroups. com
                                  >
                                  > Join the group advancing the practice of root cause analysis/
                                  evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                                  yahoogroups. com
                                  >
                                  > Â
                                  >
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                                  >
                                  > Â
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                                  >
                                  > --- On Tue, 9/1/09, jack.stanford@ att.net <jack.stanford@ att.net>
                                  wrote:
                                  >
                                  > From: jack.stanford@ att.net <jack.stanford@ att.net>
                                  > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                                  Corrective Actions?
                                  > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                  > Date: Tuesday, September 1, 2009, 10:21 AM
                                  >
                                  >
                                  > The NYC govt. should simply fire Edward Marquette. The guy has
                                  apparently falsified at least three crane inspection reports. Why
                                  do you think that he believes that falsified reports are what he is
                                  being paid to do? The man does not have integrity and should be
                                  terminated because of that, whether or not the fact that he did not
                                  perform a crane inspection is relevant to the big accident. The
                                  accident that killed seven people happened 11 days after the inspection
                                  that never took place last year. Anyone who reported false
                                  documentation intentionally, if they worked for me, would have been
                                  fired pronto. I remain unconvinced that the missed inspection is
                                  just an extraneous factor.
                                  >
                                  > Â
                                  >
                                  > JackÂ
                                  >
                                  > Â
                                  >
                                  > ------------ -- Original message from DR WILLIAM CORCORAN
                                  <William.R.Corcoran@ 1959.USNA. com>: ------------ --
                                  >
                                  > Â
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  > According to the article, even if the inspection had been done and
                                  done properly the event would still have happened.
                                  >
                                  >
                                  > Â
                                  >
                                  >
                                  > Thus if you draw a factor tree for any of the consequences the missed
                                  inspections will not be on it.
                                  >
                                  >
                                  > Take care,
                                  > Â
                                  > 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.
                                  > Â
                                  > W. R. Corcoran, Ph.D., P.E.
                                  > Nuclear Safety Review Concepts Corporation
                                  > 21 Broadleaf Circle
                                  > Windsor, CT 06095-1634
                                  > 860-285-8779
                                  >
                                  >
                                  > Â
                                  >
                                  > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                                  yahoogroups. com
                                  >
                                  > Join the group advancing the practice of root cause analysis/
                                  evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                                  yahoogroups. com
                                  >
                                  > Â
                                  >
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                                  > Â
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                                  >
                                  > --- On Mon, 8/31/09, fforck@yahoo. com fforck@yahoo. com> wrote:
                                  >
                                  > From: fforck@yahoo. com fforck@yahoo. com>
                                  > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                                  Corrective Actions?
                                  > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                  > Date: Monday, August 31, 2009, 12:08 PM
                                  >
                                  > Â
                                  >
                                  >
                                  > I understand. I think the missed inspection is a flawed defense and
                                  deserves a place on the factor tree because it is related to the event.
                                  It seems you are saying the missed inspection is unrelated (extraneous)
                                  and does not deserve a place on the factor tree. Am I receiving your
                                  message correctly?
                                  >
                                  > Sent via BlackBerry by AT&T
                                  >
                                  >
                                  >
                                  >
                                  > From: DR WILLIAM CORCORAN
                                  > Date: Mon, 31 Aug 2009 07:57:35 -0700 (PDT)
                                  > To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                                  > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                                  Corrective Actions?
                                  > Â
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  >
                                  > Fred,
                                  >
                                  >
                                  > Â
                                  >
                                  >
                                  > If the item has no place on the factor tree it would be appropriate
                                  to
                                  call it "extraneous. "
                                  >
                                  >
                                  > Take care,
                                  > Â
                                  > 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.
                                  > Â
                                  > W. R. Corcoran, Ph.D., P.E.
                                  > Nuclear Safety Review Concepts Corporation
                                  > 21 Broadleaf Circle
                                  > Windsor, CT 06095-1634
                                  > 860-285-8779
                                  >
                                  >
                                  > Â
                                  >
                                  > Subscribe to "The Firebird Forum" Â TheFirebirdForum- subscribe@
                                  yahoogroups. com
                                  >
                                  > Join the group advancing the practice of root cause analysis/
                                  evaluation  Root_Cause_State_ of_the_Practice- subscribe@
                                  yahoogroups. com
                                  >
                                  > Â
                                  >
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                                  >
                                  > Â
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                                  >
                                  > --- On Sat, 8/29/09, fforck@yahoo. com fforck@yahoo. com> wrote:
                                  >
                                  > From: fforck@yahoo. com fforck@yahoo. com>
                                  > Subject: Re: [Root_Cause_ State_of_ the_Practice] New Wave of
                                  Corrective Actions?
                                  > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                  > Date: Saturday, August 29, 2009, 9:02 AM
                                  >
                                  > Â
                                  >
                                  >
                                  > Seems to be a flawed organizational defense/control (i.e. the
                                  inspection). Inspections are built into a system to provide a layer of
                                  assurance work happens successfully.
                                  >
                                  > Just because "Officials have said it was unlikely that the missed
                                  inspection had any relation to the accident" doesn't mean the missed
                                  inspection was an unrelated factor or "extraneous" .
                                  > I wonder if the officials reaching this conclusion have a concept
                                  of
                                  "defense-in- depth"?
                                  > Fred
                                  >
                                  > Sent via BlackBerry by AT&T
                                  >
                                  >
                                  >
                                  >
                                  > From: "drbillcorcoran"
                                  > Date: Sat, 29 Aug 2009 09:31:13 -0000
                                  > To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                                  > Subject: [Root_Cause_ State_of_ the_Practice] New Wave of Corrective
                                  Actions?
                                  > Â
                                  >
                                  >
                                  >
                                  >
                                  http://www.nytimes. com/2009/ 08/29/nyregion/ 29inspectors. html?emc=
                                  tnt&tntemail1=y
                                  >
                                  > The item, not factor, being corrected was not a harmful factor of
                                  the
                                  adverse consequence, but was rather an Extraneous Condition Adverse to
                                  Quality (ECAQ).
                                  >
                                  > What do you get out of this article?
                                  >
                                  > August 29, 2009
                                  > Buildings Dept. to Track Inspectors via Cellphone and GPS Technology
                                  >
                                  > By MANNY FERNANDEZ
                                  >
                                  >
                                  > Seeking to better manage its resources and increase the supervision
                                  of
                                  its inspectors, New York City's Department of Buildings will begin
                                  tracking their whereabouts using GPS technology in their
                                  department-issued cellphones.
                                  >
                                  > The new tracking system, which has upset some inspectors, will begin
                                  monitoring the first group of 10 inspectors on Monday. By the end of
                                  next month, all of the agency's 379 inspectors â€" including crane
                                  and elevator inspectors â€" will be tracked through their
                                  cellphones, agency officials announced Friday.
                                  >
                                  > The new tracking system is being put in place in part because of the
                                  case of Edward J. Marquette, an inspector who was charged last year with
                                  faking a report that he inspected a tower crane on the East Side of
                                  Manhattan in response to a complaint. He never visited the crane, the
                                  authorities said, and 11 days later, it toppled and killed seven people.
                                  Officials have said it was unlikely that the missed inspection had any
                                  relation to the accident. Prosecutors said that Mr. Marquette, who
                                  pleaded not guilty to the charges, also filed false inspection reports
                                  for cranes at two other sites.
                                  >
                                  > "This new GPS tracking system is a simple, innovative way to
                                  ensure
                                  inspectors reach their assigned locations and are held accountable for
                                  their important work," Buildings Commissioner Robert D. LiMandri said in
                                  a statement.
                                  >
                                  > The management of the Buildings Department has long been criticized.
                                  The two tower-crane accidents last year in Manhattan that left a total
                                  of nine people dead led to the resignation of Patricia J. Lancaster, Mr.
                                  LiMandri's predecessor as commissioner, and spurred several
                                  investigations that uncovered corruption within the agency's Cranes and
                                  Derricks Division.
                                  >
                                  > A department official said the agency did not believe there was a
                                  widespread problem of inspectors misusing their time while on duty, and
                                  described the new system as one way to improve the accountability of the
                                  department and its inspectors. Supervisors will also be able to identify
                                  the closest inspector to a building-related emergency and pinpoint the
                                  location of inspectors who lose contact with their superiors while
                                  working in hazardous conditions.
                                  >
                                  > Joseph M. Corso, the president of Local 211 of the Allied Building
                                  Inspectors Union, which represents most Buildings Department inspectors,
                                  said the initial response from members employed by the agency was one of
                                  disappointment. "Just like the Justice Department monitors parolees and
                                  those under house arrest, they'll have a tracking device," he said of
                                  the inspectors. "We're going to do all we can to ensure the rights of
                                  the membership are covered."
                                  >
                                  > But one inspector who did not want to give his name said, "If
                                  you are
                                  where you're supposed to be, you've got nothing to fear."
                                  >
                                  > Department officials said the heads of inspection units would be able
                                  to monitor the movements of inspectors in real time from any computer,
                                  using a confidential log-in and password. The daily routes the
                                  inspectors travel will also be electronically recorded and stored. The
                                  union was given few details about how the system would work, Mr. Corso
                                  said, but one concern is that inspectors usually have their
                                  department-issued cellphones with them even when off duty.
                                  >
                                  > The Buildings Department's chief spokesman, Tony Sclafani, said the
                                  agency would monitor the inspectors only while on duty.
                                  >
                                  > "The software enables the tracking system to be fixed to the
                                  work
                                  schedule of each inspector," Mr. Sclafani said. "When the shift ends,
                                  the tracking system will turn off."
                                  >
                                  >
                                  > Colin Moynihan contributed reporting.
                                  >
                                  > Â
                                  >
                                  >
                                  >
                                  >
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                                  >


                                • Salot, William
                                  Fred, Sometimes extraneous findings are more significant than pertinent factors in an investigation. The investigation should report both. Both are subject to
                                  Message 16 of 30 , Sep 2, 2009
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                                    Fred,

                                     

                                    Sometimes extraneous findings are more significant than pertinent factors in an investigation.  The investigation should report both.  Both are subject to recommendations for corrective action.  

                                     

                                    Yes, it is interesting.  But in the final analysis, confusing “missed opportunities” with “extraneous” inactions will not make much difference, as long as both are taken seriously.

                                    .

                                    Bill Salot


                                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto: Root_Cause_State_of_the_Practice@yahoogroups.com ] On Behalf Of fforck@...
                                    Sent: Tuesday, September 01, 2009 6:13 PM
                                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                    Subject: Re: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality

                                     

                                     

                                    So "missed opportunities" are pertinent to investigations, but missed inspections are "extraneous" . Interesting

                                    Sent via BlackBerry by AT&T


                                    From: "wlrigot"
                                    Date: Tue, 01 Sep 2009 21:13:08 -0000
                                    To: < Root_Cause_State_ of_the_Practice@ yahoogroups. com >
                                    Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                                     


                                    Dr. Bill,

                                    I really hate to bring this up, because it always generates (unintended)
                                    controversy, but this relates to what Sydney Dekker and others call
                                    "counterfactuals" . They are behaviors that never happened, that
                                    management wished with all their little hearts would have happened.
                                    They are certainly extraneous conditions adverse to quality and should
                                    be investigated, but have nothing to do with the nature, magitude,
                                    timing and location of factors leading to the event.

                                    Unfortunately, when bad things happen and people end up dead, hordes of
                                    people in the "uh oh" squad descend on you and will always find bad
                                    things that had been buried for a long time. Unintended consequences
                                    almost always ensue. This appears to be what happened here. While some
                                    will feel good about punishing some poor soul who got caught not doing
                                    an inspection, they are no nearer determining what actually led to the
                                    event. And they are thus no nearer determining effective corrective
                                    actions that would prevent recurrence.

                                    Bill Rigot

                                  • wlrigot
                                    Bill Salot, I agree. I ve seen both. Bill Rigot
                                    Message 17 of 30 , Sep 2, 2009
                                    • 0 Attachment
                                      Bill Salot,

                                      I agree. I've seen both.

                                      Bill Rigot

                                      --- In Root_Cause_State_of_the_Practice@yahoogroups.com, "Salot, William" <william.salot@...> wrote:
                                      >
                                      > Fred,
                                      >
                                      >
                                      >
                                      > Sometimes extraneous findings are more significant than pertinent
                                      > factors in an investigation. The investigation should report both.
                                      > Both are subject to recommendations for corrective action.
                                      >
                                      >
                                      >
                                      > Yes, it is interesting. But in the final analysis, confusing "missed
                                      > opportunities" with "extraneous" inactions will not make much
                                      > difference, as long as both are taken seriously.
                                      >
                                      > .
                                      >
                                      > Bill Salot
                                      >
                                      > ________________________________
                                      >
                                      > From: Root_Cause_State_of_the_Practice@yahoogroups.com
                                      > [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of
                                      > fforck@...
                                      > Sent: Tuesday, September 01, 2009 6:13 PM
                                      > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                      > Subject: Re: [Root_Cause_State_of_the_Practice] Re: Extraneous
                                      > Conditions Adverse to Quality
                                      >
                                      >
                                      >
                                      >
                                      >
                                      > So "missed opportunities" are pertinent to investigations, but missed
                                      > inspections are "extraneous". Interesting
                                      >
                                      > Sent via BlackBerry by AT&T
                                      >
                                      > ________________________________
                                      >
                                      > From: "wlrigot"
                                      > Date: Tue, 01 Sep 2009 21:13:08 -0000
                                      > To: <Root_Cause_State_of_the_Practice@yahoogroups.com>
                                      > Subject: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions
                                      > Adverse to Quality
                                      >
                                      >
                                      >
                                      >
                                      > Dr. Bill,
                                      >
                                      > I really hate to bring this up, because it always generates (unintended)
                                      > controversy, but this relates to what Sydney Dekker and others call
                                      > "counterfactuals". They are behaviors that never happened, that
                                      > management wished with all their little hearts would have happened.
                                      > They are certainly extraneous conditions adverse to quality and should
                                      > be investigated, but have nothing to do with the nature, magitude,
                                      > timing and location of factors leading to the event.
                                      >
                                      > Unfortunately, when bad things happen and people end up dead, hordes of
                                      > people in the "uh oh" squad descend on you and will always find bad
                                      > things that had been buried for a long time. Unintended consequences
                                      > almost always ensue. This appears to be what happened here. While some
                                      > will feel good about punishing some poor soul who got caught not doing
                                      > an inspection, they are no nearer determining what actually led to the
                                      > event. And they are thus no nearer determining effective corrective
                                      > actions that would prevent recurrence.
                                      >
                                      > Bill Rigot
                                      >
                                    • DR WILLIAM CORCORAN
                                      To two Bills,   How about one example from each of you to get the point across? Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers
                                      Message 18 of 30 , Sep 2, 2009
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                                        To two Bills,
                                         
                                        How about one example from each of you to get the point across?

                                        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.
                                        Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                                         
                                        ****Internet Email Confidentiality Footer****
                                         
                                        Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


                                        --- On Wed, 9/2/09, wlrigot <william.rigot@...> wrote:

                                        From: wlrigot <william.rigot@...>
                                        Subject: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                                        To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                        Date: Wednesday, September 2, 2009, 11:43 AM

                                         
                                        Bill Salot,

                                        I agree. I've seen both.

                                        Bill Rigot

                                        --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "Salot, William" <william.salot@ ...> wrote:
                                        >
                                        > Fred,
                                        >
                                        >
                                        >
                                        > Sometimes extraneous findings are more significant than pertinent
                                        > factors in an investigation. The investigation should report both.
                                        > Both are subject to recommendations for corrective action.
                                        >
                                        >
                                        >
                                        > Yes, it is interesting. But in the final analysis, confusing "missed
                                        > opportunities" with "extraneous" inactions will not make much
                                        > difference, as long as both are taken seriously.
                                        >
                                        > .
                                        >
                                        > Bill Salot
                                        >
                                        > ____________ _________ _________ __
                                        >
                                        > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                        > [mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of
                                        > fforck@...
                                        > Sent: Tuesday, September 01, 2009 6:13 PM
                                        > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                        > Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                        > Conditions Adverse to Quality
                                        >
                                        >
                                        >
                                        >
                                        >
                                        > So "missed opportunities" are pertinent to investigations, but missed
                                        > inspections are "extraneous" . Interesting
                                        >
                                        > Sent via BlackBerry by AT&T
                                        >
                                        > ____________ _________ _________ __
                                        >
                                        > From: "wlrigot"
                                        > Date: Tue, 01 Sep 2009 21:13:08 -0000
                                        > To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                                        > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions
                                        > Adverse to Quality
                                        >
                                        >
                                        >
                                        >
                                        > Dr. Bill,
                                        >
                                        > I really hate to bring this up, because it always generates (unintended)
                                        > controversy, but this relates to what Sydney Dekker and others call
                                        > "counterfactuals" . They are behaviors that never happened, that
                                        > management wished with all their little hearts would have happened.
                                        > They are certainly extraneous conditions adverse to quality and should
                                        > be investigated, but have nothing to do with the nature, magitude,
                                        > timing and location of factors leading to the event.
                                        >
                                        > Unfortunately, when bad things happen and people end up dead, hordes of
                                        > people in the "uh oh" squad descend on you and will always find bad
                                        > things that had been buried for a long time. Unintended consequences
                                        > almost always ensue. This appears to be what happened here. While some
                                        > will feel good about punishing some poor soul who got caught not doing
                                        > an inspection, they are no nearer determining what actually led to the
                                        > event. And they are thus no nearer determining effective corrective
                                        > actions that would prevent recurrence.
                                        >
                                        > Bill Rigot
                                        >

                                      • wlrigot
                                        A sea story. It was a dark and stormy night in 1981. I was the Damage Control Assistant in USS NIMITZ standing watch as EOOW in main control observing carrier
                                        Message 19 of 30 , Sep 2, 2009
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                                          A sea story.

                                          It was a dark and stormy night in 1981. I was the Damage Control Assistant in USS NIMITZ standing watch as EOOW in main control observing carrier quals for the air wing in preparation for an upcoming Med deployment. An EA-6B was having difficulty catching the wire and was coming in for his third attempt before being sent back to Jacksonville with a failed carrier qual and bad consequences for the pilot. The plane came in well right of centerline and was waved off by the LSO. He came in anyway, and clipped the nose of an A-7 parked near the "Foul Line". The EA-6B cartwheeled into the Weapons Arming/Dearming area near the bow and ignited a towering inferno of planes, fuel, and weapons. Bottom line, 14 dead, 40 seriously injured, 14 planes destroyed, and the flight deck damaged.

                                          The investigation found that the pilot had taken 100 times the recommended dose of antihistimine to counter effects of a cold so he could fly. He did not see the flight surgeon, because he was on his last opportunity to qualify for night landings prior to the deployment. He did not know that antihistimines can trigger vertigo on dark moonless nights (such as that night). There were many missed opportunities to correct this behavior, such as his roommate, who knew about it, the NFO in the right seat who could see his dysfunction, the LSO, etc., etc. These were largely ininvestigated, because the pilot, and his crew were dead, and there seemed to be little point in punishing the dead.

                                          The investigators did find that a fuse blew on one of the AFFF stations on the bow. They found a missed PM on that station, and inferred causality. I was very nearly court martialled for this failure, until cooler heads prevailed. A later study by the Naval Aviation Safety Center found that the AFFF systems on the carriers were never designed for that type of accident, and that other means of fire fighting would need to be put in place to put the fire out. This was the Extraneous Condition Adverse to Quality that the investigators focused so on much, that missed the point of why the pilot took antihisimines prior to flight in the first place.

                                          As a footnote, I was the Chief Engineer in NIMITZ 8 years later when a similar fire erupted on the flight deck. Because we had learned from the first fire, we escaped with only two deaths, no injuries, and only a few lost aircraft. That fire was extinguished in 11 minutes compared to 1 1/2 hours for the one in 1981. But that sea story will have to wait for another time.

                                          Bill Rigot

                                          --- In Root_Cause_State_of_the_Practice@yahoogroups.com, DR WILLIAM CORCORAN <William.R.Corcoran@...> wrote:
                                          >
                                          > To two Bills,
                                          >  
                                          > How about one example from each of you to get the point across?
                                          >
                                          >
                                          >
                                          > 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.
                                          > Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                                          >  
                                          > ****Internet Email Confidentiality Footer****
                                          >  
                                          > Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
                                          >
                                          > --- On Wed, 9/2/09, wlrigot <william.rigot@...> wrote:
                                          >
                                          >
                                          > From: wlrigot <william.rigot@...>
                                          > Subject: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                                          > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                          > Date: Wednesday, September 2, 2009, 11:43 AM
                                          >
                                          >
                                          >  
                                          >
                                          >
                                          >
                                          > Bill Salot,
                                          >
                                          > I agree. I've seen both.
                                          >
                                          > Bill Rigot
                                          >
                                          > --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "Salot, William" <william.salot@ ...> wrote:
                                          > >
                                          > > Fred,
                                          > >
                                          > >
                                          > >
                                          > > Sometimes extraneous findings are more significant than pertinent
                                          > > factors in an investigation. The investigation should report both.
                                          > > Both are subject to recommendations for corrective action.
                                          > >
                                          > >
                                          > >
                                          > > Yes, it is interesting. But in the final analysis, confusing "missed
                                          > > opportunities" with "extraneous" inactions will not make much
                                          > > difference, as long as both are taken seriously.
                                          > >
                                          > > .
                                          > >
                                          > > Bill Salot
                                          > >
                                          > > ____________ _________ _________ __
                                          > >
                                          > > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                          > > [mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of
                                          > > fforck@
                                          > > Sent: Tuesday, September 01, 2009 6:13 PM
                                          > > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                          > > Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                          > > Conditions Adverse to Quality
                                          > >
                                          > >
                                          > >
                                          > >
                                          > >
                                          > > So "missed opportunities" are pertinent to investigations, but missed
                                          > > inspections are "extraneous" . Interesting
                                          > >
                                          > > Sent via BlackBerry by AT&T
                                          > >
                                          > > ____________ _________ _________ __
                                          > >
                                          > > From: "wlrigot"
                                          > > Date: Tue, 01 Sep 2009 21:13:08 -0000
                                          > > To: <Root_Cause_State_ of_the_Practice@ yahoogroups. com>
                                          > > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions
                                          > > Adverse to Quality
                                          > >
                                          > >
                                          > >
                                          > >
                                          > > Dr. Bill,
                                          > >
                                          > > I really hate to bring this up, because it always generates (unintended)
                                          > > controversy, but this relates to what Sydney Dekker and others call
                                          > > "counterfactuals" . They are behaviors that never happened, that
                                          > > management wished with all their little hearts would have happened.
                                          > > They are certainly extraneous conditions adverse to quality and should
                                          > > be investigated, but have nothing to do with the nature, magitude,
                                          > > timing and location of factors leading to the event.
                                          > >
                                          > > Unfortunately, when bad things happen and people end up dead, hordes of
                                          > > people in the "uh oh" squad descend on you and will always find bad
                                          > > things that had been buried for a long time. Unintended consequences
                                          > > almost always ensue. This appears to be what happened here. While some
                                          > > will feel good about punishing some poor soul who got caught not doing
                                          > > an inspection, they are no nearer determining what actually led to the
                                          > > event. And they are thus no nearer determining effective corrective
                                          > > actions that would prevent recurrence.
                                          > >
                                          > > Bill Rigot
                                          > >
                                          >
                                        • DR WILLIAM CORCORAN
                                          Bill Rigot,   If AFFF=Aircraft Fire Fighting Foam or something like that, I get it.   Sometimes the Extraneous Conditions Adverse to Quality get air time to
                                          Message 20 of 30 , Sep 2, 2009
                                          • 0 Attachment
                                            Bill Rigot,
                                             
                                            If AFFF=Aircraft Fire Fighting Foam or something like that, I get it.
                                             
                                            Sometimes the Extraneous Conditions Adverse to Quality get air time to distract attention from the harmful factors that are embarrassing.
                                            But at other times the harmful factors get air time to distract attention from the Extraneous Conditions Adverse to Quality that are embarrassing.
                                            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.
                                            Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                                             
                                            ****Internet Email Confidentiality Footer****
                                             
                                            Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


                                            --- On Wed, 9/2/09, wlrigot <william.rigot@...> wrote:

                                            From: wlrigot <william.rigot@...>
                                            Subject: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                            Date: Wednesday, September 2, 2009, 2:52 PM

                                             
                                            A sea story.

                                            It was a dark and stormy night in 1981. I was the Damage Control Assistant in USS NIMITZ standing watch as EOOW in main control observing carrier quals for the air wing in preparation for an upcoming Med deployment. An EA-6B was having difficulty catching the wire and was coming in for his third attempt before being sent back to Jacksonville with a failed carrier qual and bad consequences for the pilot. The plane came in well right of centerline and was waved off by the LSO. He came in anyway, and clipped the nose of an A-7 parked near the "Foul Line". The EA-6B cartwheeled into the Weapons Arming/Dearming area near the bow and ignited a towering inferno of planes, fuel, and weapons. Bottom line, 14 dead, 40 seriously injured, 14 planes destroyed, and the flight deck damaged.

                                            The investigation found that the pilot had taken 100 times the recommended dose of antihistimine to counter effects of a cold so he could fly. He did not see the flight surgeon, because he was on his last opportunity to qualify for night landings prior to the deployment. He did not know that antihistimines can trigger vertigo on dark moonless nights (such as that night). There were many missed opportunities to correct this behavior, such as his roommate, who knew about it, the NFO in the right seat who could see his dysfunction, the LSO, etc., etc. These were largely ininvestigated, because the pilot, and his crew were dead, and there seemed to be little point in punishing the dead.

                                            The investigators did find that a fuse blew on one of the AFFF stations on the bow. They found a missed PM on that station, and inferred causality. I was very nearly court martialled for this failure, until cooler heads prevailed. A later study by the Naval Aviation Safety Center found that the AFFF systems on the carriers were never designed for that type of accident, and that other means of fire fighting would need to be put in place to put the fire out. This was the Extraneous Condition Adverse to Quality that the investigators focused so on much, that missed the point of why the pilot took antihisimines prior to flight in the first place.

                                            As a footnote, I was the Chief Engineer in NIMITZ 8 years later when a similar fire erupted on the flight deck. Because we had learned from the first fire, we escaped with only two deaths, no injuries, and only a few lost aircraft. That fire was extinguished in 11 minutes compared to 1 1/2 hours for the one in 1981. But that sea story will have to wait for another time.

                                            Bill Rigot

                                            --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM CORCORAN <William.R.Corcoran @...> wrote:
                                            >
                                            > To two Bills,
                                            >  
                                            > How about one example from each of you to get the point across?
                                            >
                                            >
                                            >
                                            > 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.
                                            > Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                                            >  
                                            > ****Internet Email Confidentiality Footer****
                                            >  
                                            > Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
                                            >
                                            > --- On Wed, 9/2/09, wlrigot <william.rigot@ ...> wrote:
                                            >
                                            >
                                            > From: wlrigot <william.rigot@ ...>
                                            > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                                            > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                            > Date: Wednesday, September 2, 2009, 11:43 AM
                                            >
                                            >
                                            >  
                                            >
                                            >
                                            >
                                            > Bill Salot,
                                            >
                                            > I agree. I've seen both.
                                            >
                                            > Bill Rigot
                                            >
                                            > --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "Salot, William" <william.salot@ ...> wrote:
                                            > >
                                            > > Fred,
                                            > >
                                            > >
                                            > >
                                            > > Sometimes extraneous findings are more significant than pertinent
                                            > > factors in an investigation. The investigation should report both.
                                            > > Both are subject to recommendations for corrective action.
                                            > >
                                            > >
                                            > >
                                            > > Yes, it is interesting. But in the final analysis, confusing "missed
                                            > > opportunities" with "extraneous" inactions will not make much
                                            > > difference, as long as both are taken seriously.
                                            > >
                                            > > .
                                            > >
                                            > > Bill Salot
                                            > >
                                            > > ____________ _________ _________ __
                                            > >
                                            > > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                            > > [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of
                                            > > fforck@
                                            > > Sent: Tuesday, September 01, 2009 6:13 PM
                                            > > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                            > > Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                            > > Conditions Adverse to Quality
                                            > >
                                            > >
                                            > >
                                            > >
                                            > >
                                            > > So "missed opportunities" are pertinent to investigations, but missed
                                            > > inspections are "extraneous" . Interesting
                                            > >
                                            > > Sent via BlackBerry by AT&T
                                            > >
                                            > > ____________ _________ _________ __
                                            > >
                                            > > From: "wlrigot"
                                            > > Date: Tue, 01 Sep 2009 21:13:08 -0000
                                            > > To: <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                                            > > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions
                                            > > Adverse to Quality
                                            > >
                                            > >
                                            > >
                                            > >
                                            > > Dr. Bill,
                                            > >
                                            > > I really hate to bring this up, because it always generates (unintended)
                                            > > controversy, but this relates to what Sydney Dekker and others call
                                            > > "counterfactuals" . They are behaviors that never happened, that
                                            > > management wished with all their little hearts would have happened.
                                            > > They are certainly extraneous conditions adverse to quality and should
                                            > > be investigated, but have nothing to do with the nature, magitude,
                                            > > timing and location of factors leading to the event.
                                            > >
                                            > > Unfortunately, when bad things happen and people end up dead, hordes of
                                            > > people in the "uh oh" squad descend on you and will always find bad
                                            > > things that had been buried for a long time. Unintended consequences
                                            > > almost always ensue. This appears to be what happened here. While some
                                            > > will feel good about punishing some poor soul who got caught not doing
                                            > > an inspection, they are no nearer determining what actually led to the
                                            > > event. And they are thus no nearer determining effective corrective
                                            > > actions that would prevent recurrence.
                                            > >
                                            > > Bill Rigot
                                            > >
                                            >

                                          • wlrigot
                                            Dr. Bill, AFFF = Aqueous Fire Fighting Foam BTW, another ECAQ from that event was the discovery that over half the flight deck crew who died in the fire had
                                            Message 21 of 30 , Sep 2, 2009
                                            • 0 Attachment
                                              Dr. Bill,

                                              AFFF = Aqueous Fire Fighting Foam

                                              BTW, another ECAQ from that event was the discovery that over half the flight deck crew who died in the fire had marijuana in their systems at the time of their deaths. The ship had been underway for weeks, which meant that they had been using it while underway. This discovery led the Navy to finally initiate their very comprehensive urinalysis program, which actually had a positive effect in significantly reducing drug abuse in the Navy.

                                              All the best,

                                              Bill Rigot

                                              --- In Root_Cause_State_of_the_Practice@yahoogroups.com, DR WILLIAM CORCORAN <William.R.Corcoran@...> wrote:
                                              >
                                              > Bill Rigot,
                                              >  
                                              > If AFFF=Aircraft Fire Fighting Foam or something like that, I get it.
                                              >  
                                              > Sometimes the Extraneous Conditions Adverse to Quality get air time to distract attention from the harmful factors that are embarrassing.
                                              >
                                              > But at other times the harmful factors get air time to distract attention from the Extraneous Conditions Adverse to Quality that are embarrassing.
                                              >
                                              >
                                              > 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.
                                              > Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                                              >  
                                              > ****Internet Email Confidentiality Footer****
                                              >  
                                              > Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
                                              >
                                              > --- On Wed, 9/2/09, wlrigot <william.rigot@...> wrote:
                                              >
                                              >
                                              > From: wlrigot <william.rigot@...>
                                              > Subject: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                                              > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                              > Date: Wednesday, September 2, 2009, 2:52 PM
                                              >
                                              >
                                              >  
                                              >
                                              >
                                              >
                                              > A sea story.
                                              >
                                              > It was a dark and stormy night in 1981. I was the Damage Control Assistant in USS NIMITZ standing watch as EOOW in main control observing carrier quals for the air wing in preparation for an upcoming Med deployment. An EA-6B was having difficulty catching the wire and was coming in for his third attempt before being sent back to Jacksonville with a failed carrier qual and bad consequences for the pilot. The plane came in well right of centerline and was waved off by the LSO. He came in anyway, and clipped the nose of an A-7 parked near the "Foul Line". The EA-6B cartwheeled into the Weapons Arming/Dearming area near the bow and ignited a towering inferno of planes, fuel, and weapons. Bottom line, 14 dead, 40 seriously injured, 14 planes destroyed, and the flight deck damaged.
                                              >
                                              > The investigation found that the pilot had taken 100 times the recommended dose of antihistimine to counter effects of a cold so he could fly. He did not see the flight surgeon, because he was on his last opportunity to qualify for night landings prior to the deployment. He did not know that antihistimines can trigger vertigo on dark moonless nights (such as that night). There were many missed opportunities to correct this behavior, such as his roommate, who knew about it, the NFO in the right seat who could see his dysfunction, the LSO, etc., etc. These were largely ininvestigated, because the pilot, and his crew were dead, and there seemed to be little point in punishing the dead.
                                              >
                                              > The investigators did find that a fuse blew on one of the AFFF stations on the bow. They found a missed PM on that station, and inferred causality. I was very nearly court martialled for this failure, until cooler heads prevailed. A later study by the Naval Aviation Safety Center found that the AFFF systems on the carriers were never designed for that type of accident, and that other means of fire fighting would need to be put in place to put the fire out. This was the Extraneous Condition Adverse to Quality that the investigators focused so on much, that missed the point of why the pilot took antihisimines prior to flight in the first place.
                                              >
                                              > As a footnote, I was the Chief Engineer in NIMITZ 8 years later when a similar fire erupted on the flight deck. Because we had learned from the first fire, we escaped with only two deaths, no injuries, and only a few lost aircraft. That fire was extinguished in 11 minutes compared to 1 1/2 hours for the one in 1981. But that sea story will have to wait for another time.
                                              >
                                              > Bill Rigot
                                              >
                                              > --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM CORCORAN <William.R.Corcoran @...> wrote:
                                              > >
                                              > > To two Bills,
                                              > >  
                                              > > How about one example from each of you to get the point across?
                                              > >
                                              > >
                                              > >
                                              > > 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.
                                              > > Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                                              > >  
                                              > > ****Internet Email Confidentiality Footer****
                                              > >  
                                              > > Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
                                              > >
                                              > > --- On Wed, 9/2/09, wlrigot <william.rigot@ ...> wrote:
                                              > >
                                              > >
                                              > > From: wlrigot <william.rigot@ ...>
                                              > > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                                              > > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                              > > Date: Wednesday, September 2, 2009, 11:43 AM
                                              > >
                                              > >
                                              > >  
                                              > >
                                              > >
                                              > >
                                              > > Bill Salot,
                                              > >
                                              > > I agree. I've seen both.
                                              > >
                                              > > Bill Rigot
                                              > >
                                              > > --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "Salot, William" <william.salot@ ...> wrote:
                                              > > >
                                              > > > Fred,
                                              > > >
                                              > > >
                                              > > >
                                              > > > Sometimes extraneous findings are more significant than pertinent
                                              > > > factors in an investigation. The investigation should report both.
                                              > > > Both are subject to recommendations for corrective action.
                                              > > >
                                              > > >
                                              > > >
                                              > > > Yes, it is interesting. But in the final analysis, confusing "missed
                                              > > > opportunities" with "extraneous" inactions will not make much
                                              > > > difference, as long as both are taken seriously.
                                              > > >
                                              > > > .
                                              > > >
                                              > > > Bill Salot
                                              > > >
                                              > > > ____________ _________ _________ __
                                              > > >
                                              > > > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                              > > > [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of
                                              > > > fforck@
                                              > > > Sent: Tuesday, September 01, 2009 6:13 PM
                                              > > > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                              > > > Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                              > > > Conditions Adverse to Quality
                                              > > >
                                              > > >
                                              > > >
                                              > > >
                                              > > >
                                              > > > So "missed opportunities" are pertinent to investigations, but missed
                                              > > > inspections are "extraneous" . Interesting
                                              > > >
                                              > > > Sent via BlackBerry by AT&T
                                              > > >
                                              > > > ____________ _________ _________ __
                                              > > >
                                              > > > From: "wlrigot"
                                              > > > Date: Tue, 01 Sep 2009 21:13:08 -0000
                                              > > > To: <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                                              > > > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions
                                              > > > Adverse to Quality
                                              > > >
                                              > > >
                                              > > >
                                              > > >
                                              > > > Dr. Bill,
                                              > > >
                                              > > > I really hate to bring this up, because it always generates (unintended)
                                              > > > controversy, but this relates to what Sydney Dekker and others call
                                              > > > "counterfactuals" . They are behaviors that never happened, that
                                              > > > management wished with all their little hearts would have happened.
                                              > > > They are certainly extraneous conditions adverse to quality and should
                                              > > > be investigated, but have nothing to do with the nature, magitude,
                                              > > > timing and location of factors leading to the event.
                                              > > >
                                              > > > Unfortunately, when bad things happen and people end up dead, hordes of
                                              > > > people in the "uh oh" squad descend on you and will always find bad
                                              > > > things that had been buried for a long time. Unintended consequences
                                              > > > almost always ensue. This appears to be what happened here. While some
                                              > > > will feel good about punishing some poor soul who got caught not doing
                                              > > > an inspection, they are no nearer determining what actually led to the
                                              > > > event. And they are thus no nearer determining effective corrective
                                              > > > actions that would prevent recurrence.
                                              > > >
                                              > > > Bill Rigot
                                              > > >
                                              > >
                                              >
                                            • jack.stanford@att.net
                                              Interesting comments on fitness for duty testing. Way back when I was a Duty Officer I was summoned by our nurse as a maintenance supervisor had just tested
                                              Message 22 of 30 , Sep 2, 2009
                                              • 0 Attachment
                                                Interesting comments on fitness for duty testing.  Way back when I was a Duty Officer I was summoned by our nurse as a maintenance supervisor had just tested positive for alcohol.  I made the prompt report to the NRC.  Then she asked me if I wanted to speak to him.  Now, why would I want to do that?  I chose not to speak to him, as he was in danger of losing his job and was a good friend of mine.  Well, he did not get fired, but I am very sure that he entered a special type of program.  I took FFD very seriously since the law was implemented in 1989 and have not smoked pot once since then as a nuclear power plant employee.  I do not even smoke it now, dedicated fan that I was.  That was 20 years ago...
                                                 
                                                Jack
                                                 
                                                -------------- Original message from "wlrigot" <william.rigot@...>: --------------

                                                 

                                                Dr. Bill,

                                                AFFF = Aqueous Fire Fighting Foam

                                                BTW, another ECAQ from that event was the discovery that over half the flight deck crew who died in the fire had marijuana in their systems at the time of their deaths. The ship had been underway for weeks, which meant that they had been using it while underway. This discovery led the Navy to finally initiate their very comprehensive urinalysis program, which actually had a positive effect in significantly reducing drug abuse in the Navy.

                                                All the best,

                                                Bill Rigot

                                                --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM CORCORAN <William.R.Corcoran @...> wrote:
                                                >
                                                > Bill Rigot,
                                                >  
                                                > If AFFF=Aircraft Fire Fighting Foam or something like that, I get it.
                                                >  
                                                > Sometimes the Extraneous Conditions Adverse to Quality get air time to distract attention from the harmful factors that are embarrassing.
                                                >
                                                > But at other times the harmful factors get air time to distract attention from the Extraneous Conditions Adverse to Quality that are embarrassing.
                                                >
                                                >
                                                > 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.
                                                > Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                                                >  
                                                > ****Internet Email Confidentiality Footer****
                                                >  
                                                > Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
                                                >
                                                > --- On Wed, 9/2/09, wlrigot <william.rigot@ ...> wrote:
                                                >
                                                >
                                                > From: wlrigot <william.rigot@ ...>
                                                > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                                                > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                > Date: Wednesday, September 2, 2009, 2:52 PM
                                                >
                                                >
                                                >  
                                                >
                                                >
                                                >
                                                > A sea story.
                                                >
                                                > It was a dark and stormy night in 1981. I was the Damage Control Assistant in USS NIMITZ standing watch as EOOW in main control observing carrier quals for the air wing in preparation for an upcoming Med deployment. An EA-6B was having difficulty catching the wire and was coming in for his third attempt before being sent back to Jacksonville with a failed carrier qual and bad consequences for the pilot. The plane came in well right of centerline and was waved off by the LSO. He came in anyway, and clipped the nose of an A-7 parked near the "Foul Line". The EA-6B cartwheeled into the Weapons Arming/Dearming area near the bow and ignited a towering inferno of planes, fuel, and weapons. Bottom line, 14 dead, 40 seriously injured, 14 planes destroyed, and the flight deck damaged.
                                                >
                                                > The investigation found that the pilot had taken 100 times the recommended dose of antihistimine to counter effects of a cold so he could fly. He did not see the flight surgeon, because he was on his last opportunity to qualify for night landings prior to the deployment. He did not know that antihistimines can trigger vertigo on dark moonless nights (such as that night). There were many missed opportunities to correct this behavior, such as his roommate, who knew about it, the NFO in the right seat who could see his dysfunction, the LSO, etc., etc. These were largely ininvestigated, because the pilot, and his crew were dead, and there seemed to be little point in punishing the dead.
                                                >
                                                > The investigators did find that a fuse blew on one of the AFFF stations on the bow. They found a missed PM on that station, and inferred causality. I was very nearly court martialled for this failure, until cooler heads prevailed. A later study by the Naval Aviation Safety Center found that the AFFF systems on the carriers were never designed for that type of accident, and that other means of fire fighting would need to be put in place to put the fire out. This was the Extraneous Condition Adverse to Quality that the investigators focused so on much, that missed the point of why the pilot took antihisimines prior to flight in the first place.
                                                >
                                                > As a footnote, I was the Chief Engineer in NIMITZ 8 years later when a similar fire erupted on the flight deck. Because we had learned from the first fire, we escaped with only two deaths, no injuries, and only a few lost aircraft. That fire was extinguished in 11 minutes compared to 1 1/2 hours for the one in 1981. But that sea story will have to wait for another time.
                                                >
                                                > Bill Rigot
                                                >
                                                > --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM CORCORAN <William.R.Corcoran @...> wrote:
                                                > >
                                                > > To two Bills,
                                                > >  
                                                > > How about one example from each of you to get the point across?
                                                > >
                                                > >
                                                > >
                                                > > 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.
                                                > > Nuclear Safety Review Concepts 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/ evaluation  Root_ Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                                                > >  
                                                > > ****Internet Email Confidentiality Footer****
                                                > >  
                                                > > Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
                                                > >
                                                > > --- On Wed, 9/2/09, wlrigot <william.rigot@ ...> wrote:
                                                > >
                                                > >
                                                > > From: wlrigot <william.rigot@ ...>
                                                > > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                                                > > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                > > Date: Wednesday, September 2, 2009, 11:43 AM
                                                > >
                                                > >
                                                > >  
                                                > >
                                                > >
                                                > >
                                                > > Bill Salot,
                                                > >
                                                > > I agree. I've seen both.
                                                > >
                                                > > Bill Rigot
                                                > >
                                                > > --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "Salot, William" <william.salot@ ...> wrote:
                                                > > >
                                                > > > Fred,
                                                > > >
                                                > > >
                                                > > >
                                                > > > Sometimes extraneous findings are more significant than pertinent
                                                > > > factors in an investigation. The investigation should report both.
                                                > > > Both are subject to recommendations for corrective action.
                                                > > >
                                                > > >
                                                > > >
                                                > > > Yes, it is interesting. But in the final analysis, confusing "missed
                                                > > > opportunities" with "extraneous" inactions will not make much
                                                > > > difference, as long as both are taken seriously.
                                                > > >
                                                > > > .
                                                > > >
                                                > > > Bill Salot
                                                > > >
                                                > > > ____________ _________ _________ __
                                                > > >
                                                > > > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                > > > [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of
                                                > > > fforck@
                                                > > > Sent: Tuesday, September 01, 2009 6:13 PM
                                                > > > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                > > > Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                                > > > Conditions Adverse to Quality
                                                > > >
                                                > > >
                                                > > >
                                                > > >
                                                > > >
                                                > > > So "missed opportunities" are pertinent to investigations, but missed
                                                > > > inspections are "extraneous" . Interesting
                                                > > >
                                                > > > Sent via BlackBerry by AT&T
                                                > > >
                                                > > > ____________ _________ _________ __
                                                > > >
                                                > > > From: "wlrigot"
                                                > > > Date: Tue, 01 Sep 2009 21:13:08 -0000
                                                > > > To: <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                                                > > > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions
                                                > > > Adverse to Quality
                                                > > >
                                                > > >
                                                > > >
                                                > > >
                                                > > > Dr. Bill,
                                                > > >
                                                > > > I really hate to bring this up, because it always generates (unintended)
                                                > > > controversy, but this relates to what Sydney Dekker and others call
                                                > > > "counterfactuals" . They are behaviors that never happened, that
                                                > > > management wished with all their little hearts would have happened.
                                                > > > They are certainly extraneous conditions adverse to quality and should
                                                > > > be investigated, but have nothing to do with the nature, magitude,
                                                > > > timing and location of factors leading to the event.
                                                > > >
                                                > > > Unfortunately, when bad things happen and people end up dead, hordes of
                                                > > > people in the "uh oh" squad descend on you and will always find bad
                                                > > > things that had been buried for a long time. Unintended consequences
                                                > > > almost always ensue. This appears to be what happened here. While some
                                                > > > will feel good about punishing some poor soul who got caught not doing
                                                > > > an inspection, they are no nearer determining what actually led to the
                                                > > > event. And they are thus no nearer determining effective corrective
                                                > > > actions that would prevent recurrence.
                                                > > >
                                                > > > Bill Rigot
                                                > > >
                                                > >
                                                >

                                              • DR WILLIAM CORCORAN
                                                Bill Rigot,   Thanks for your ECAQs.   You have a good grasp of ECAQs and their potential significance.   I would like to invite others to post examples of
                                                Message 23 of 30 , Sep 3, 2009
                                                • 0 Attachment
                                                  Bill Rigot,
                                                   
                                                  Thanks for your ECAQs.
                                                   
                                                  You have a good grasp of ECAQs and their potential significance.
                                                   
                                                  I would like to invite others to post examples of ECAQs from their experience.
                                                   
                                                  OBTW: The important ECAQs that have come up illustrate The Kitty Litter Principle: "If you dig beneath the surface you find the lumps."
                                                   
                                                  The digging does not create the lumps. It just reveals them.

                                                  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.
                                                  Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                                                   
                                                  ****Internet Email Confidentiality Footer****
                                                   
                                                  Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


                                                  --- On Wed, 9/2/09, wlrigot <william.rigot@...> wrote:

                                                  From: wlrigot <william.rigot@...>
                                                  Subject: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                                                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                  Date: Wednesday, September 2, 2009, 4:58 PM

                                                   
                                                  Dr. Bill,

                                                  AFFF = Aqueous Fire Fighting Foam

                                                  BTW, another ECAQ from that event was the discovery that over half the flight deck crew who died in the fire had marijuana in their systems at the time of their deaths. The ship had been underway for weeks, which meant that they had been using it while underway. This discovery led the Navy to finally initiate their very comprehensive urinalysis program, which actually had a positive effect in significantly reducing drug abuse in the Navy.

                                                  All the best,

                                                  Bill Rigot

                                                  --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM CORCORAN <William.R.Corcoran @...> wrote:
                                                  >
                                                  > Bill Rigot,
                                                  >  
                                                  > If AFFF=Aircraft Fire Fighting Foam or something like that, I get it.
                                                  >  
                                                  > Sometimes the Extraneous Conditions Adverse to Quality get air time to distract attention from the harmful factors that are embarrassing.
                                                  >
                                                  > But at other times the harmful factors get air time to distract attention from the Extraneous Conditions Adverse to Quality that are embarrassing.
                                                  >
                                                  >
                                                  > 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.
                                                  > Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                                                  >  
                                                  > ****Internet Email Confidentiality Footer****
                                                  >  
                                                  > Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
                                                  >
                                                  > --- On Wed, 9/2/09, wlrigot <william.rigot@ ...> wrote:
                                                  >
                                                  >
                                                  > From: wlrigot <william.rigot@ ...>
                                                  > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                                                  > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                  > Date: Wednesday, September 2, 2009, 2:52 PM
                                                  >
                                                  >
                                                  >  
                                                  >
                                                  >
                                                  >
                                                  > A sea story.
                                                  >
                                                  > It was a dark and stormy night in 1981. I was the Damage Control Assistant in USS NIMITZ standing watch as EOOW in main control observing carrier quals for the air wing in preparation for an upcoming Med deployment. An EA-6B was having difficulty catching the wire and was coming in for his third attempt before being sent back to Jacksonville with a failed carrier qual and bad consequences for the pilot. The plane came in well right of centerline and was waved off by the LSO. He came in anyway, and clipped the nose of an A-7 parked near the "Foul Line". The EA-6B cartwheeled into the Weapons Arming/Dearming area near the bow and ignited a towering inferno of planes, fuel, and weapons. Bottom line, 14 dead, 40 seriously injured, 14 planes destroyed, and the flight deck damaged.
                                                  >
                                                  > The investigation found that the pilot had taken 100 times the recommended dose of antihistimine to counter effects of a cold so he could fly. He did not see the flight surgeon, because he was on his last opportunity to qualify for night landings prior to the deployment. He did not know that antihistimines can trigger vertigo on dark moonless nights (such as that night). There were many missed opportunities to correct this behavior, such as his roommate, who knew about it, the NFO in the right seat who could see his dysfunction, the LSO, etc., etc. These were largely ininvestigated, because the pilot, and his crew were dead, and there seemed to be little point in punishing the dead.
                                                  >
                                                  > The investigators did find that a fuse blew on one of the AFFF stations on the bow. They found a missed PM on that station, and inferred causality. I was very nearly court martialled for this failure, until cooler heads prevailed. A later study by the Naval Aviation Safety Center found that the AFFF systems on the carriers were never designed for that type of accident, and that other means of fire fighting would need to be put in place to put the fire out. This was the Extraneous Condition Adverse to Quality that the investigators focused so on much, that missed the point of why the pilot took antihisimines prior to flight in the first place.
                                                  >
                                                  > As a footnote, I was the Chief Engineer in NIMITZ 8 years later when a similar fire erupted on the flight deck. Because we had learned from the first fire, we escaped with only two deaths, no injuries, and only a few lost aircraft. That fire was extinguished in 11 minutes compared to 1 1/2 hours for the one in 1981. But that sea story will have to wait for another time.
                                                  >
                                                  > Bill Rigot
                                                  >
                                                  > --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, DR WILLIAM CORCORAN <William.R.Corcoran @...> wrote:
                                                  > >
                                                  > > To two Bills,
                                                  > >  
                                                  > > How about one example from each of you to get the point across?
                                                  > >
                                                  > >
                                                  > >
                                                  > > 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.
                                                  > > Nuclear Safety Review Concepts 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/ evaluation  Root_ Cause_State_ of_the_Practice- subscribe@ yahoogroups. com
                                                  > >  
                                                  > > ****Internet Email Confidentiality Footer****
                                                  > >  
                                                  > > Privileged/Confiden tial Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.
                                                  > >
                                                  > > --- On Wed, 9/2/09, wlrigot <william.rigot@ ...> wrote:
                                                  > >
                                                  > >
                                                  > > From: wlrigot <william.rigot@ ...>
                                                  > > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                                                  > > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                  > > Date: Wednesday, September 2, 2009, 11:43 AM
                                                  > >
                                                  > >
                                                  > >  
                                                  > >
                                                  > >
                                                  > >
                                                  > > Bill Salot,
                                                  > >
                                                  > > I agree. I've seen both.
                                                  > >
                                                  > > Bill Rigot
                                                  > >
                                                  > > --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, "Salot, William" <william.salot@ ...> wrote:
                                                  > > >
                                                  > > > Fred,
                                                  > > >
                                                  > > >
                                                  > > >
                                                  > > > Sometimes extraneous findings are more significant than pertinent
                                                  > > > factors in an investigation. The investigation should report both.
                                                  > > > Both are subject to recommendations for corrective action.
                                                  > > >
                                                  > > >
                                                  > > >
                                                  > > > Yes, it is interesting. But in the final analysis, confusing "missed
                                                  > > > opportunities" with "extraneous" inactions will not make much
                                                  > > > difference, as long as both are taken seriously.
                                                  > > >
                                                  > > > .
                                                  > > >
                                                  > > > Bill Salot
                                                  > > >
                                                  > > > ____________ _________ _________ __
                                                  > > >
                                                  > > > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                  > > > [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of
                                                  > > > fforck@
                                                  > > > Sent: Tuesday, September 01, 2009 6:13 PM
                                                  > > > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                  > > > Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                                  > > > Conditions Adverse to Quality
                                                  > > >
                                                  > > >
                                                  > > >
                                                  > > >
                                                  > > >
                                                  > > > So "missed opportunities" are pertinent to investigations, but missed
                                                  > > > inspections are "extraneous" . Interesting
                                                  > > >
                                                  > > > Sent via BlackBerry by AT&T
                                                  > > >
                                                  > > > ____________ _________ _________ __
                                                  > > >
                                                  > > > From: "wlrigot"
                                                  > > > Date: Tue, 01 Sep 2009 21:13:08 -0000
                                                  > > > To: <Root_Cause_ State_ of_the_Practice@ yahoogroups. com>
                                                  > > > Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions
                                                  > > > Adverse to Quality
                                                  > > >
                                                  > > >
                                                  > > >
                                                  > > >
                                                  > > > Dr. Bill,
                                                  > > >
                                                  > > > I really hate to bring this up, because it always generates (unintended)
                                                  > > > controversy, but this relates to what Sydney Dekker and others call
                                                  > > > "counterfactuals" . They are behaviors that never happened, that
                                                  > > > management wished with all their little hearts would have happened.
                                                  > > > They are certainly extraneous conditions adverse to quality and should
                                                  > > > be investigated, but have nothing to do with the nature, magitude,
                                                  > > > timing and location of factors leading to the event.
                                                  > > >
                                                  > > > Unfortunately, when bad things happen and people end up dead, hordes of
                                                  > > > people in the "uh oh" squad descend on you and will always find bad
                                                  > > > things that had been buried for a long time. Unintended consequences
                                                  > > > almost always ensue. This appears to be what happened here. While some
                                                  > > > will feel good about punishing some poor soul who got caught not doing
                                                  > > > an inspection, they are no nearer determining what actually led to the
                                                  > > > event. And they are thus no nearer determining effective corrective
                                                  > > > actions that would prevent recurrence.
                                                  > > >
                                                  > > > Bill Rigot
                                                  > > >
                                                  > >
                                                  >

                                                • Salot, William
                                                  Bill C, I assume you are asking for a real-life example of an investigation that uncovered an ECAQ that was more significant than the pertinent factors.
                                                  Message 24 of 30 , Sep 3, 2009
                                                  • 0 Attachment

                                                    Bill C,

                                                     

                                                    I assume you are asking for a real-life example of an investigation that uncovered an ECAQ that was more significant than the pertinent factors.

                                                     

                                                    Real-life examples tend to be complex.  It is difficult to do justice to them in the space of a short e-mail.

                                                     

                                                    But here is a somewhat simplified version of one that came to mind:

                                                     

                                                    We installed a new improved agitator assembly into an existing pressure vessel.  During the pressure test just prior to initial startup, the reinforced PTFE gasket between the mechanical seal and the agitator housing blew out.  This was considered a near miss because the consequences would have been much worse if the gasket had blown out during operation.

                                                     

                                                    The investigation identified pertinent factors such as the fact that the bolts were not tightened enough to properly seal the joint against the test pressure, and underlying human and systemic factors that led to the under-tightened bolts.  (It went deeper than the man with the wrench.)

                                                     

                                                    The ECAQ that was more significant was that the normal operating temperature of the pressure vessel was much higher than the maximum temperature rating of the reinforced PTFE gasket.  If the bolts had been properly tightened, the gasket would have passed the pressure test, but would have relaxed and blown out in operation with more serious consequences. (That illustrates the point under discussion.)

                                                     

                                                    We separately investigated what led to the installation of the improper gasket material.  Of course there were some underlying “cultural” factors common to both errors.  (That’s all I can share abut the incident.) 

                                                     

                                                     Bill Salot

                                                     

                                                     


                                                    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: Wednesday, September 02, 2009 2:23 PM
                                                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                    Subject: Re: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality

                                                     

                                                     

                                                    To two Bills,

                                                     

                                                    How about one example from each of you to get the point across?

                                                    Take care,
                                                     
                                                    Bill Corcoran

                                                     

                                                     

                                                    --- On Wed, 9/2/09, wlrigot <william.rigot@ srs.gov> wrote:


                                                    From: wlrigot <william.rigot@ srs.gov>
                                                    Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                                                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                    Date: Wednesday, September 2, 2009, 11:43 AM

                                                     

                                                    Bill Salot,

                                                    I agree. I've seen both.

                                                    Bill Rigot

                                                     


                                                    --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, " Salot, William " <william.salot@ ...> wrote:

                                                    >
                                                    > Fred,
                                                    >
                                                    > Sometimes extraneous findings are more significant than pertinent
                                                    > factors in an investigation. The investigation should report both.
                                                    > Both are subject to recommendations for corrective action.
                                                    >
                                                    > Yes, it is interesting. But in the final analysis, confusing
                                                    "missed
                                                    > opportunities" with "extraneous" inactions will not make
                                                    much
                                                    > difference, as long as both are taken seriously.
                                                    >
                                                    > Bill Salot
                                                    >
                                                    > ____________ _________ _________ __
                                                    >
                                                    > From:
                                                    href="http://us.mc815.mail.yahoo.com/mc/compose?to=Root_Cause_State_of_the_Practice%40yahoogroups.com" target="_blank" ymailto="mailto:Root_Cause_State_of_the_Practice%40yahoogroups.com">Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                    > [mailto:
                                                    href="http://us.mc815.mail.yahoo.com/mc/compose?to=Root_Cause_State_of_the_Practice%40yahoogroups.com" target="_blank" ymailto="mailto:Root_Cause_State_of_the_Practice%40yahoogroups.com">Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of
                                                    > fforck@...
                                                    > Sent: Tuesday, September 01, 2009 6:13 PM
                                                    > To:
                                                    href="http://us.mc815.mail.yahoo.com/mc/compose?to=Root_Cause_State_of_the_Practice%40yahoogroups.com" target="_blank" ymailto="mailto:Root_Cause_State_of_the_Practice%40yahoogroups.com">Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                    > Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                                    > Conditions Adverse to Quality
                                                    >
                                                    >  
                                                    > So "missed opportunities" are pertinent to investigations, but
                                                    missed
                                                    > inspections are "extraneous" . Interesting

                                                  • DR WILLIAM CORCORAN
                                                    Bill Salot,   Thanks for the great ECAQ.   It is also an example of how human error can be a mitigating factor. Take care,   Bill Corcoran Mission: Saving
                                                    Message 25 of 30 , Sep 3, 2009
                                                    • 0 Attachment
                                                      Bill Salot,
                                                       
                                                      Thanks for the great ECAQ.
                                                       
                                                      It is also an example of how human error can be a mitigating factor.

                                                      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.
                                                      Nuclear Safety Review Concepts 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/ evaluation  Root_Cause_State_of_the_Practice-subscribe@yahoogroups.com
                                                       
                                                      ****Internet Email Confidentiality Footer****
                                                       
                                                      Privileged/Confidential Information may be contained in this message. If you are not the addressee indicated in this message (or responsible for delivery of the message to such person), you may not copy or deliver this message to anyone. In such case, you should destroy this message and notify the sender by reply email. Please advise immediately if you or your employer do not consent to Internet email for messages of this kind. Opinions, conclusions and other information in this message that do not relate to the official business of NSRC Corp. shall be understood as neither given nor endorsed by it.


                                                      --- On Thu, 9/3/09, Salot, William <william.salot@...> wrote:

                                                      From: Salot, William <william.salot@...>
                                                      Subject: RE: [Root_Cause_State_of_the_Practice] Re: Extraneous Conditions Adverse to Quality
                                                      To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                                      Date: Thursday, September 3, 2009, 7:52 AM

                                                       

                                                      Bill C,

                                                       

                                                      I assume you are asking for a real-life example of an investigation that uncovered an ECAQ that was more significant than the pertinent factors.

                                                       

                                                      Real-life examples tend to be complex.  It is difficult to do justice to them in the space of a short e-mail.

                                                       

                                                      But here is a somewhat simplified version of one that came to mind:

                                                       

                                                      We installed a new improved agitator assembly into an existing pressure vessel.  During the pressure test just prior to initial startup, the reinforced PTFE gasket between the mechanical seal and the agitator housing blew out.  This was considered a near miss because the consequences would have been much worse if the gasket had blown out during operation.

                                                       

                                                      The investigation identified pertinent factors such as the fact that the bolts were not tightened enough to properly seal the joint against the test pressure, and underlying human and systemic factors that led to the under-tightened bolts.  (It went deeper than the man with the wrench.)

                                                       

                                                      The ECAQ that was more significant was that the normal operating temperature of the pressure vessel was much higher than the maximum temperature rating of the reinforced PTFE gasket.  If the bolts had been properly tightened, the gasket would have passed the pressure test, but would have relaxed and blown out in operation with more serious consequences. (That illustrates the point under discussion.)

                                                       

                                                      We separately investigated what led to the installation of the improper gasket material.  Of course there were some underlying “cultural” factors common to both errors.  (That’s all I can share abut the incident.) 

                                                       

                                                       Bill Salot

                                                       

                                                       


                                                      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: Wednesday, September 02, 2009 2:23 PM
                                                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                      Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality

                                                       

                                                       

                                                       

                                                      How about one example from each of you to get the point across?

                                                      Take care,
                                                       
                                                      Bill Corcoran

                                                       

                                                       

                                                      --- On Wed, 9/2/09, wlrigot <william.rigot@ srs.gov> wrote:


                                                      From: wlrigot <william.rigot@ srs.gov>
                                                      Subject: [Root_Cause_ State_of_ the_Practice] Re: Extraneous Conditions Adverse to Quality
                                                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                      Date: Wednesday, September 2, 2009, 11:43 AM

                                                       

                                                      Bill Salot,

                                                      I agree. I've seen both.

                                                      Bill Rigot

                                                       


                                                      --- In Root_Cause_State_ of_the_Practice@ yahoogroups. com, " Salot, William " <william.salot@ ...> wrote:
                                                      >
                                                      > Fred,
                                                      >
                                                      > Sometimes extraneous findings are more significant than pertinent
                                                      > factors in an investigation. The investigation should report both.
                                                      > Both are subject to recommendations for corrective action.
                                                      >
                                                      > Yes, it is interesting. But in the final analysis, confusing "missed
                                                      > opportunities" with "extraneous" inactions will not make much
                                                      > difference, as long as both are taken seriously.
                                                      >
                                                      > Bill Salot
                                                      >
                                                      > ____________ _________ _________ __
                                                      >
                                                      > From: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                      > [mailto:Root_Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of
                                                      > fforck@...
                                                      > Sent: Tuesday, September 01, 2009 6:13 PM
                                                      > To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                                                      > Subject: Re: [Root_Cause_ State_of_ the_Practice] Re: Extraneous
                                                      > Conditions Adverse to Quality
                                                      >
                                                      >  
                                                      > So "missed opportunities" are pertinent to investigations, but missed
                                                      > inspections are "extraneous" . Interesting

                                                      To two Bills,

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