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RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

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  • Arsenault, Gerry
    UNRESTRICTED | ILLIMITÉ I believe it depends in large part on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch
    Message 1 of 26 , Feb 1, 2010
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      UNRESTRICTED | ILLIMITÉ

       

      I believe it depends in large part  on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch the KPI’s mentality that prevails? This will have a direct impact on whether or not an individual will be able to provide objective input in the investigation. Objectivity on the part on the part of the investigating team is very important if effective corrective actions are to be put in place. I have struggled with this idea since I began as an analyst . Even though I am in an oversight role as an investigator, I still work for the same employer as  the people who were involved in the event. Our biases make us the individuals that we are, we can’t get away from that, the wonders of individuality.  Not that I can’t be objective, rather how can I maintain an appropriate level of objectivity that will allow me to see the issues and recognize the real factors  and pursue them by asking the tough questions. This means that sometimes, a firm stand must be taken when factors that are clearly identified are being resisted by senior managers. All team members must be ready to take this approach or else it becomes an exercise in futility.

       

      Just my thoughts.

      Gerry A.

       

       

      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: Saturday, January 30, 2010 6:21 AM
      To: Dr. Bill Corcoran
      Subject: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

       

       

      Colleague,

       

      A correspondent asked me the following:

       


       

      The management team here at my facility routinely assigns individuals directly involved in events as members of the team analyzing the event, and occasionally as the lead for the assessment. 

       

      I have pointed out that this practice can significantly interfere with the objectivity of the analysis leading to misidentification of cause, leading to ineffective corrective actions and that potential for this to happen far out weights any potential benefit obtained from enhanced learning through direct involvement in the analysis.   Thus far my objection to this practice has fell on deaf ears.  The common justification provided is to “maximize the learning” for the individual and that an appropriate level of objectivity can be maintained if sufficient oversight is provided.  

       

      Would you like to weigh in on the issue?    Any expert opinion you might care to share would be appreciated.


      How should I reply?

       

       

      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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    • DR WILLIAM CORCORAN
      Thanks, Gerry, What is your experience using perpetrators as investigators? Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers
      Message 2 of 26 , Feb 1, 2010
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        Thanks, Gerry,

        What is your experience using perpetrators as investigators?

        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, 2/1/10, Arsenault, Gerry <arsenaultg@...> wrote:

        From: Arsenault, Gerry <arsenaultg@...>
        Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Date: Monday, February 1, 2010, 11:09 AM

         

        UNRESTRICTED | ILLIMITÉ

         

        I believe it depends in large part  on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch the KPI’s mentality that prevails? This will have a direct impact on whether or not an individual will be able to provide objective input in the investigation. Objectivity on the part on the part of the investigating team is very important if effective corrective actions are to be put in place. I have struggled with this idea since I began as an analyst . Even though I am in an oversight role as an investigator, I still work for the same employer as  the people who were involved in the event. Our biases make us the individuals that we are, we can’t get away from that, the wonders of individuality.  Not that I can’t be objective, rather how can I maintain an appropriate level of objectivity that will allow me to see the issues and recognize the real factors  and pursue them by asking the tough questions. This means that sometimes, a firm stand must be taken when factors that are clearly identified are being resisted by senior managers. All team members must be ready to take this approach or else it becomes an exercise in futility.

         

        Just my thoughts.

        Gerry A.

         

         

        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: Saturday, January 30, 2010 6:21 AM
        To: Dr. Bill Corcoran
        Subject: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

         

         

        Colleague,

         

        A correspondent asked me the following:

         


         

        The management team here at my facility routinely assigns individuals directly involved in events as members of the team analyzing the event, and occasionally as the lead for the assessment. 

         

        I have pointed out that this practice can significantly interfere with the objectivity of the analysis leading to misidentification of cause, leading to ineffective corrective actions and that potential for this to happen far out weights any potential benefit obtained from enhanced learning through direct involvement in the analysis.   Thus far my objection to this practice has fell on deaf ears.  The common justification provided is to “maximize the learning” for the individual and that an appropriate level of objectivity can be maintained if sufficient oversight is provided.  

         

        Would you like to weigh in on the issue?    Any expert opinion you might care to share would be appreciated.


        How should I reply?

         

         

        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.




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        This e-mail, and any attachments, may contain information that
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        Any unauthorized review, disclosure, retransmission, 
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        Le présent courriel, et toute pièce jointe, peut contenir de 
        l'information qui est confidentielle, régie par les droits 
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        envers celle-ci peut être illégale et est strictement interdite.
      • Jim Bryant
        I heard a rumor from a good source that there was a a number of sailors that were over exposed during a refueling at EB, maybe back in the 60s.  Does anyone
        Message 3 of 26 , Feb 1, 2010
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          I heard a rumor from a good source that there was a a number of sailors that were over exposed during a refueling at EB, maybe back in the 60s.  Does anyone recall this incident or what might have caused former sailors to think they were over exposed.  There is a possibility of a cancer lawsuit.  It doesn't sound right to me, especially with the care taken during refueling to prevent such an incident.
          Jim Bryant



          From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Sent: Mon, February 1, 2010 12:57:00 PM
          Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

           

          Thanks, Gerry,

          What is your experience using perpetrators as investigators?

          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, 2/1/10, Arsenault, Gerry <arsenaultg@aecl. ca> wrote:

          From: Arsenault, Gerry <arsenaultg@aecl. ca>
          Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators
          To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
          Date: Monday, February 1, 2010, 11:09 AM

           

          UNRESTRICTED | ILLIMITÉ

           

          I believe it depends in large part  on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch the KPI’s mentality that prevails? This will have a direct impact on whether or not an individual will be able to provide objective input in the investigation. Objectivity on the part on the part of the investigating team is very important if effective corrective actions are to be put in place. I have struggled with this idea since I began as an analyst . Even though I am in an oversight role as an investigator, I still work for the same employer as  the people who were involved in the event. Our biases make us the individuals that we are, we can’t get away from that, the wonders of individuality.  Not that I can’t be objective, rather how can I maintain an appropriate level of objectivity that will allow me to see the issues and recognize the real factors  and pursue them by asking the tough questions. This means that sometimes, a firm stand must be taken when factors that are clearly identified are being resisted by senior managers. All team members must be ready to take this approach or else it becomes an exercise in futility.

           

          Just my thoughts.

          Gerry A.

           

           

          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: Saturday, January 30, 2010 6:21 AM
          To: Dr. Bill Corcoran
          Subject: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

           

           

          Colleague,

           

          A correspondent asked me the following:

           


           

          The management team here at my facility routinely assigns individuals directly involved in events as members of the team analyzing the event, and occasionally as the lead for the assessment. 

           

          I have pointed out that this practice can significantly interfere with the objectivity of the analysis leading to misidentification of cause, leading to ineffective corrective actions and that potential for this to happen far out weights any potential benefit obtained from enhanced learning through direct involvement in the analysis.   Thus far my objection to this practice has fell on deaf ears.  The common justification provided is to “maximize the learning” for the individual and that an appropriate level of objectivity can be maintained if sufficient oversight is provided.  

           

          Would you like to weigh in on the issue?    Any expert opinion you might care to share would be appreciated.


          How should I reply?

           

           

          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.




          CONFIDENTIAL AND PRIVILEGED INFORMATION NOTICE

          This e-mail, and any attachments, may contain information that
          is confidential, subject to copyright, or exempt from disclosure.
          Any unauthorized review, disclosure, retransmission, 
          dissemination or other use of or reliance on this information 
          may be unlawful and is strictly prohibited.  

          AVIS D'INFORMATION CONFIDENTIELLE ET PRIVILÉGIÉE

          Le présent courriel, et toute pièce jointe, peut contenir de 
          l'information qui est confidentielle, régie par les droits 
          d'auteur, ou interdite de divulgation. Tout examen , 
          divulgation, retransmission, diffusion ou autres utilisations 
          non autorisées de l'information ou dépendance non autorisée 
          envers celle-ci peut être illégale et est strictement interdite.


        • Arsenault, Gerry
          UNRESTRICTED | ILLIMITÉ We do not normally include them on the investigating team, but they would likely be interviewed by the team in gathering the facts
          Message 4 of 26 , Feb 2, 2010
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            UNRESTRICTED | ILLIMITÉ

             

            We do not normally include them on the investigating team, but they would likely be interviewed by the team in gathering the facts surrounding  the events, particularly if they are the SME.

            G.

             

            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Jim Bryant
            Sent: Monday, February 01, 2010 2:41 PM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: Re: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

             

             

             

            I heard a rumor from a good source that there was a a number of sailors that were over exposed during a refueling at EB, maybe back in the 60s.  Does anyone recall this incident or what might have caused former sailors to think they were over exposed.  There is a possibility of a cancer lawsuit.  It doesn't sound right to me, especially with the care taken during refueling to prevent such an incident.

            Jim Bryant

             


            From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Sent: Mon, February 1, 2010 12:57:00 PM
            Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

             

            Thanks, Gerry,

             

            What is your experience using perpetrators as investigators?

            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, 2/1/10, Arsenault, Gerry <arsenaultg@aecl. ca> wrote:


            From: Arsenault, Gerry <arsenaultg@aecl. ca>
            Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators
            To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
            Date: Monday, February 1, 2010, 11:09 AM

             

            UNRESTRICTED | ILLIMITÉ

             

            I believe it depends in large part  on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch the KPI’s mentality that prevails? This will have a direct impact on whether or not an individual will be able to provide objective input in the investigation. Objectivity on the part on the part of the investigating team is very important if effective corrective actions are to be put in place. I have struggled with this idea since I began as an analyst . Even though I am in an oversight role as an investigator, I still work for the same employer as  the people who were involved in the event. Our biases make us the individuals that we are, we can’t get away from that, the wonders of individuality.  Not that I can’t be objective, rather how can I maintain an appropriate level of objectivity that will allow me to see the issues and recognize the real factors  and pursue them by asking the tough questions. This means that sometimes, a firm stand must be taken when factors that are clearly identified are being resisted by senior managers. All team members must be ready to take this approach or else it becomes an exercise in futility.

             

            Just my thoughts.

            Gerry A.

             

             

            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: Saturday, January 30, 2010 6:21 AM
            To: Dr. Bill Corcoran
            Subject: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

             

             

            Colleague,

             

            A correspondent asked me the following:

             


             

            The management team here at my facility routinely assigns individuals directly involved in events as members of the team analyzing the event, and occasionally as the lead for the assessment. 

             

            I have pointed out that this practice can significantly interfere with the objectivity of the analysis leading to misidentification of cause, leading to ineffective corrective actions and that potential for this to happen far out weights any potential benefit obtained from enhanced learning through direct involvement in the analysis.   Thus far my objection to this practice has fell on deaf ears.  The common justification provided is to “maximize the learning” for the individual and that an appropriate level of objectivity can be maintained if sufficient oversight is provided.  

             

            Would you like to weigh in on the issue?    Any expert opinion you might care to share would be appreciated.


            How should I reply?

             

             

            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.

             


            CONFIDENTIAL AND PRIVILEGED INFORMATION NOTICE

            This e-mail, and any attachments, may contain information that
            is confidential, subject to copyright, or exempt from disclosure.
            Any unauthorized review, disclosure, retransmission, 
            dissemination or other use of or reliance on this information 
            may be unlawful and is strictly prohibited.  

            AVIS D'INFORMATION CONFIDENTIELLE ET PRIVILÉGIÉE

            Le présent courriel, et toute pièce jointe, peut contenir de 
            l'information qui est confidentielle, régie par les droits 
            d'auteur, ou interdite de divulgation. Tout examen , 
            divulgation, retransmission, diffusion ou autres utilisations 
            non autorisées de l'information ou dépendance non autorisée 
            envers celle-ci peut être illégale et est strictement interdite.

             




            CONFIDENTIAL AND PRIVILEGED INFORMATION NOTICE

            This e-mail, and any attachments, may contain information that
            is confidential, subject to copyright, or exempt from disclosure.
            Any unauthorized review, disclosure, retransmission, 
            dissemination or other use of or reliance on this information 
            may be unlawful and is strictly prohibited.  

            AVIS D'INFORMATION CONFIDENTIELLE ET PRIVILÉGIÉE

            Le présent courriel, et toute pièce jointe, peut contenir de 
            l'information qui est confidentielle, régie par les droits 
            d'auteur, ou interdite de divulgation. Tout examen, 
            divulgation, retransmission, diffusion ou autres utilisations 
            non autorisées de l'information ou dépendance non autorisée 
            envers celle-ci peut être illégale et est strictement interdite.
          • DR WILLIAM CORCORAN
            Gerry, I have a lot of experience with perpetrators participating as investigators. This experience is at Susquehanna, Millstone, LaSalle, Calvert Cliffs, Zion
            Message 5 of 26 , Feb 2, 2010
            • 0 Attachment
              Gerry,

              I have a lot of experience with perpetrators participating as investigators.

              This experience is at Susquehanna, Millstone, LaSalle, Calvert Cliffs, Zion and other high hazard industry activities.

              In all cases it appeared to me that the products of the investigation were better with perpetrators participating as investigators than they otherwise would have been. This was true even when with perpetrators participating as investigators impeded the investigation.

              The perpetrators are invaluable in fleshing out the Missed Opportunity Matrix, the Barrier Analysis Matrix, and the Change/Difference Analysis. Many perpetrators request that they be entered in the Missed Opportunity Matrix.

              I have no experience with a perpetrator as an investigation team leader except in some cases outside the nuclear industry in which the investigation team leader was a high level official who was one of the people on the Missed Opportunity Matrix.  These high level officials included a Corporate Safety VP, a CFO, a Company President, and an Executive Vice President.

              I can recall one case of an investigation with perpetrators participating as investigators in which the perpetrator obstructed the investigation. In this case, the sponsor and the other investigators pressured and worked around the obstructor.

              In another case the investigation team I was on represented a government regulatory agency that supplied all of the members. Several team member regulators could have surfaced the problem at an earlier, better, cheaper, safer opportunity, but didn't. They learned nothing that I could see, but did not impede the investigation.

              In another case team members belonged to the QA Department. They had very difficult times seeing that they were part of the problem.

              In all other cases each of the perpetrators found out that they could have singlehandedly prevented the event and that they allowed themselves to be set up for their own dysfunctional behavior.

              Most perpetrators participating as investigators seem to realize that their appointment to the investigation team is an opportunity to show that "they got it" or not. Management can use the appointment as a 'second chance" or as an opportunity to see the true colors of the perpetrator(s). This doesn't work all the time when management doesn't "get 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 Tue, 2/2/10, Arsenault, Gerry <arsenaultg@...> wrote:

              From: Arsenault, Gerry <arsenaultg@...>
              Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Date: Tuesday, February 2, 2010, 10:06 AM

               

              UNRESTRICTED | ILLIMITÉ

               

              We do not normally include them on the investigating team, but they would likely be interviewed by the team in gathering the facts surrounding  the events, particularly if they are the SME.

              G.

               

              From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Jim Bryant
              Sent: Monday, February 01, 2010 2:41 PM
              To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
              Subject: Re: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

               

               

               

              I heard a rumor from a good source that there was a a number of sailors that were over exposed during a refueling at EB, maybe back in the 60s.  Does anyone recall this incident or what might have caused former sailors to think they were over exposed.  There is a possibility of a cancer lawsuit.  It doesn't sound right to me, especially with the care taken during refueling to prevent such an incident.

              Jim Bryant

               


              From: DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>
              To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
              Sent: Mon, February 1, 2010 12:57:00 PM
              Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

               

              Thanks, Gerry,

               

              What is your experience using perpetrators as investigators?

              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, 2/1/10, Arsenault, Gerry <arsenaultg@aecl. ca> wrote:


              From: Arsenault, Gerry <arsenaultg@aecl. ca>
              Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators
              To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
              Date: Monday, February 1, 2010, 11:09 AM

               

              UNRESTRICTED | ILLIMITÉ

               

              I believe it depends in large part  on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch the KPI’s mentality that prevails? This will have a direct impact on whether or not an individual will be able to provide objective input in the investigation. Objectivity on the part on the part of the investigating team is very important if effective corrective actions are to be put in place. I have struggled with this idea since I began as an analyst . Even though I am in an oversight role as an investigator, I still work for the same employer as  the people who were involved in the event. Our biases make us the individuals that we are, we can’t get away from that, the wonders of individuality.  Not that I can’t be objective, rather how can I maintain an appropriate level of objectivity that will allow me to see the issues and recognize the real factors  and pursue them by asking the tough questions. This means that sometimes, a firm stand must be taken when factors that are clearly identified are being resisted by senior managers. All team members must be ready to take this approach or else it becomes an exercise in futility.

               

              Just my thoughts.

              Gerry A.

               

               

              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: Saturday, January 30, 2010 6:21 AM
              To: Dr. Bill Corcoran
              Subject: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

               

               

              Colleague,

               

              A correspondent asked me the following:

               


               

              The management team here at my facility routinely assigns individuals directly involved in events as members of the team analyzing the event, and occasionally as the lead for the assessment. 

               

              I have pointed out that this practice can significantly interfere with the objectivity of the analysis leading to misidentification of cause, leading to ineffective corrective actions and that potential for this to happen far out weights any potential benefit obtained from enhanced learning through direct involvement in the analysis.   Thus far my objection to this practice has fell on deaf ears.  The common justification provided is to “maximize the learning” for the individual and that an appropriate level of objectivity can be maintained if sufficient oversight is provided.  

               

              Would you like to weigh in on the issue?    Any expert opinion you might care to share would be appreciated.


              How should I reply?

               

               

              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.

               


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              may be unlawful and is strictly prohibited.  

              AVIS D'INFORMATION CONFIDENTIELLE ET PRIVILÉGIÉE

              Le présent courriel, et toute pièce jointe, peut contenir de 
              l'information qui est confidentielle, régie par les droits 
              d'auteur, ou interdite de divulgation. Tout examen, 
              divulgation, retransmission, diffusion ou autres utilisations 
              non autorisées de l'information ou dépendance non autorisée 
              envers celle-ci peut être illégale et est strictement interdite.
            • Arsenault, Gerry
              UNRESTRICTED | ILLIMITÉ Bill, Very interesting. I will forward your information to our rooticians for discussion. I would have thought perpetrator
              Message 6 of 26 , Feb 2, 2010
              • 0 Attachment

                UNRESTRICTED | ILLIMITÉ

                 

                Bill,

                Very interesting. I will forward your information to our rooticians for discussion.

                 

                I would have thought perpetrator participation as a team member would most likely be a hinderance to the process.  

                G.

                 

                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: Tuesday, February 02, 2010 10:18 AM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

                 

                 

                Gerry,

                 

                I have a lot of experience with perpetrators participating as investigators.

                 

                This experience is at Susquehanna, Millstone, LaSalle, Calvert Cliffs, Zion and other high hazard industry activities.

                 

                In all cases it appeared to me that the products of the investigation were better with perpetrators participating as investigators than they otherwise would have been. This was true even when with perpetrators participating as investigators impeded the investigation.

                 

                The perpetrators are invaluable in fleshing out the Missed Opportunity Matrix, the Barrier Analysis Matrix, and the Change/Difference Analysis. Many perpetrators request that they be entered in the Missed Opportunity Matrix.

                 

                I have no experience with a perpetrator as an investigation team leader except in some cases outside the nuclear industry in which the investigation team leader was a high level official who was one of the people on the Missed Opportunity Matrix.  These high level officials included a Corporate Safety VP, a CFO, a Company President, and an Executive Vice President.

                 

                I can recall one case of an investigation with perpetrators participating as investigators in which the perpetrator obstructed the investigation. In this case, the sponsor and the other investigators pressured and worked around the obstructor.

                 

                In another case the investigation team I was on represented a government regulatory agency that supplied all of the members. Several team member regulators could have surfaced the problem at an earlier, better, cheaper, safer opportunity, but didn't. They learned nothing that I could see, but did not impede the investigation.

                 

                In another case team members belonged to the QA Department. They had very difficult times seeing that they were part of the problem.

                 

                In all other cases each of the perpetrators found out that they could have singlehandedly prevented the event and that they allowed themselves to be set up for their own dysfunctional behavior.

                 

                Most perpetrators participating as investigators seem to realize that their appointment to the investigation team is an opportunity to show that "they got it" or not. Management can use the appointment as a 'second chance" or as an opportunity to see the true colors of the perpetrator(s). This doesn't work all the time when management doesn't "get 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/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, 2/2/10, Arsenault, Gerry <arsenaultg@...> wrote:


                From: Arsenault, Gerry <arsenaultg@...>
                Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Date: Tuesday, February 2, 2010, 10:06 AM

                 

                UNRESTRICTED | ILLIMITÉ

                 

                We do not normally include them on the investigating team, but they would likely be interviewed by the team in gathering the facts surrounding  the events, particularly if they are the SME.

                G.

                 

                From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Jim Bryant
                Sent: Monday, February 01, 2010 2:41 PM
                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                Subject: Re: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                 

                 

                 

                I heard a rumor from a good source that there was a a number of sailors that were over exposed during a refueling at EB, maybe back in the 60s.  Does anyone recall this incident or what might have caused former sailors to think they were over exposed.  There is a possibility of a cancer lawsuit.  It doesn't sound right to me, especially with the care taken during refueling to prevent such an incident.

                Jim Bryant

                 


                From: DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>
                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                Sent: Mon, February 1, 2010 12:57:00 PM
                Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                 

                Thanks, Gerry,

                 

                What is your experience using perpetrators as investigators?

                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, 2/1/10, Arsenault, Gerry <arsenaultg@aecl. ca> wrote:


                From: Arsenault, Gerry <arsenaultg@aecl. ca>
                Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators
                To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                Date: Monday, February 1, 2010, 11:09 AM

                 

                UNRESTRICTED | ILLIMITÉ

                 

                I believe it depends in large part  on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch the KPI’s mentality that prevails? This will have a direct impact on whether or not an individual will be able to provide objective input in the investigation. Objectivity on the part on the part of the investigating team is very important if effective corrective actions are to be put in place. I have struggled with this idea since I began as an analyst . Even though I am in an oversight role as an investigator, I still work for the same employer as  the people who were involved in the event. Our biases make us the individuals that we are, we can’t get away from that, the wonders of individuality.  Not that I can’t be objective, rather how can I maintain an appropriate level of objectivity that will allow me to see the issues and recognize the real factors  and pursue them by asking the tough questions. This means that sometimes, a firm stand must be taken when factors that are clearly identified are being resisted by senior managers. All team members must be ready to take this approach or else it becomes an exercise in futility.

                 

                Just my thoughts.

                Gerry A.

                 

                 

                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: Saturday, January 30, 2010 6:21 AM
                To: Dr. Bill Corcoran
                Subject: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                 

                 

                Colleague,

                 

                A correspondent asked me the following:

                 


                 

                The management team here at my facility routinely assigns individuals directly involved in events as members of the team analyzing the event, and occasionally as the lead for the assessment. 

                 

                I have pointed out that this practice can significantly interfere with the objectivity of the analysis leading to misidentification of cause, leading to ineffective corrective actions and that potential for this to happen far out weights any potential benefit obtained from enhanced learning through direct involvement in the analysis.   Thus far my objection to this practice has fell on deaf ears.  The common justification provided is to “maximize the learning” for the individual and that an appropriate level of objectivity can be maintained if sufficient oversight is provided.  

                 

                Would you like to weigh in on the issue?    Any expert opinion you might care to share would be appreciated.


                How should I reply?

                 

                 

                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.

                 


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                This e-mail, and any attachments, may contain information that
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                non autorisées de l'information ou dépendance non autorisée 
                envers celle-ci peut être illégale et est strictement interdite.

                 

                 


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                This e-mail, and any attachments, may contain information that
                is confidential, subject to copyright, or exempt from disclosure.
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                dissemination or other use of or reliance on this information 
                may be unlawful and is strictly prohibited.  

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                Le présent courriel, et toute pièce jointe, peut contenir de 
                l'information qui est confidentielle, régie par les droits 
                d'auteur, ou interdite de divulgation. Tout examen, 
                divulgation, retransmission, diffusion ou autres utilisations 
                non autorisées de l'information ou dépendance non autorisée 
                envers celle-ci peut être illégale et est strictement interdite.




                CONFIDENTIAL AND PRIVILEGED INFORMATION NOTICE

                This e-mail, and any attachments, may contain information that
                is confidential, subject to copyright, or exempt from disclosure.
                Any unauthorized review, disclosure, retransmission, 
                dissemination or other use of or reliance on this information 
                may be unlawful and is strictly prohibited.  

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                Le présent courriel, et toute pièce jointe, peut contenir de 
                l'information qui est confidentielle, régie par les droits 
                d'auteur, ou interdite de divulgation. Tout examen, 
                divulgation, retransmission, diffusion ou autres utilisations 
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                envers celle-ci peut être illégale et est strictement interdite.
              • Van Leuken, Mike
                Wouldn’t that depend on the “perp” and on the organizational culture as to whether they would be a help or a hindrance? I think that is part of what Bill
                Message 7 of 26 , Feb 2, 2010
                • 0 Attachment

                  Wouldn’t that depend on the “perp” and on the organizational culture as to whether they would be a help or a hindrance? I think that is part of what Bill was saying? If a person is much more interested in learning that dodging blame then they might be a good addition to the team especially if they know where the bodies (or some of the bodies) are buried, so to speak. Management directive cannot compel a person to learn or to help so, to me, that would not be a deciding factor because people can decide to either actively or passively thwart the investigation.

                   

                  Mike VL.

                   

                  From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Arsenault, Gerry
                  Sent: 2010 February 02 8:24 AM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Cc: Blackstock, Chris; Bromley, Colin; Campbell, Monique; Moir, Thomas; Sanders, Sharon; Smith, David W.
                  Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

                   

                   

                  UNRESTRICTED | ILLIMITÉ

                   

                  Bill,

                  Very interesting. I will forward your information to our rooticians for discussion.

                   

                  I would have thought perpetrator participation as a team member would most likely be a hinderance to the process.  

                  G.

                   

                  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: Tuesday, February 02, 2010 10:18 AM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

                   

                   

                  Gerry,

                   

                  I have a lot of experience with perpetrators participating as investigators.

                   

                  This experience is at Susquehanna, Millstone, LaSalle, Calvert Cliffs, Zion and other high hazard industry activities.

                   

                  In all cases it appeared to me that the products of the investigation were better with perpetrators participating as investigators than they otherwise would have been. This was true even when with perpetrators participating as investigators impeded the investigation.

                   

                  The perpetrators are invaluable in fleshing out the Missed Opportunity Matrix, the Barrier Analysis Matrix, and the Change/Difference Analysis. Many perpetrators request that they be entered in the Missed Opportunity Matrix.

                   

                  I have no experience with a perpetrator as an investigation team leader except in some cases outside the nuclear industry in which the investigation team leader was a high level official who was one of the people on the Missed Opportunity Matrix.  These high level officials included a Corporate Safety VP, a CFO, a Company President, and an Executive Vice President.

                   

                  I can recall one case of an investigation with perpetrators participating as investigators in which the perpetrator obstructed the investigation. In this case, the sponsor and the other investigators pressured and worked around the obstructor.

                   

                  In another case the investigation team I was on represented a government regulatory agency that supplied all of the members. Several team member regulators could have surfaced the problem at an earlier, better, cheaper, safer opportunity, but didn't. They learned nothing that I could see, but did not impede the investigation.

                   

                  In another case team members belonged to the QA Department. They had very difficult times seeing that they were part of the problem.

                   

                  In all other cases each of the perpetrators found out that they could have singlehandedly prevented the event and that they allowed themselves to be set up for their own dysfunctional behavior.

                   

                  Most perpetrators participating as investigators seem to realize that their appointment to the investigation team is an opportunity to show that "they got it" or not. Management can use the appointment as a 'second chance" or as an opportunity to see the true colors of the perpetrator(s). This doesn't work all the time when management doesn't "get 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/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, 2/2/10, Arsenault, Gerry <arsenaultg@...> wrote:


                  From: Arsenault, Gerry <arsenaultg@...>
                  Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Date: Tuesday, February 2, 2010, 10:06 AM

                   

                  UNRESTRICTED | ILLIMITÉ

                   

                  We do not normally include them on the investigating team, but they would likely be interviewed by the team in gathering the facts surrounding  the events, particularly if they are the SME.

                  G.

                   

                  From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Jim Bryant
                  Sent: Monday, February 01, 2010 2:41 PM
                  To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                  Subject: Re: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                   

                   

                   

                  I heard a rumor from a good source that there was a a number of sailors that were over exposed during a refueling at EB, maybe back in the 60s.  Does anyone recall this incident or what might have caused former sailors to think they were over exposed.  There is a possibility of a cancer lawsuit.  It doesn't sound right to me, especially with the care taken during refueling to prevent such an incident.

                  Jim Bryant

                   


                  From: DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>
                  To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                  Sent: Mon, February 1, 2010 12:57:00 PM
                  Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                   

                  Thanks, Gerry,

                   

                  What is your experience using perpetrators as investigators?

                  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, 2/1/10, Arsenault, Gerry <arsenaultg@aecl. ca> wrote:


                  From: Arsenault, Gerry <arsenaultg@aecl. ca>
                  Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators
                  To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                  Date: Monday, February 1, 2010, 11:09 AM

                   

                  UNRESTRICTED | ILLIMITÉ

                   

                  I believe it depends in large part  on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch the KPI’s mentality that prevails? This will have a direct impact on whether or not an individual will be able to provide objective input in the investigation. Objectivity on the part on the part of the investigating team is very important if effective corrective actions are to be put in place. I have struggled with this idea since I began as an analyst . Even though I am in an oversight role as an investigator, I still work for the same employer as  the people who were involved in the event. Our biases make us the individuals that we are, we can’t get away from that, the wonders of individuality.  Not that I can’t be objective, rather how can I maintain an appropriate level of objectivity that will allow me to see the issues and recognize the real factors  and pursue them by asking the tough questions. This means that sometimes, a firm stand must be taken when factors that are clearly identified are being resisted by senior managers. All team members must be ready to take this approach or else it becomes an exercise in futility.

                   

                  Just my thoughts.

                  Gerry A.

                   

                   

                  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: Saturday, January 30, 2010 6:21 AM
                  To: Dr. Bill Corcoran
                  Subject: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                   

                   

                  Colleague,

                   

                  A correspondent asked me the following:

                   


                   

                  The management team here at my facility routinely assigns individuals directly involved in events as members of the team analyzing the event, and occasionally as the lead for the assessment. 

                   

                  I have pointed out that this practice can significantly interfere with the objectivity of the analysis leading to misidentification of cause, leading to ineffective corrective actions and that potential for this to happen far out weights any potential benefit obtained from enhanced learning through direct involvement in the analysis.   Thus far my objection to this practice has fell on deaf ears.  The common justification provided is to “maximize the learning” for the individual and that an appropriate level of objectivity can be maintained if sufficient oversight is provided.  

                   

                  Would you like to weigh in on the issue?    Any expert opinion you might care to share would be appreciated.


                  How should I reply?

                   

                   

                  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.

                   


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                • Noga, Scott T
                  My opinion: A perp on the team has the potential to bring a bias to the team. The same is true of other team members who may swing in a different direction.
                  Message 8 of 26 , Feb 2, 2010
                  • 0 Attachment

                    My opinion:

                     

                    A perp on the team has the potential to bring a bias to the team.  The same is true of other team members who may swing in a different direction.  Everyone has certain biases for a variety of reasons.  The purpose of the cause analysis methodology is to eliminate bias.  The purpose of having multiple team members is to eliminate bias.  If a perp sways the output of the team, or there is a concern that a perp could sway the output of the team, then I would seriously question the robustness of the investigative and analytical methodology that the company relies upon.  It should be able to withstand such challenges and the role of the analyst is to ensure that a sound methodology is strictly adhered to and logic prevails, supported by hard evidence.

                     

                    It’s been my experience that having a perp participant can open their eyes to the inescapable logic and enhance the buy-in.  The same might occur when the perp digests the final report but being a participant in how the team got there seems to aid digestion – not to mention they feel the pain of the whole process rather than sitting on the sideline. ;-)

                     

                    Bottom line is I can work either way, with or without a perp on the team.  I don’t go out of my way to include or exclude.  Normally I am grateful for every body I can get on the team – the more the better – and the rest I will interview.

                     

                     

                    Scott Noga

                    Risk Management Program

                    WRPS

                    ph. 509/373-1484

                     

                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Arsenault, Gerry
                    Sent: Tuesday, February 02, 2010 7:24 AM
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Cc: Blackstock, Chris; Bromley, Colin; Campbell, Monique; Moir, Thomas; Sanders, Sharon; Smith, David W.
                    Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

                     

                     

                    UNRESTRICTED | ILLIMITÉ

                     

                    Bill,

                    Very interesting. I will forward your information to our rooticians for discussion.

                     

                    I would have thought perpetrator participation as a team member would most likely be a hinderance to the process.  

                    G.

                     

                    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: Tuesday, February 02, 2010 10:18 AM
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators

                     

                     

                    Gerry,

                     

                    I have a lot of experience with perpetrators participating as investigators.

                     

                    This experience is at Susquehanna, Millstone, LaSalle, Calvert Cliffs, Zion and other high hazard industry activities.

                     

                    In all cases it appeared to me that the products of the investigation were better with perpetrators participating as investigators than they otherwise would have been. This was true even when with perpetrators participating as investigators impeded the investigation.

                     

                    The perpetrators are invaluable in fleshing out the Missed Opportunity Matrix, the Barrier Analysis Matrix, and the Change/Difference Analysis. Many perpetrators request that they be entered in the Missed Opportunity Matrix.

                     

                    I have no experience with a perpetrator as an investigation team leader except in some cases outside the nuclear industry in which the investigation team leader was a high level official who was one of the people on the Missed Opportunity Matrix.  These high level officials included a Corporate Safety VP, a CFO, a Company President, and an Executive Vice President.

                     

                    I can recall one case of an investigation with perpetrators participating as investigators in which the perpetrator obstructed the investigation. In this case, the sponsor and the other investigators pressured and worked around the obstructor.

                     

                    In another case the investigation team I was on represented a government regulatory agency that supplied all of the members. Several team member regulators could have surfaced the problem at an earlier, better, cheaper, safer opportunity, but didn't. They learned nothing that I could see, but did not impede the investigation.

                     

                    In another case team members belonged to the QA Department. They had very difficult times seeing that they were part of the problem.

                     

                    In all other cases each of the perpetrators found out that they could have singlehandedly prevented the event and that they allowed themselves to be set up for their own dysfunctional behavior.

                     

                    Most perpetrators participating as investigators seem to realize that their appointment to the investigation team is an opportunity to show that "they got it" or not. Management can use the appointment as a 'second chance" or as an opportunity to see the true colors of the perpetrator(s). This doesn't work all the time when management doesn't "get 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


                    --- On Tue, 2/2/10, Arsenault, Gerry <arsenaultg@...> wrote:


                    From: Arsenault, Gerry <arsenaultg@...>
                    Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Date: Tuesday, February 2, 2010, 10:06 AM

                     

                    UNRESTRICTED | ILLIMITÉ

                     

                    We do not normally include them on the investigating team, but they would likely be interviewed by the team in gathering the facts surrounding  the events, particularly if they are the SME.

                    G.

                     

                    From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Jim Bryant
                    Sent: Monday, February 01, 2010 2:41 PM
                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                    Subject: Re: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                     

                      

                    I heard a rumor from a good source that there was a a number of sailors that were over exposed during a refueling at EB, maybe back in the 60s.  Does anyone recall this incident or what might have caused former sailors to think they were over exposed.  There is a possibility of a cancer lawsuit.  It doesn't sound right to me, especially with the care taken during refueling to prevent such an incident.

                    Jim Bryant

                     


                    From: DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>
                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                    Sent: Mon, February 1, 2010 12:57:00 PM
                    Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                     

                    Thanks, Gerry,

                     

                    What is your experience using perpetrators as investigators?

                    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


                    --- On Mon, 2/1/10, Arsenault, Gerry <arsenaultg@aecl. ca> wrote:


                    From: Arsenault, Gerry <arsenaultg@aecl. ca>
                    Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators
                    To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                    Date: Monday, February 1, 2010, 11:09 AM

                     

                    UNRESTRICTED | ILLIMITÉ

                     

                    I believe it depends in large part  on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch the KPI’s mentality that prevails? This will have a direct impact on whether or not an individual will be able to provide objective input in the investigation. Objectivity on the part on the part of the investigating team is very important if effective corrective actions are to be put in place. I have struggled with this idea since I began as an analyst . Even though I am in an oversight role as an investigator, I still work for the same employer as  the people who were involved in the event. Our biases make us the individuals that we are, we can’t get away from that, the wonders of individuality.  Not that I can’t be objective, rather how can I maintain an appropriate level of objectivity that will allow me to see the issues and recognize the real factors  and pursue them by asking the tough questions. This means that sometimes, a firm stand must be taken when factors that are clearly identified are being resisted by senior managers. All team members must be ready to take this approach or else it becomes an exercise in futility.

                     

                    Just my thoughts.

                    Gerry A.

                     

                     

                    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: Saturday, January 30, 2010 6:21 AM
                    To: Dr. Bill Corcoran
                    Subject: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                     

                     

                    Colleague,

                     

                    A correspondent asked me the following:

                     


                     

                    The management team here at my facility routinely assigns individuals directly involved in events as members of the team analyzing the event, and occasionally as the lead for the assessment. 

                     

                    I have pointed out that this practice can significantly interfere with the objectivity of the analysis leading to misidentification of cause, leading to ineffective corrective actions and that potential for this to happen far out weights any potential benefit obtained from enhanced learning through direct involvement in the analysis.   Thus far my objection to this practice has fell on deaf ears.  The common justification provided is to “maximize the learning” for the individual and that an appropriate level of objectivity can be maintained if sufficient oversight is provided.  

                     

                    Would you like to weigh in on the issue?    Any expert opinion you might care to share would be appreciated.


                    How should I reply?

                     

                     

                    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

                     

                     

                     

                    .

                    Image removed by sender.

                  • DR WILLIAM CORCORAN
                    Scott, Thanks. That s the way I see it. OBTW: In most real cases the investigators of previous events were perps , in that if they had found and gotten
                    Message 9 of 26 , Feb 2, 2010
                    • 0 Attachment
                      Scott,

                      Thanks.

                      That's the way I see it.

                      OBTW: In most real cases the investigators of previous events were "perps", in that if they had found and gotten attention to the factors of the previous events and the extents of them this event would not have happened.

                      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, 2/2/10, Noga, Scott T <scott_t_noga@...> wrote:

                      From: Noga, Scott T <scott_t_noga@...>
                      Subject: RE: [Root_Cause_State_of_the_Practice] Perpetrators as Investigators
                      To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                      Cc: "Blackstock, Chris" <blackstc@...>, "Bromley, Colin" <bromleyc@...>, "Campbell, Monique" <campbema@...>, "Moir, Thomas" <moirt@...>, "Sanders, Sharon" <sanderss@...>, "Smith, David W." <smithdw@...>
                      Date: Tuesday, February 2, 2010, 1:07 PM

                       

                      My opinion:

                       

                      A perp on the team has the potential to bring a bias to the team.  The same is true of other team members who may swing in a different direction.  Everyone has certain biases for a variety of reasons.  The purpose of the cause analysis methodology is to eliminate bias.  The purpose of having multiple team members is to eliminate bias.  If a perp sways the output of the team, or there is a concern that a perp could sway the output of the team, then I would seriously question the robustness of the investigative and analytical methodology that the company relies upon.  It should be able to withstand such challenges and the role of the analyst is to ensure that a sound methodology is strictly adhered to and logic prevails, supported by hard evidence.

                       

                      It’s been my experience that having a perp participant can open their eyes to the inescapable logic and enhance the buy-in.  The same might occur when the perp digests the final report but being a participant in how the team got there seems to aid digestion – not to mention they feel the pain of the whole process rather than sitting on the sideline. ;-)

                       

                      Bottom line is I can work either way, with or without a perp on the team.  I don’t go out of my way to include or exclude.  Normally I am grateful for every body I can get on the team – the more the better – and the rest I will interview.

                       

                       

                      Scott Noga

                      Risk Management Program

                      WRPS

                      ph. 509/373-1484

                       

                      From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Arsenault, Gerry
                      Sent: Tuesday, February 02, 2010 7:24 AM
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Cc: Blackstock, Chris; Bromley, Colin; Campbell, Monique; Moir, Thomas; Sanders, Sharon; Smith, David W.
                      Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                       

                       

                      UNRESTRICTED | ILLIMITÉ

                       

                      Bill,

                      Very interesting. I will forward your information to our rooticians for discussion.

                       

                      I would have thought perpetrator participation as a team member would most likely be a hinderance to the process.  

                      G.

                       

                      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: Tuesday, February 02, 2010 10:18 AM
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                       

                       

                      Gerry,

                       

                      I have a lot of experience with perpetrators participating as investigators.

                       

                      This experience is at Susquehanna, Millstone, LaSalle, Calvert Cliffs, Zion and other high hazard industry activities.

                       

                      In all cases it appeared to me that the products of the investigation were better with perpetrators participating as investigators than they otherwise would have been. This was true even when with perpetrators participating as investigators impeded the investigation.

                       

                      The perpetrators are invaluable in fleshing out the Missed Opportunity Matrix, the Barrier Analysis Matrix, and the Change/Difference Analysis. Many perpetrators request that they be entered in the Missed Opportunity Matrix.

                       

                      I have no experience with a perpetrator as an investigation team leader except in some cases outside the nuclear industry in which the investigation team leader was a high level official who was one of the people on the Missed Opportunity Matrix.  These high level officials included a Corporate Safety VP, a CFO, a Company President, and an Executive Vice President.

                       

                      I can recall one case of an investigation with perpetrators participating as investigators in which the perpetrator obstructed the investigation. In this case, the sponsor and the other investigators pressured and worked around the obstructor.

                       

                      In another case the investigation team I was on represented a government regulatory agency that supplied all of the members. Several team member regulators could have surfaced the problem at an earlier, better, cheaper, safer opportunity, but didn't. They learned nothing that I could see, but did not impede the investigation.

                       

                      In another case team members belonged to the QA Department. They had very difficult times seeing that they were part of the problem.

                       

                      In all other cases each of the perpetrators found out that they could have singlehandedly prevented the event and that they allowed themselves to be set up for their own dysfunctional behavior.

                       

                      Most perpetrators participating as investigators seem to realize that their appointment to the investigation team is an opportunity to show that "they got it" or not. Management can use the appointment as a 'second chance" or as an opportunity to see the true colors of the perpetrator( s). This doesn't work all the time when management doesn't "get 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


                      --- On Tue, 2/2/10, Arsenault, Gerry <arsenaultg@aecl. ca> wrote:


                      From: Arsenault, Gerry <arsenaultg@aecl. ca>
                      Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Date: Tuesday, February 2, 2010, 10:06 AM

                       

                      UNRESTRICTED | ILLIMITÉ

                       

                      We do not normally include them on the investigating team, but they would likely be interviewed by the team in gathering the facts surrounding  the events, particularly if they are the SME.

                      G.

                       

                      From: Root_Cause_State_ of_the_Practice@ yahoogroups. com [mailto:Root_ Cause_State_ of_the_Practice@ yahoogroups. com] On Behalf Of Jim Bryant
                      Sent: Monday, February 01, 2010 2:41 PM
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Subject: Re: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                       

                        

                      I heard a rumor from a good source that there was a a number of sailors that were over exposed during a refueling at EB, maybe back in the 60s.  Does anyone recall this incident or what might have caused former sailors to think they were over exposed.  There is a possibility of a cancer lawsuit.  It doesn't sound right to me, especially with the care taken during refueling to prevent such an incident.

                      Jim Bryant

                       


                      From: DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Sent: Mon, February 1, 2010 12:57:00 PM
                      Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                       

                      Thanks, Gerry,

                       

                      What is your experience using perpetrators as investigators?

                      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


                      --- On Mon, 2/1/10, Arsenault, Gerry <arsenaultg@aecl. ca> wrote:


                      From: Arsenault, Gerry <arsenaultg@aecl. ca>
                      Subject: RE: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators
                      To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                      Date: Monday, February 1, 2010, 11:09 AM

                       

                      UNRESTRICTED | ILLIMITÉ

                       

                      I believe it depends in large part  on the culture that is prevalent. Is it a learning organization or a “get’er done” and watch the KPI’s mentality that prevails? This will have a direct impact on whether or not an individual will be able to provide objective input in the investigation. Objectivity on the part on the part of the investigating team is very important if effective corrective actions are to be put in place. I have struggled with this idea since I began as an analyst . Even though I am in an oversight role as an investigator, I still work for the same employer as  the people who were involved in the event. Our biases make us the individuals that we are, we can’t get away from that, the wonders of individuality.  Not that I can’t be objective, rather how can I maintain an appropriate level of objectivity that will allow me to see the issues and recognize the real factors  and pursue them by asking the tough questions. This means that sometimes, a firm stand must be taken when factors that are clearly identified are being resisted by senior managers. All team members must be ready to take this approach or else it becomes an exercise in futility.

                       

                      Just my thoughts.

                      Gerry A.

                       

                       

                      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: Saturday, January 30, 2010 6:21 AM
                      To: Dr. Bill Corcoran
                      Subject: [Root_Cause_ State_of_ the_Practice] Perpetrators as Investigators

                       

                       

                      Colleague,

                       

                      A correspondent asked me the following:

                       


                       

                      The management team here at my facility routinely assigns individuals directly involved in events as members of the team analyzing the event, and occasionally as the lead for the assessment. 

                       

                      I have pointed out that this practice can significantly interfere with the objectivity of the analysis leading to misidentification of cause, leading to ineffective corrective actions and that potential for this to happen far out weights any potential benefit obtained from enhanced learning through direct involvement in the analysis.   Thus far my objection to this practice has fell on deaf ears.  The common justification provided is to “maximize the learning” for the individual and that an appropriate level of objectivity can be maintained if sufficient oversight is provided.  

                       

                      Would you like to weigh in on the issue?    Any expert opinion you might care to share would be appreciated.


                      How should I reply?

                       

                       

                      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

                       

                       

                       

                      .

                      Image removed by sender.

                    • Michael Mulligan
                      Wolf Creek?     Wow, did you see last year’s loss of all offsite power at Wolf Creek, the second one in but a few mouths. this is a brand new report. The
                      Message 10 of 26 , Feb 2, 2010
                      • 0 Attachment

                        Wolf Creek?

                         

                         

                        Wow, did you see last year’s loss of all offsite power at Wolf Creek, the second one in but a few mouths. this is a brand new report. The essential cooling water lines were corroded...that supplied a Diesel Generator....a water hammer event occurred during the loss of all off site power, a lightning strike... and they weren’t far from losing both Diesel Generators. Can you imagine a US nuclear plant being with any electrcity for 8 hours?

                         

                        Weren’t we talking about Wolf Creek last year banging on a boron injection safety check valves with a hammer to unleak them. You could tell by the inspection report and that the employees were distrustful to the NRC. I am convinced the inspector’s wording was a warning for bigger accidents to come...you can’t get a accident much worst than this. That is what I thought, a big accident is on the way if they don’t get a handle on this plant.

                         

                        You want my opinion with what is going on here, predicted core damage and risk regulation is preventing us from seeing what a dangerous precipice we are sitting on?  

                            

                         

                        Mike

                         

                        February 2, 2010

                        Matthew W. Sunseri, President and

                        Chief Executive Officer

                        Wolf Creek Nuclear Operating Corporation

                        P. O. Box 411

                        Burlington, KS 66839

                        Subject: WOLF CREEK GENERATING STATION - NRC SPECIAL INSPECTION

                        REPORT 05000482/2009007

                        Dear Mr. Sunseri:

                        On December 4, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a special inspection at your Wolf Creek Generating Station. This inspection examined activities associated with the station’s performance during a loss of offsite power on August 19, 2009. The NRC’s initial evaluation of this issue, using the criteria in NRC Management Directive 8.3, “NRC Incident Investigation Program,” determined that the estimated Incremental Conditional Core Damage Probability was 6.1 x 10–6. This guided the NRC to charter and conduct a special inspection. The enclosed report documents the inspection results, which were discussed at the exit meeting on December 22, 2009, with you and other members of your staff. The inspection examined activities conducted under your license as they relate to safety and compliance with the Commission’s rules and regulations and with the conditions of your license. The inspection team reviewed selected procedures and records, observed activities, and interviewed personnel. This report documents seven NRC-identified and self-revealing findings of very low safety significance (Green). Six of these findings were determined to involve violations of NRC requirements. Additionally, one licensee-identified violation, which was determined to be of very low safety significance, is listed in this report.

                         

                         

                         


                      • DR WILLIAM CORCORAN
                        Mike, Do you have links for the documentation? Take care,   Bill Corcoran Mission: Saving lives, pain, assets, and careers through thoughtful inquiry. Motto:
                        Message 11 of 26 , Feb 2, 2010
                        • 0 Attachment
                          Mike,

                          Do you have links for the documentation?

                          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, 2/2/10, Michael Mulligan <steamshovel2002@...> wrote:

                          From: Michael Mulligan <steamshovel2002@...>
                          Subject: [Root_Cause_State_of_the_Practice] Wolf Creek's near miss.
                          To: Root_Cause_State_of_the_Practice@yahoogroups.com
                          Date: Tuesday, February 2, 2010, 3:29 PM

                           

                          Wolf Creek?

                           

                           

                          Wow, did you see last year’s loss of all offsite power at Wolf Creek, the second one in but a few mouths. this is a brand new report. The essential cooling water lines were corroded...that supplied a Diesel Generator... .a water hammer event occurred during the loss of all off site power, a lightning strike... and they weren’t far from losing both Diesel Generators. Can you imagine a US nuclear plant being with any electrcity for 8 hours?

                           

                          Weren’t we talking about Wolf Creek last year banging on a boron injection safety check valves with a hammer to unleak them. You could tell by the inspection report and that the employees were distrustful to the NRC. I am convinced the inspector’s wording was a warning for bigger accidents to come...you can’t get a accident much worst than this. That is what I thought, a big accident is on the way if they don’t get a handle on this plant.

                           

                          You want my opinion with what is going on here, predicted core damage and risk regulation is preventing us from seeing what a dangerous precipice we are sitting on?  

                              

                           

                          Mike

                           

                          February 2, 2010

                          Matthew W. Sunseri, President and

                          Chief Executive Officer

                          Wolf Creek Nuclear Operating Corporation

                          P. O. Box 411

                          Burlington, KS 66839

                          Subject: WOLF CREEK GENERATING STATION - NRC SPECIAL INSPECTION

                          REPORT 05000482/2009007

                          Dear Mr. Sunseri:

                          On December 4, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a special inspection at your Wolf Creek Generating Station. This inspection examined activities associated with the station’s performance during a loss of offsite power on August 19, 2009. The NRC’s initial evaluation of this issue, using the criteria in NRC Management Directive 8.3, “NRC Incident Investigation Program,” determined that the estimated Incremental Conditional Core Damage Probability was 6.1 x 10–6. This guided the NRC to charter and conduct a special inspection. The enclosed report documents the inspection results, which were discussed at the exit meeting on December 22, 2009, with you and other members of your staff. The inspection examined activities conducted under your license as they relate to safety and compliance with the Commission’s rules and regulations and with the conditions of your license. The inspection team reviewed selected procedures and records, observed activities, and interviewed personnel. This report documents seven NRC-identified and self-revealing findings of very low safety significance (Green). Six of these findings were determined to involve violations of NRC requirements. Additionally, one licensee-identified violation, which was determined to be of very low safety significance, is listed in this report.

                           

                           

                           


                        • Michael Mulligan
                          Bill, Bill, You got to be kidding, I been pulling my hair out with the new and improved public Adams for two days now. It is just torture. The NRC site usually
                          Message 12 of 26 , Feb 2, 2010
                          • 0 Attachment
                            Bill,
                             
                            Bill,
                             
                            You got to be kidding, I been pulling my hair out with the new and improved public Adams for two days now. It is just torture.
                            The NRC site usually breaks the link.
                             
                            I'll try.
                             
                            mike

                            From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            Sent: Tue, February 2, 2010 3:53:23 PM
                            Subject: Re: [Root_Cause_State_of_the_Practice] Wolf Creek's near miss.

                             

                            Mike,

                            Do you have links for the documentation?

                            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, 2/2/10, Michael Mulligan <steamshovel2002@ yahoo.com> wrote:

                            From: Michael Mulligan <steamshovel2002@ yahoo.com>
                            Subject: [Root_Cause_ State_of_ the_Practice] Wolf Creek's near miss.
                            To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                            Date: Tuesday, February 2, 2010, 3:29 PM

                             

                            Wolf Creek?

                             

                             

                            Wow, did you see last year’s loss of all offsite power at Wolf Creek, the second one in but a few mouths. this is a brand new report. The essential cooling water lines were corroded...that supplied a Diesel Generator... .a water hammer event occurred during the loss of all off site power, a lightning strike... and they weren’t far from losing both Diesel Generators. Can you imagine a US nuclear plant being with any electrcity for 8 hours?

                             

                            Weren’t we talking about Wolf Creek last year banging on a boron injection safety check valves with a hammer to unleak them. You could tell by the inspection report and that the employees were distrustful to the NRC. I am convinced the inspector’s wording was a warning for bigger accidents to come...you can’t get a accident much worst than this. That is what I thought, a big accident is on the way if they don’t get a handle on this plant.

                             

                            You want my opinion with what is going on here, predicted core damage and risk regulation is preventing us from seeing what a dangerous precipice we are sitting on?  

                                

                             

                            Mike

                             

                            February 2, 2010

                            Matthew W. Sunseri, President and

                            Chief Executive Officer

                            Wolf Creek Nuclear Operating Corporation

                            P. O. Box 411

                            Burlington, KS 66839

                            Subject: WOLF CREEK GENERATING STATION - NRC SPECIAL INSPECTION

                            REPORT 05000482/2009007

                            Dear Mr. Sunseri:

                            On December 4, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a special inspection at your Wolf Creek Generating Station. This inspection examined activities associated with the station’s performance during a loss of offsite power on August 19, 2009. The NRC’s initial evaluation of this issue, using the criteria in NRC Management Directive 8.3, “NRC Incident Investigation Program,” determined that the estimated Incremental Conditional Core Damage Probability was 6.1 x 10–6. This guided the NRC to charter and conduct a special inspection. The enclosed report documents the inspection results, which were discussed at the exit meeting on December 22, 2009, with you and other members of your staff. The inspection examined activities conducted under your license as they relate to safety and compliance with the Commission’s rules and regulations and with the conditions of your license. The inspection team reviewed selected procedures and records, observed activities, and interviewed personnel. This report documents seven NRC-identified and self-revealing findings of very low safety significance (Green). Six of these findings were determined to involve violations of NRC requirements. Additionally, one licensee-identified violation, which was determined to be of very low safety significance, is listed in this report.

                             

                             

                             



                          • Michael Mulligan
                            Bill, I frame the communication with the NRC as a whole...as inhibiting public participation with the NRC and the licencing conditions surround any nuclear
                            Message 13 of 26 , Feb 2, 2010
                            Bill,
                             
                            I frame the communication with the NRC as a whole...as inhibiting public participation with the NRC and the licencing conditions surround any nuclear plant.
                             
                            I can't find a link...I should be about get a link to any NRC documnent I want and it should be easy to get.
                             
                            Here is the report.
                             
                            Mike
                             
                            Mike

                             


                            From: Michael Mulligan <steamshovel2002@...>
                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            Sent: Tue, February 2, 2010 4:29:06 PM
                            Subject: Re: [Root_Cause_State_of_the_Practice] Wolf Creek's near miss.

                             

                            Bill,
                             
                            Bill,
                             
                            You got to be kidding, I been pulling my hair out with the new and improved public Adams for two days now. It is just torture.
                            The NRC site usually breaks the link.
                             
                            I'll try.
                             
                            mike

                            From: DR WILLIAM CORCORAN <William.R.Corcoran@ 1959.USNA. com>
                            To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                            Sent: Tue, February 2, 2010 3:53:23 PM
                            Subject: Re: [Root_Cause_ State_of_ the_Practice] Wolf Creek's near miss.

                             

                            Mike,

                            Do you have links for the documentation?

                            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, 2/2/10, Michael Mulligan <steamshovel2002@ yahoo.com> wrote:

                            From: Michael Mulligan <steamshovel2002@ yahoo.com>
                            Subject: [Root_Cause_ State_of_ the_Practice] Wolf Creek's near miss.
                            To: Root_Cause_State_ of_the_Practice@ yahoogroups. com
                            Date: Tuesday, February 2, 2010, 3:29 PM

                             

                            Wolf Creek?

                             

                             

                            Wow, did you see last year’s loss of all offsite power at Wolf Creek, the second one in but a few mouths. this is a brand new report. The essential cooling water lines were corroded...that supplied a Diesel Generator... .a water hammer event occurred during the loss of all off site power, a lightning strike... and they weren’t far from losing both Diesel Generators. Can you imagine a US nuclear plant being with any electrcity for 8 hours?

                             

                            Weren’t we talking about Wolf Creek last year banging on a boron injection safety check valves with a hammer to unleak them. You could tell by the inspection report and that the employees were distrustful to the NRC. I am convinced the inspector’s wording was a warning for bigger accidents to come...you can’t get a accident much worst than this. That is what I thought, a big accident is on the way if they don’t get a handle on this plant.

                             

                            You want my opinion with what is going on here, predicted core damage and risk regulation is preventing us from seeing what a dangerous precipice we are sitting on?  

                                

                             

                            Mike

                             

                            February 2, 2010

                            Matthew W. Sunseri, President and

                            Chief Executive Officer

                            Wolf Creek Nuclear Operating Corporation

                            P. O. Box 411

                            Burlington, KS 66839

                            Subject: WOLF CREEK GENERATING STATION - NRC SPECIAL INSPECTION

                            REPORT 05000482/2009007

                            Dear Mr. Sunseri:

                            On December 4, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a special inspection at your Wolf Creek Generating Station. This inspection examined activities associated with the station’s performance during a loss of offsite power on August 19, 2009. The NRC’s initial evaluation of this issue, using the criteria in NRC Management Directive 8.3, “NRC Incident Investigation Program,” determined that the estimated Incremental Conditional Core Damage Probability was 6.1 x 10–6. This guided the NRC to charter and conduct a special inspection. The enclosed report documents the inspection results, which were discussed at the exit meeting on December 22, 2009, with you and other members of your staff. The inspection examined activities conducted under your license as they relate to safety and compliance with the Commission’s rules and regulations and with the conditions of your license. The inspection team reviewed selected procedures and records, observed activities, and interviewed personnel. This report documents seven NRC-identified and self-revealing findings of very low safety significance (Green). Six of these findings were determined to involve violations of NRC requirements. Additionally, one licensee-identified violation, which was determined to be of very low safety significance, is listed in this report.

                             

                             

                             




                          • emridgell@aep.com
                            http://adamswebsearch2.nrc.gov/idmws/doccontent.dll?library=PU_ADAMS^PBNTAD01&ID=100330259 DR WILLIAM CORCORAN Sent by:
                            Message 14 of 26 , Feb 3, 2010
                            • 0 Attachment

                              http://adamswebsearch2.nrc.gov/idmws/doccontent.dll?library=PU_ADAMS^PBNTAD01&ID=100330259




                              DR WILLIAM CORCORAN <William.R.Corcoran@...>
                              Sent by: Root_Cause_State_of_the_Practice@yahoogroups.com

                              02/02/2010 03:53 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] Wolf Creek's near miss.





                               

                              Mike,

                              Do you have links for the documentation?

                              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, 2/2/10, Michael Mulligan <steamshovel2002@...> wrote:


                              From: Michael Mulligan <steamshovel2002@...>
                              Subject: [Root_Cause_State_of_the_Practice] Wolf Creek's near miss.
                              To: Root_Cause_State_of_the_Practice@yahoogroups.com
                              Date: Tuesday, February 2, 2010, 3:29 PM

                               

                              Wolf Creek?

                               

                               

                              Wow, did you see last year’s loss of all offsite power at Wolf Creek, the second one in but a few mouths. this is a brand new report. The essential cooling water lines were corroded...that supplied a Diesel Generator... .a water hammer event occurred during the loss of all off site power, a lightning strike... and they weren’t far from losing both Diesel Generators. Can you imagine a US nuclear plant being with any electrcity for 8 hours?

                               

                              Weren’t we talking about Wolf Creek last year banging on a boron injection safety check valves with a hammer to unleak them. You could tell by the inspection report and that the employees were distrustful to the NRC. I am convinced the inspector’s wording was a warning for bigger accidents to come...you can’t get a accident much worst than this. That is what I thought, a big accident is on the way if they don’t get a handle on this plant.

                               

                              You want my opinion with what is going on here, predicted core damage and risk regulation is preventing us from seeing what a dangerous precipice we are sitting on?  

                                 

                               

                              Mike

                               

                              February 2, 2010

                              Matthew W. Sunseri, President and

                              Chief Executive Officer

                              Wolf Creek Nuclear Operating Corporation

                              P. O. Box 411

                              Burlington, KS 66839

                              Subject: WOLF CREEK GENERATING STATION - NRC SPECIAL INSPECTION

                              REPORT 05000482/2009007

                              Dear Mr. Sunseri:

                              On December 4, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a special inspection at your Wolf Creek Generating Station. This inspection examined activities associated with the station’s performance during a loss of offsite power on August 19, 2009. The NRC’s initial evaluation of this issue, using the criteria in NRC Management Directive 8.3, “NRC Incident Investigation Program,” determined that the estimated Incremental Conditional Core Damage Probability was 6.1 x 10–6. This guided the NRC to charter and conduct a special inspection. The enclosed report documents the inspection results, which were discussed at the exit meeting on December 22, 2009, with you and other members of your staff. The inspection examined activities conducted under your license as they relate to safety and compliance with the Commission’s rules and regulations and with the conditions of your license. The inspection team reviewed selected procedures and records, observed activities, and interviewed personnel. This report documents seven NRC-identified and self-revealing findings of very low safety significance (Green). Six of these findings were determined to involve violations of NRC requirements. Additionally, one licensee-identified violation, which was determined to be of very low safety significance, is listed in this report.

                               

                               

                               





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                            • bruce.hart@srs.gov
                              Bill, I have not had time to read the Repeat Issue Firebird, but happened to note as I skimmed through it the section on my page 7 An Abstract Repeat Event
                              Message 15 of 26 , Feb 3, 2010
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                                Bill,
                                I have not had time to read the Repeat Issue Firebird, but happened to note as I skimmed through it the section on my page 7  "An Abstract Repeat Event Story."  There are 2 options presented for why there are repeat events: 1) the harmful factors of Event A and its successors had not been identified by the investigators or 2) the corrective actions for them had not been identified as ineffective before they were implemented or afterwards.

                                Although you may have meant it as a subset of 2), I experience what to me is a third distinct problem.  Harmful factors are identified and documented in the RCA, but no CA is applied due to it being a perceived low threat, with a low risk of repeatability and/or consequence (cost/benefit decision), or "too hard" for the limits perceived to be on resources for CAs.

                                Thoughts?
                                Thanks,
                                B.


                              • rey_cloutier
                                I used to avoid them on the investigation team for obvious reasons. Then I read a book from Adam Kahane Solving Tough Problems . This is not a RCA book as
                                Message 16 of 26 , Feb 3, 2010
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                                  I used to avoid them on the investigation team for obvious reasons.

                                  Then I read a book from Adam Kahane "Solving Tough Problems". This is not a RCA book as most will expect as the style of problems being presented is how to successfully move out of apartheid! Nevertheless, one sentence is worth repeating: "If you are part of the problem, you should be part of the solution". Even (or especially) if the problem is big!

                                  For some reasons, this sentence has stuck with me and I've been adding "perpetrator" on the problem solving team. One rule I'm using to select members on the problem solving team is get people close to the work and/or to the problem.

                                  The following conditions must be met before inviting them to join the team:
                                  -Amnesty is granted
                                  -Having them on the problem solving team will lead to more transparency.
                                  -We need to understand the problem to the point that we will have act the same way the perpetrator did (Thanks to Bob Nelms!)

                                  I believe that the final solution(s) did benefit from their participation. I believe the team has learned more by having them on the team then if the perpetrators were "only" interviewed.

                                  I also strongly believe by NOT having the so-called "bad guy" on the problem solving team is leading to future implementation issues and low long term effectiveness of the solution.

                                  BTW, I will not use the term "perpetrator" when referring to them.

                                  Best regards,
                                  Rey
                                • Dillard, Tedd A (E S SF RNA FS 1 1 E)
                                  Rey, I agree with you and especially about the use of the term perpetrator . We may have an inside definition of the word that is benign but it carries too
                                  Message 17 of 26 , Feb 3, 2010
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                                    Rey,
                                    I agree with you and especially about the use of the term "perpetrator".
                                    We may have an inside definition of the word that is benign but it carries too much baggage I think.
                                    Besides as Dr. Bill has pointed out before we are all perpetrators if we have not been effective in preventing events.
                                    By this standard all upper management are perpetrators but we don't have the gall to call them that.
                                    The words we use do mean something.
                                    Unless there is overwhelming evidence that an individual deliberately did something they are only the sharp end of the stick.
                                    And should be treated the same and called the same as all other members of the organization.
                                    Tedd 


                                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of rey_cloutier
                                    Sent: Wednesday, February 03, 2010 4:06 PM
                                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                    Subject: [Root_Cause_State_of_the_Practice] Re: Perpetrators as Investigators

                                     

                                    I used to avoid them on the investigation team for obvious reasons.

                                    Then I read a book from Adam Kahane "Solving Tough Problems". This is not a RCA book as most will expect as the style of problems being presented is how to successfully move out of apartheid! Nevertheless, one sentence is worth repeating: "If you are part of the problem, you should be part of the solution". Even (or especially) if the problem is big!

                                    For some reasons, this sentence has stuck with me and I've been adding "perpetrator" on the problem solving team. One rule I'm using to select members on the problem solving team is get people close to the work and/or to the problem.

                                    The following conditions must be met before inviting them to join the team:
                                    -Amnesty is granted
                                    -Having them on the problem solving team will lead to more transparency.
                                    -We need to understand the problem to the point that we will have act the same way the perpetrator did (Thanks to Bob Nelms!)

                                    I believe that the final solution(s) did benefit from their participation. I believe the team has learned more by having them on the team then if the perpetrators were "only" interviewed.

                                    I also strongly believe by NOT having the so-called "bad guy" on the problem solving team is leading to future implementation issues and low long term effectiveness of the solution.

                                    BTW, I will not use the term "perpetrator" when referring to them.

                                    Best regards,
                                    Rey

                                  • Michael Mulligan
                                    Yea well, I know for a fact for most accidents and incidences the employees were talking about it 6 month or longer before it happened. They basically say,
                                    Message 18 of 26 , Feb 3, 2010
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                                      Yea well, I know for a fact for most accidents and incidences the employees were talking about it 6 month or longer before it happened. They basically say, they guess, this is how I think this thing or change is going to turn out. I have been in the group shoot the bull secession and have been astonished with how accurate they were.

                                       

                                      At the end of the day, people just don’t have the courage to follow their convictions. They have to have absolute triplicate proof of the outcome before they will take even the slightest risk.

                                       

                                      Mike  

                                       

                                       

                                       

                                       

                                       a


                                      From: rey_cloutier <rey_cloutier@...>
                                      To: Root_Cause_State_of_the_Practice@yahoogroups.com
                                      Sent: Wed, February 3, 2010 4:06:24 PM
                                      Subject: [Root_Cause_State_of_the_Practice] Re: Perpetrators as Investigators

                                       

                                      I used to avoid them on the investigation team for obvious reasons.

                                      Then I read a book from Adam Kahane "Solving Tough Problems". This is not a RCA book as most will expect as the style of problems being presented is how to successfully move out of apartheid! Nevertheless, one sentence is worth repeating: "If you are part of the problem, you should be part of the solution". Even (or especially) if the problem is big!

                                      For some reasons, this sentence has stuck with me and I've been adding "perpetrator" on the problem solving team. One rule I'm using to select members on the problem solving team is get people close to the work and/or to the problem.

                                      The following conditions must be met before inviting them to join the team:
                                      -Amnesty is granted
                                      -Having them on the problem solving team will lead to more transparency.
                                      -We need to understand the problem to the point that we will have act the same way the perpetrator did (Thanks to Bob Nelms!)

                                      I believe that the final solution(s) did benefit from their participation. I believe the team has learned more by having them on the team then if the perpetrators were "only" interviewed.

                                      I also strongly believe by NOT having the so-called "bad guy" on the problem solving team is leading to future implementation issues and low long term effectiveness of the solution.

                                      BTW, I will not use the term "perpetrator" when referring to them.

                                      Best regards,
                                      Rey


                                    • bruce.hart@srs.gov
                                      Mike, Although your last sentence might be a bit of an overstatement, I see the same thing you bring out in the last paragraph all too often in all venues. I
                                      Message 19 of 26 , Feb 4, 2010
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                                        Mike,
                                        Although your last sentence might be a bit of an overstatement, I see the same thing you bring out in the last paragraph all too often in all venues.  I have to keep reminding myself that  "behavior is sustained by consequences" and they are merely being guided by the set of consequences,  whether real or imagined,  that they view as most important,.  They are doing what makes the most sense to them at the time.  

                                        And it can be maddening, especially in the professional world, whether it be war-fighting or word-smithing.

                                        Thanks,
                                        B.




                                        Michael Mulligan <steamshovel2002@...>
                                        Sent by: Root_Cause_State_of_the_Practice@yahoogroups.com

                                        02/03/2010 08:02 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: Perpetrators as Investigators





                                         

                                        Yea well, I know for a fact for most accidents and incidences the employees were talking about it 6 month or longer before it happened. They basically say, they guess, this is how I think this thing or change is going to turn out. I have been in the group shoot the bull secession and have been astonished with how accurate they were.

                                         

                                        At the end of the day, people just don’t have the courage to follow their convictions. They have to have absolute triplicate proof of the outcome before they will take even the slightest risk.

                                         

                                        Mike  

                                         

                                         

                                         

                                         

                                         a


                                        From: rey_cloutier <rey_cloutier@...>
                                        To:
                                        Root_Cause_State_of_the_Practice@yahoogroups.com
                                        Sent:
                                        Wed, February 3, 2010 4:06:24 PM
                                        Subject:
                                        [Root_Cause_State_of_the_Practice] Re: Perpetrators as Investigators


                                         

                                        I used to avoid them on the investigation team for obvious reasons.

                                        Then I read a book from Adam Kahane "Solving Tough Problems". This is not a RCA book as most will expect as the style of problems being presented is how to successfully move out of apartheid! Nevertheless, one sentence is worth repeating: "If you are part of the problem, you should be part of the solution". Even (or especially) if the problem is big!

                                        For some reasons, this sentence has stuck with me and I've been adding "perpetrator" on the problem solving team. One rule I'm using to select members on the problem solving team is get people close to the work and/or to the problem.

                                        The following conditions must be met before inviting them to join the team:
                                        -Amnesty is granted
                                        -Having them on the problem solving team will lead to more transparency.
                                        -We need to understand the problem to the point that we will have act the same way the perpetrator did (Thanks to Bob Nelms!)

                                        I believe that the final solution(s) did benefit from their participation. I believe the team has learned more by having them on the team then if the perpetrators were "only" interviewed.

                                        I also strongly believe by NOT having the so-called "bad guy" on the problem solving team is leading to future implementation issues and low long term effectiveness of the solution.

                                        BTW, I will not use the term "perpetrator" when referring to them.

                                        Best regards,
                                        Rey


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