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Re: [Root_Cause_State_of_the_Practice]Culture

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  • DR WILLIAM CORCORAN
    Captain Jim, Thanks. That is very helpful. The books The History of the Conquest of Mexico and The History of the Conquest of Peru , though history, read
    Message 1 of 24 , Jan 1, 2011
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      Captain Jim,

      Thanks. That is very helpful.

      The books "The History of the Conquest of Mexico" and "The History of the Conquest of Peru", though history, read like fiction.

      (For those who have not yet read Prescott see the following for a start: http://en.wikipedia.org/wiki/William_H._Prescott )


      Did those books remind you of "The Rise and Fall of the Third Reich?"

      (For those who have not yet read Shirer see the following for a start: http://en.wikipedia.org/wiki/The_Rise_and_Fall_of_the_Third_Reich )


      Certainly with our current views on culture, it would be easy to a make a case for "Culture was a set-up factor for disaster."

      You said:


      By culture I mean every aspect of their life, including their technology and decision making process.


      Do you have any links that would elaborate on your statement?

      Would you include in "culture":
      1. Mental content: how people think, their beliefs, values, priorities, mores, mental models, shared stories, etc?
      2. Norms: what people usually do in situations that repeat?
      3. Institutions: how people get things done, ceremonies, "sacraments", committees, programs, etc?
      4. Artifacts: physical objects that are the result of or are used to support the above?




       
      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.
      Method: Mastering Investigative Technology
       
      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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      From: Jim Bryant <captjim1971@...>
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Sent: Fri, December 31, 2010 11:52:47 AM
      Subject: Re: [Root_Cause_State_of_the_Practice]Culture

      Bill, Happy New Year back to you.
      By culture I mean every aspect of their life, including their technology and decision making process.  This is a snapshot as these things are always in motion.  Anthropologists look for trends in tools, weapons, textiles, pottery and art to define a particulate period.  All the major cultures in South America left written records, so understanding them is easier.  At the time of the Spanish Conquest collecting slaves for sacrifice helped with population control and kept conquered tribes under control by fear.  This regulatory system worked well for them until Cortez became a rally point for subjugated tribes/city states.
      When Cortez arrived the Aztecs thought they were Gods, and treated them like guests.  It sounds like the spiritual policy over rode the piratical and military observations on what was reality.  I think we see that today.  It was obvious that Cortez was using the subjugated tribes as allies, but the "feel good, I believe folks" were in control.  They needed a regulatory policy change and they stayed with the old  ways when things were changing.  It was no surprise that there was a new technology and new people in their world.  They could have beat the Spanish if they had fought them on their own terms.
      As for references there are many.  The Discovery Channel and progressive writing likes to treat the Incas, Aztecs, etc as superior to Europeans.  The book Germs, Guns and Steel explains why they weren't.  Broken Spears is supposedly an eye witness account, but it is filled with agenda, including some Cuban Communist influences.
      When Cortez was treated like a God it violated military, ceremonial and common sense regulatory barriers.  The results can be debated for days.
      Jim
       


      From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Cc: HPI_SC_RCA HPI_SC_RCA <HPI_SC_RCA@yahoogroups.com>
      Sent: Thu, December 30, 2010 5:14:06 PM
      Subject: Re: [Root_Cause_State_of_the_Practice]Culture

      Captain Jim,

      Happy New Year and thanks for your input.

      When you say "cultures like the Mayans and Aztecs" what do you mean by "culture?"

      How would I distinguish between something that was part of the "culture" and something that was not part of it?

      Do you have any links to articles that would help answer the questions?
       
      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.
      Method: Mastering Investigative Technology
       
      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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      From: Jim Bryant <captjim1971@...>
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Sent: Thu, December 30, 2010 12:37:54 PM
      Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

      Mike,
      I enjoy your comments, although like a lay person listening to a Persian Period Jewish Prophet, I don't always understand how you come to your conclusion.  One of my hobbies is Paleo Anthropology and my study suggests that only technology changes changes.  Early man had false Prophets, used ceremony instead of science to control over hunting and fishing.  There were religions that brought down cultures like the Mayans and Aztecs through internal wars and taking too many slaves from neighbors for sacrifice.  Cortez had no problems finding allies to fight against the Aztecs.
      Climate change had early man going back and forth from Spain to France during glaciations.  We finally beat the Neanderthals because our tight fitting clothes were better than their natural physical advantage against the cold.
      Tribes that survived did so through adaption to climate change, finding new sources of food, keeping good relations with extended kin and just making good decisions. Not adapting to changing game migration routes or not developing new sources of food, like fishing, agriculture was a disaster.  Following a false prophet or staying with old ways could result in the end of the tribe.  A failed mammoth hunt could result in starvation and reduced population rates.  The mammoth hunt had to planned, practiced and timed to get the number of hunters, weapons and food processors together at the right place.  This required a sophisticated process that could end badly in a number of ways if technological, procedural, physical or ceremonial barriers were violated.
      Jim

      From: Michael Mulligan <steamshovel2002@...>
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Sent: Wed, December 29, 2010 9:43:37 PM
      Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

      I just think these organization are too mono culture and not diverse thinkers, they are stoved piped...most of the employees' have the self interest of the American consumer dream...they have squeezed the independent mind right out of us. '

       

      This is a deep spiritual problem, how we related to each other, it is systemic in our nation...it is the matter of the heart...it is not going to be fixed by some mechanical process.

       

      We are in a deep national and planetary development crisis...and everything is interrelated.

       

      It is fundamentally a communication problem...it is spiritual in nature in that we don't value each other adequately because of the massive amount of dishonest, inaccurate and shallow communication between us...fundamentally honest and true relationship between us is the weak link in planetary development. We value each other us in a money or trading relationship...we have lost track how spectacular and miraculous our humanity is in each other.

       

      We have all become fallen angels! It is always in my highest interest to talk to you honestly, accurately and deeply to another human. It is contrary to all our interest not to.

       

      It says a lot about the free market, if I gain the most by miscommunication to you? If I value you that least.




      From: "Brown, Robert L" <robert_l_brown@...>
      To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
      Sent: Wed, December 29, 2010 3:54:40 PM
      Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

       

      Sustainable, without getting into the morass that involves culture means recognizing the following:  Note, I prepared this based on borrowing from Bill.   Memos have a half life that is real short.  Briefings are almost always ceremonial.  Changing procedures can be fundamental if the changes are tied to commitments.  Lacking any way of citing the procedure change as a commitment means you only have a slightly longer half life than a memo because the next guy that changes the procedure won’t know why the text is there unless it is annotated.

      Bob Brown, CHP

      Contractor Assurance

      Washington River Protection Solutions

      Contractor to DOE

      (509) 372-2932

      Cell 438-1286

       

      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
      Sent: Wednesday, December 29, 2010 11:42 AM
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

       

       

      I don’t know of any specific links offhand, but a quick opinion:  In a nutshell, for administrative type corrective actions (vs. engineered ones), it’s important to embed it into a process.  (Even engineered fixes can be undone or be replaced with something else unless something administratively accompanies it to document why it is so and a process exists to control engineering change.)  Counseling/reprimands, briefings/E-mails/required reading, issuing lessons learned documents, one time training, etc., are not at all sustainable yet are the most common corrective actions I see.  If it’s worth fixing, improve the process(es), establish/ensure oversight, and proceduralize both, and maintain a requirements tracking system that documents why that item is in the procedure or other supporting documents so if anyone in the future wants to change it they can find out what’s driving it to be done that way.  The same applies to lesson plans and schedules.  Anything short of that doesn’t pass muster.

       

      Weakness in requirements tracking is a common malady.  It’s often seen as too labor intensive so is not done and companies end up paying dearly for it over the long term.

       

      Note: A risk assessment as part of a corrective action plan can help put some focus on long term sustainability.  I don’t see that in reports very often.

       

      Scott

       

      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
      Sent: Wednesday, December 29, 2010 10:43 AM
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

       

       

      Scott and Tedd,

      What attributes of a corrective action tend to make it sustainable?

      Do you have a link to a discussion or examples?

       

      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.
      Method: Mastering Investigative Technology
       
      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.

       

       


      From: "Noga, Scott T" <scott_t_noga@...>
      To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
      Sent: Wed, December 29, 2010 11:53:05 AM
      Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

       

      Tedd,

       

      Yes, I had assumed you were referring to the costly window dressing that later catches fire.  I was supporting your point, but stated it differently.

       

      It could be argued, somewhat cynically though I don’t believe it’s intentional, a lack of sustainability is what keeps rooticians generally employed (and very busy).

       

      Scott

       

      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
      Sent: Wednesday, December 29, 2010 8:22 AM
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

       

       

      

      Scott,

      I did not mean that we should not do any causal investigation, clearly we need to determine what actually caused each event in order to be sure that we have effective corrective action in the first place.

      But I have seen, and for the reasons that you state, effective corrective action degrade or disappear and the event repeats.

      As far as I know that effect has not been investigated and corrective action developed.

      Tedd

       


      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
      Sent: Wednesday, December 29, 2010 10:51 AM
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

       

      It looks like sustainability could be a new topic of discussion.  Lessons learned may well have been learned at the time but are inherently transitory.  Competing interests come along, people come and go, and memories fade.  It’s why I’ve made it a point to include sustainability as a corrective action plan quality criterion during initial review and in subsequent effectiveness evaluations.

      Causal investigation and analysis is definitely not a waste of time if performed adequately and efficiently, but it certainly can be very costly window dressing if not.

      Scott Noga

      Risk Management Program

      WRPS - Hanford, USDOE contractor

      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 Salot, William
      Sent: Wednesday, December 29, 2010 4:54 AM
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

       

      Lessons learned that don’t stay learned were never learned in the first place (LLTDSLWNLITFP) ☺☺  


      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
      Sent: Tuesday, December 28, 2010 4:55 PM
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

       

      Bill,

      You are absolutely correct.

      I still think that we are wasting our time on causal investigation anyway.

      We keep having the same things happen, multiple times, after we have learned the supposedly lessons to be learned.

      What we need to be studying is why lessons learned don't stay learned.

      Tedd 


      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of william.rigot@...
      Sent: Tuesday, December 28, 2010 9:38 AM
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Subject: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

       

      Dr. Bill,

      My concern with this line of questioning is that the initial premise is that BP is guilty of something at the onset of the investigation.  When the entering argument is that "something bad happened, ergo criminal activity must have initiated it", then participants in the investigation are treated as criminals.  How does this inspire trust, openness and learning?  If you believe that What You Look For is What You Find (WYLFIWYF), then if you are looking for criminal activity, you're going to find it.  This notion that blaming people or even organizations for having bad things happen to them is comforting in hindsight, I suppose, but not particularly helpful in addressing what actually happened.  So if your causal analysis doesn't recognize the principle of WYLFIWYF, then WYFIWYF (what you find is what you fix).

      So, to answer your question, do you need to preserve evidence in a way that preserves fidelity to investigators?  Of course.  Do you need to ensure that the organization under investigation is separated from that evidence?  I don't think so.  After all, only that organization understands the context of the evidence.  The independent investigators certainly don't understand the context, without the willing participation of those decision makers whose bad decisions (in hindsight) led to the event.  It's a tricky balance, but I think it must be addressed up front in the investigation.  The number of times I've seen actual criminal activity in an accident investigation you could count on the fingers of one hand.  And when it happens, it's pretty obvious, and you need to stop what you're doing and get criminal investigators in quickly.  If you have properly preserved the fidelity of the evidence, you should be able to meet any challenges from a criminal investigation.  

      In this case, the CSB has got its panties in a wad over the wrong issue.  Why are there so many overlapping Federal investigations?  How is adding more complexity in the investigation process going to assure a better output?  And what would a better output look like?

      Just my opinions,

      Bill
      William L. Rigot
      Human Performance SME
      Savannah River Nuclear Solutions
      Aiken, SC  29808
      (O) 803.208.8673
      (C) 803.507.8144
      Strengths Finder:  Strategic/Positivity/Communication/Arranger/Connectedness




    • Dillard, Tedd A (E S SF RNA FS 1 1 E)
      The books Guns Germs and Steel and the sequel, Collapse, are two of the best books I have ever read and really explain a lot of things both about what happened
      Message 2 of 24 , Jan 1, 2011
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        The books Guns Germs and Steel and the sequel, Collapse, are two of the best books I have ever read and really explain a lot of things both about what happened  and what is still happening.
        Tedd

        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Jim Bryant
        Sent: Friday, December 31, 2010 11:53 AM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: Re: [Root_Cause_State_of_the_Practice]Culture

        Bill, Happy New Year back to you.
        By culture I mean every aspect of their life, including their technology and decision making process.  This is a snapshot as these things are always in motion.  Anthropologists look for trends in tools, weapons, textiles, pottery and art to define a particulate period.  All the major cultures in South America left written records, so understanding them is easier.  At the time of the Spanish Conquest collecting slaves for sacrifice helped with population control and kept conquered tribes under control by fear.  This regulatory system worked well for them until Cortez became a rally point for subjugated tribes/city states.
        When Cortez arrived the Aztecs thought they were Gods, and treated them like guests.  It sounds like the spiritual policy over rode the piratical and military observations on what was reality.  I think we see that today.  It was obvious that Cortez was using the subjugated tribes as allies, but the "feel good, I believe folks" were in control.  They needed a regulatory policy change and they stayed with the old  ways when things were changing.  It was no surprise that there was a new technology and new people in their world.  They could have beat the Spanish if they had fought them on their own terms.
        As for references there are many.  The Discovery Channel and progressive writing likes to treat the Incas, Aztecs, etc as superior to Europeans.  The book Germs, Guns and Steel explains why they weren't.  Broken Spears is supposedly an eye witness account, but it is filled with agenda, including some Cuban Communist influences.
        When Cortez was treated like a God it violated military, ceremonial and common sense regulatory barriers.  The results can be debated for days.
        Jim
         


        From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Cc: HPI_SC_RCA HPI_SC_RCA <HPI_SC_RCA@yahoogroups.com>
        Sent: Thu, December 30, 2010 5:14:06 PM
        Subject: Re: [Root_Cause_State_of_the_Practice]Culture

        Captain Jim,

        Happy New Year and thanks for your input.

        When you say "cultures like the Mayans and Aztecs" what do you mean by "culture?"

        How would I distinguish between something that was part of the "culture" and something that was not part of it?

        Do you have any links to articles that would help answer the questions?
         
        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.
        Method: Mastering Investigative Technology
         
        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.



        From: Jim Bryant <captjim1971@...>
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Sent: Thu, December 30, 2010 12:37:54 PM
        Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

        Mike,
        I enjoy your comments, although like a lay person listening to a Persian Period Jewish Prophet, I don't always understand how you come to your conclusion.  One of my hobbies is Paleo Anthropology and my study suggests that only technology changes changes.  Early man had false Prophets, used ceremony instead of science to control over hunting and fishing.  There were religions that brought down cultures like the Mayans and Aztecs through internal wars and taking too many slaves from neighbors for sacrifice.  Cortez had no problems finding allies to fight against the Aztecs.
        Climate change had early man going back and forth from Spain to France during glaciations.  We finally beat the Neanderthals because our tight fitting clothes were better than their natural physical advantage against the cold.
        Tribes that survived did so through adaption to climate change, finding new sources of food, keeping good relations with extended kin and just making good decisions. Not adapting to changing game migration routes or not developing new sources of food, like fishing, agriculture was a disaster.  Following a false prophet or staying with old ways could result in the end of the tribe.  A failed mammoth hunt could result in starvation and reduced population rates.  The mammoth hunt had to planned, practiced and timed to get the number of hunters, weapons and food processors together at the right place.  This required a sophisticated process that could end badly in a number of ways if technological, procedural, physical or ceremonial barriers were violated.
        Jim

        From: Michael Mulligan <steamshovel2002@...>
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Sent: Wed, December 29, 2010 9:43:37 PM
        Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

        I just think these organization are too mono culture and not diverse thinkers, they are stoved piped...most of the employees' have the self interest of the American consumer dream...they have squeezed the independent mind right out of us. '

         

        This is a deep spiritual problem, how we related to each other, it is systemic in our nation...it is the matter of the heart...it is not going to be fixed by some mechanical process.

         

        We are in a deep national and planetary development crisis...and everything is interrelated.

         

        It is fundamentally a communication problem...it is spiritual in nature in that we don't value each other adequately because of the massive amount of dishonest, inaccurate and shallow communication between us...fundamentally honest and true relationship between us is the weak link in planetary development. We value each other us in a money or trading relationship...we have lost track how spectacular and miraculous our humanity is in each other.

         

        We have all become fallen angels! It is always in my highest interest to talk to you honestly, accurately and deeply to another human. It is contrary to all our interest not to.

         

        It says a lot about the free market, if I gain the most by miscommunication to you? If I value you that least.




        From: "Brown, Robert L" <robert_l_brown@...>
        To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
        Sent: Wed, December 29, 2010 3:54:40 PM
        Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

         

        Sustainable, without getting into the morass that involves culture means recognizing the following:  Note, I prepared this based on borrowing from Bill.   Memos have a half life that is real short.  Briefings are almost always ceremonial.  Changing procedures can be fundamental if the changes are tied to commitments.  Lacking any way of citing the procedure change as a commitment means you only have a slightly longer half life than a memo because the next guy that changes the procedure won’t know why the text is there unless it is annotated.

        Bob Brown, CHP

        Contractor Assurance

        Washington River Protection Solutions

        Contractor to DOE

        (509) 372-2932

        Cell 438-1286

         

        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
        Sent: Wednesday, December 29, 2010 11:42 AM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

         

        I don’t know of any specific links offhand, but a quick opinion:  In a nutshell, for administrative type corrective actions (vs. engineered ones), it’s important to embed it into a process.  (Even engineered fixes can be undone or be replaced with something else unless something administratively accompanies it to document why it is so and a process exists to control engineering change.)  Counseling/reprimands, briefings/E-mails/required reading, issuing lessons learned documents, one time training, etc., are not at all sustainable yet are the most common corrective actions I see.  If it’s worth fixing, improve the process(es), establish/ensure oversight, and proceduralize both, and maintain a requirements tracking system that documents why that item is in the procedure or other supporting documents so if anyone in the future wants to change it they can find out what’s driving it to be done that way.  The same applies to lesson plans and schedules.  Anything short of that doesn’t pass muster.

         

        Weakness in requirements tracking is a common malady.  It’s often seen as too labor intensive so is not done and companies end up paying dearly for it over the long term.

         

        Note: A risk assessment as part of a corrective action plan can help put some focus on long term sustainability.  I don’t see that in reports very often.

         

        Scott

         

        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
        Sent: Wednesday, December 29, 2010 10:43 AM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

         

        Scott and Tedd,

        What attributes of a corrective action tend to make it sustainable?

        Do you have a link to a discussion or examples?

         

        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.
        Method: Mastering Investigative Technology
         
        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.

         

         


        From: "Noga, Scott T" <scott_t_noga@...>
        To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
        Sent: Wed, December 29, 2010 11:53:05 AM
        Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

         

        Tedd,

         

        Yes, I had assumed you were referring to the costly window dressing that later catches fire.  I was supporting your point, but stated it differently.

         

        It could be argued, somewhat cynically though I don’t believe it’s intentional, a lack of sustainability is what keeps rooticians generally employed (and very busy).

         

        Scott

         

        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
        Sent: Wednesday, December 29, 2010 8:22 AM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

         

        

        Scott,

        I did not mean that we should not do any causal investigation, clearly we need to determine what actually caused each event in order to be sure that we have effective corrective action in the first place.

        But I have seen, and for the reasons that you state, effective corrective action degrade or disappear and the event repeats.

        As far as I know that effect has not been investigated and corrective action developed.

        Tedd

         


        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
        Sent: Wednesday, December 29, 2010 10:51 AM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

        It looks like sustainability could be a new topic of discussion.  Lessons learned may well have been learned at the time but are inherently transitory.  Competing interests come along, people come and go, and memories fade.  It’s why I’ve made it a point to include sustainability as a corrective action plan quality criterion during initial review and in subsequent effectiveness evaluations.

        Causal investigation and analysis is definitely not a waste of time if performed adequately and efficiently, but it certainly can be very costly window dressing if not.

        Scott Noga

        Risk Management Program

        WRPS - Hanford, USDOE contractor

        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 Salot, William
        Sent: Wednesday, December 29, 2010 4:54 AM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

        Lessons learned that don’t stay learned were never learned in the first place (LLTDSLWNLITFP) ☺☺  


        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
        Sent: Tuesday, December 28, 2010 4:55 PM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

        Bill,

        You are absolutely correct.

        I still think that we are wasting our time on causal investigation anyway.

        We keep having the same things happen, multiple times, after we have learned the supposedly lessons to be learned.

        What we need to be studying is why lessons learned don't stay learned.

        Tedd 


        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of william.rigot@...
        Sent: Tuesday, December 28, 2010 9:38 AM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

        Dr. Bill,

        My concern with this line of questioning is that the initial premise is that BP is guilty of something at the onset of the investigation.  When the entering argument is that "something bad happened, ergo criminal activity must have initiated it", then participants in the investigation are treated as criminals.  How does this inspire trust, openness and learning?  If you believe that What You Look For is What You Find (WYLFIWYF), then if you are looking for criminal activity, you're going to find it.  This notion that blaming people or even organizations for having bad things happen to them is comforting in hindsight, I suppose, but not particularly helpful in addressing what actually happened.  So if your causal analysis doesn't recognize the principle of WYLFIWYF, then WYFIWYF (what you find is what you fix).

        So, to answer your question, do you need to preserve evidence in a way that preserves fidelity to investigators?  Of course.  Do you need to ensure that the organization under investigation is separated from that evidence?  I don't think so.  After all, only that organization understands the context of the evidence.  The independent investigators certainly don't understand the context, without the willing participation of those decision makers whose bad decisions (in hindsight) led to the event.  It's a tricky balance, but I think it must be addressed up front in the investigation.  The number of times I've seen actual criminal activity in an accident investigation you could count on the fingers of one hand.  And when it happens, it's pretty obvious, and you need to stop what you're doing and get criminal investigators in quickly.  If you have properly preserved the fidelity of the evidence, you should be able to meet any challenges from a criminal investigation.  

        In this case, the CSB has got its panties in a wad over the wrong issue.  Why are there so many overlapping Federal investigations?  How is adding more complexity in the investigation process going to assure a better output?  And what would a better output look like?

        Just my opinions,

        Bill
        William L. Rigot
        Human Performance SME
        Savannah River Nuclear Solutions
        Aiken, SC  29808
        (O) 803.208.8673
        (C) 803.507.8144
        Strengths Finder:  Strategic/Positivity/Communication/Arranger/Connectedness




      • DR WILLIAM CORCORAN
        Tedd, Thanks. I went up to Westfield, MA, where he was visiting and met him--very interesting person and very excited about teaching and learning. From what
        Message 3 of 24 , Jan 1, 2011
        • 0 Attachment
          Tedd,

          Thanks.

          I went up to Westfield, MA, where he was visiting and met him--very interesting person and very excited about teaching and learning.

          From what you know of his writing what do you think culture is?
           
          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.
          Method: Mastering Investigative Technology
           
          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.



          From: "Dillard, Tedd A (E S SF RNA FS 1 1 E)" <tedd.dillard@...>
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Sent: Sat, January 1, 2011 10:39:36 AM
          Subject: RE: [Root_Cause_State_of_the_Practice]Culture

           

          

          The books Guns Germs and Steel and the sequel, Collapse, are two of the best books I have ever read and really explain a lot of things both about what happened  and what is still happening.
          Tedd

          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Jim Bryant
          Sent: Friday, December 31, 2010 11:53 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: Re: [Root_Cause_State_of_the_Practice]Culture

          Bill, Happy New Year back to you.
          By culture I mean every aspect of their life, including their technology and decision making process.  This is a snapshot as these things are always in motion.  Anthropologists look for trends in tools, weapons, textiles, pottery and art to define a particulate period.  All the major cultures in South America left written records, so understanding them is easier.  At the time of the Spanish Conquest collecting slaves for sacrifice helped with population control and kept conquered tribes under control by fear.  This regulatory system worked well for them until Cortez became a rally point for subjugated tribes/city states.
          When Cortez arrived the Aztecs thought they were Gods, and treated them like guests.  It sounds like the spiritual policy over rode the piratical and military observations on what was reality.  I think we see that today.  It was obvious that Cortez was using the subjugated tribes as allies, but the "feel good, I believe folks" were in control.  They needed a regulatory policy change and they stayed with the old  ways when things were changing.  It was no surprise that there was a new technology and new people in their world.  They could have beat the Spanish if they had fought them on their own terms.
          As for references there are many.  The Discovery Channel and progressive writing likes to treat the Incas, Aztecs, etc as superior to Europeans.  The book Germs, Guns and Steel explains why they weren't.  Broken Spears is supposedly an eye witness account, but it is filled with agenda, including some Cuban Communist influences.
          When Cortez was treated like a God it violated military, ceremonial and common sense regulatory barriers.  The results can be debated for days.
          Jim
           


          From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Cc: HPI_SC_RCA HPI_SC_RCA <HPI_SC_RCA@yahoogroups.com>
          Sent: Thu, December 30, 2010 5:14:06 PM
          Subject: Re: [Root_Cause_State_of_the_Practice]Culture

          Captain Jim,

          Happy New Year and thanks for your input.

          When you say "cultures like the Mayans and Aztecs" what do you mean by "culture?"

          How would I distinguish between something that was part of the "culture" and something that was not part of it?

          Do you have any links to articles that would help answer the questions?
           
          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.
          Method: Mastering Investigative Technology
           
          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.



          From: Jim Bryant <captjim1971@...>
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Sent: Thu, December 30, 2010 12:37:54 PM
          Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

          Mike,
          I enjoy your comments, although like a lay person listening to a Persian Period Jewish Prophet, I don't always understand how you come to your conclusion.  One of my hobbies is Paleo Anthropology and my study suggests that only technology changes changes.  Early man had false Prophets, used ceremony instead of science to control over hunting and fishing.  There were religions that brought down cultures like the Mayans and Aztecs through internal wars and taking too many slaves from neighbors for sacrifice.  Cortez had no problems finding allies to fight against the Aztecs.
          Climate change had early man going back and forth from Spain to France during glaciations.  We finally beat the Neanderthals because our tight fitting clothes were better than their natural physical advantage against the cold.
          Tribes that survived did so through adaption to climate change, finding new sources of food, keeping good relations with extended kin and just making good decisions. Not adapting to changing game migration routes or not developing new sources of food, like fishing, agriculture was a disaster.  Following a false prophet or staying with old ways could result in the end of the tribe.  A failed mammoth hunt could result in starvation and reduced population rates.  The mammoth hunt had to planned, practiced and timed to get the number of hunters, weapons and food processors together at the right place.  This required a sophisticated process that could end badly in a number of ways if technological, procedural, physical or ceremonial barriers were violated.
          Jim

          From: Michael Mulligan <steamshovel2002@...>
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Sent: Wed, December 29, 2010 9:43:37 PM
          Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

          I just think these organization are too mono culture and not diverse thinkers, they are stoved piped...most of the employees' have the self interest of the American consumer dream...they have squeezed the independent mind right out of us. '

           

          This is a deep spiritual problem, how we related to each other, it is systemic in our nation...it is the matter of the heart...it is not going to be fixed by some mechanical process.

           

          We are in a deep national and planetary development crisis...and everything is interrelated.

           

          It is fundamentally a communication problem...it is spiritual in nature in that we don't value each other adequately because of the massive amount of dishonest, inaccurate and shallow communication between us...fundamentally honest and true relationship between us is the weak link in planetary development. We value each other us in a money or trading relationship...we have lost track how spectacular and miraculous our humanity is in each other.

           

          We have all become fallen angels! It is always in my highest interest to talk to you honestly, accurately and deeply to another human. It is contrary to all our interest not to.

           

          It says a lot about the free market, if I gain the most by miscommunication to you? If I value you that least.




          From: "Brown, Robert L" <robert_l_brown@...>
          To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
          Sent: Wed, December 29, 2010 3:54:40 PM
          Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

           

          Sustainable, without getting into the morass that involves culture means recognizing the following:  Note, I prepared this based on borrowing from Bill.   Memos have a half life that is real short.  Briefings are almost always ceremonial.  Changing procedures can be fundamental if the changes are tied to commitments.  Lacking any way of citing the procedure change as a commitment means you only have a slightly longer half life than a memo because the next guy that changes the procedure won’t know why the text is there unless it is annotated.

          Bob Brown, CHP

          Contractor Assurance

          Washington River Protection Solutions

          Contractor to DOE

          (509) 372-2932

          Cell 438-1286

           

          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
          Sent: Wednesday, December 29, 2010 11:42 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

           

          I don’t know of any specific links offhand, but a quick opinion:  In a nutshell, for administrative type corrective actions (vs. engineered ones), it’s important to embed it into a process.  (Even engineered fixes can be undone or be replaced with something else unless something administratively accompanies it to document why it is so and a process exists to control engineering change.)  Counseling/reprimands, briefings/E-mails/required reading, issuing lessons learned documents, one time training, etc., are not at all sustainable yet are the most common corrective actions I see.  If it’s worth fixing, improve the process(es), establish/ensure oversight, and proceduralize both, and maintain a requirements tracking system that documents why that item is in the procedure or other supporting documents so if anyone in the future wants to change it they can find out what’s driving it to be done that way.  The same applies to lesson plans and schedules.  Anything short of that doesn’t pass muster.

           

          Weakness in requirements tracking is a common malady.  It’s often seen as too labor intensive so is not done and companies end up paying dearly for it over the long term.

           

          Note: A risk assessment as part of a corrective action plan can help put some focus on long term sustainability.  I don’t see that in reports very often.

           

          Scott

           

          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
          Sent: Wednesday, December 29, 2010 10:43 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

           

          Scott and Tedd,

          What attributes of a corrective action tend to make it sustainable?

          Do you have a link to a discussion or examples?

           

          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.
          Method: Mastering Investigative Technology
           
          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.

           

           


          From: "Noga, Scott T" <scott_t_noga@...>
          To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
          Sent: Wed, December 29, 2010 11:53:05 AM
          Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

           

          Tedd,

           

          Yes, I had assumed you were referring to the costly window dressing that later catches fire.  I was supporting your point, but stated it differently.

           

          It could be argued, somewhat cynically though I don’t believe it’s intentional, a lack of sustainability is what keeps rooticians generally employed (and very busy).

           

          Scott

           

          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
          Sent: Wednesday, December 29, 2010 8:22 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

           

          

          Scott,

          I did not mean that we should not do any causal investigation, clearly we need to determine what actually caused each event in order to be sure that we have effective corrective action in the first place.

          But I have seen, and for the reasons that you state, effective corrective action degrade or disappear and the event repeats.

          As far as I know that effect has not been investigated and corrective action developed.

          Tedd

           


          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
          Sent: Wednesday, December 29, 2010 10:51 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

          It looks like sustainability could be a new topic of discussion.  Lessons learned may well have been learned at the time but are inherently transitory.  Competing interests come along, people come and go, and memories fade.  It’s why I’ve made it a point to include sustainability as a corrective action plan quality criterion during initial review and in subsequent effectiveness evaluations.

          Causal investigation and analysis is definitely not a waste of time if performed adequately and efficiently, but it certainly can be very costly window dressing if not.

          Scott Noga

          Risk Management Program

          WRPS - Hanford, USDOE contractor

          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 Salot, William
          Sent: Wednesday, December 29, 2010 4:54 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

          Lessons learned that don’t stay learned were never learned in the first place (LLTDSLWNLITFP) ☺☺  


          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
          Sent: Tuesday, December 28, 2010 4:55 PM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

          Bill,

          You are absolutely correct.

          I still think that we are wasting our time on causal investigation anyway.

          We keep having the same things happen, multiple times, after we have learned the supposedly lessons to be learned.

          What we need to be studying is why lessons learned don't stay learned.

          Tedd 


          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of william.rigot@...
          Sent: Tuesday, December 28, 2010 9:38 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

          Dr. Bill,

          My concern with this line of questioning is that the initial premise is that BP is guilty of something at the onset of the investigation.  When the entering argument is that "something bad happened, ergo criminal activity must have initiated it", then participants in the investigation are treated as criminals.  How does this inspire trust, openness and learning?  If you believe that What You Look For is What You Find (WYLFIWYF), then if you are looking for criminal activity, you're going to find it.  This notion that blaming people or even organizations for having bad things happen to them is comforting in hindsight, I suppose, but not particularly helpful in addressing what actually happened.  So if your causal analysis doesn't recognize the principle of WYLFIWYF, then WYFIWYF (what you find is what you fix).

          So, to answer your question, do you need to preserve evidence in a way that preserves fidelity to investigators?  Of course.  Do you need to ensure that the organization under investigation is separated from that evidence?  I don't think so.  After all, only that organization understands the context of the evidence.  The independent investigators certainly don't understand the context, without the willing participation of those decision makers whose bad decisions (in hindsight) led to the event.  It's a tricky balance, but I think it must be addressed up front in the investigation.  The number of times I've seen actual criminal activity in an accident investigation you could count on the fingers of one hand.  And when it happens, it's pretty obvious, and you need to stop what you're doing and get criminal investigators in quickly.  If you have properly preserved the fidelity of the evidence, you should be able to meet any challenges from a criminal investigation.  

          In this case, the CSB has got its panties in a wad over the wrong issue.  Why are there so many overlapping Federal investigations?  How is adding more complexity in the investigation process going to assure a better output?  And what would a better output look like?

          Just my opinions,

          Bill
          William L. Rigot
          Human Performance SME
          Savannah River Nuclear Solutions
          Aiken, SC  29808
          (O) 803.208.8673
          (C) 803.507.8144
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        • Dillard, Tedd A (E S SF RNA FS 1 1 E)
          Dr. Bill, I think I gotta go with Jim Bryant. I think you have to look at almost everything that a society does to define it s culture. The same action or
          Message 4 of 24 , Jan 1, 2011
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            Dr. Bill,
            I think I gotta go with Jim Bryant.
            I think you have to look at almost everything that a society does to define it's culture.
            The same action or behavior can have different meanings in different societies.
            You can accurately say that a specific activity is present in a specific society and means a specific thing with in that society but you can't say that that same activity means the same thing to another society.
            Tedd 


            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 01, 2011 10:54 AM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: Re: [Root_Cause_State_of_the_Practice]Culture

            Tedd,

            Thanks.

            I went up to Westfield, MA, where he was visiting and met him--very interesting person and very excited about teaching and learning.

            From what you know of his writing what do you think culture is?
             
            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.
            Method: Mastering Investigative Technology
             
            W. R. Corcoran, Ph.D., P.E.
            Nuclear Safety Review Concepts Corporation
            21 Broadleaf Circle
            Windsor, CT 06095-1634
            860-285-8779

            Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
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            From: "Dillard, Tedd A (E S SF RNA FS 1 1 E)" <tedd.dillard@...>
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Sent: Sat, January 1, 2011 10:39:36 AM
            Subject: RE: [Root_Cause_State_of_the_Practice]Culture

             

            

            The books Guns Germs and Steel and the sequel, Collapse, are two of the best books I have ever read and really explain a lot of things both about what happened  and what is still happening.
            Tedd

            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Jim Bryant
            Sent: Friday, December 31, 2010 11:53 AM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: Re: [Root_Cause_State_of_the_Practice]Culture

            Bill, Happy New Year back to you.
            By culture I mean every aspect of their life, including their technology and decision making process.  This is a snapshot as these things are always in motion.  Anthropologists look for trends in tools, weapons, textiles, pottery and art to define a particulate period.  All the major cultures in South America left written records, so understanding them is easier.  At the time of the Spanish Conquest collecting slaves for sacrifice helped with population control and kept conquered tribes under control by fear.  This regulatory system worked well for them until Cortez became a rally point for subjugated tribes/city states.
            When Cortez arrived the Aztecs thought they were Gods, and treated them like guests.  It sounds like the spiritual policy over rode the piratical and military observations on what was reality.  I think we see that today.  It was obvious that Cortez was using the subjugated tribes as allies, but the "feel good, I believe folks" were in control.  They needed a regulatory policy change and they stayed with the old  ways when things were changing.  It was no surprise that there was a new technology and new people in their world.  They could have beat the Spanish if they had fought them on their own terms.
            As for references there are many.  The Discovery Channel and progressive writing likes to treat the Incas, Aztecs, etc as superior to Europeans.  The book Germs, Guns and Steel explains why they weren't.  Broken Spears is supposedly an eye witness account, but it is filled with agenda, including some Cuban Communist influences.
            When Cortez was treated like a God it violated military, ceremonial and common sense regulatory barriers.  The results can be debated for days.
            Jim
             


            From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Cc: HPI_SC_RCA HPI_SC_RCA <HPI_SC_RCA@yahoogroups.com>
            Sent: Thu, December 30, 2010 5:14:06 PM
            Subject: Re: [Root_Cause_State_of_the_Practice]Culture

            Captain Jim,

            Happy New Year and thanks for your input.

            When you say "cultures like the Mayans and Aztecs" what do you mean by "culture?"

            How would I distinguish between something that was part of the "culture" and something that was not part of it?

            Do you have any links to articles that would help answer the questions?
             
            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.
            Method: Mastering Investigative Technology
             
            W. R. Corcoran, Ph.D., P.E.
            Nuclear Safety Review Concepts Corporation
            21 Broadleaf Circle
            Windsor, CT 06095-1634
            860-285-8779

            Subscribe to "The Firebird Forum"  TheFirebirdForum-subscribe@yahoogroups.com
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            From: Jim Bryant <captjim1971@...>
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Sent: Thu, December 30, 2010 12:37:54 PM
            Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

            Mike,
            I enjoy your comments, although like a lay person listening to a Persian Period Jewish Prophet, I don't always understand how you come to your conclusion.  One of my hobbies is Paleo Anthropology and my study suggests that only technology changes changes.  Early man had false Prophets, used ceremony instead of science to control over hunting and fishing.  There were religions that brought down cultures like the Mayans and Aztecs through internal wars and taking too many slaves from neighbors for sacrifice.  Cortez had no problems finding allies to fight against the Aztecs.
            Climate change had early man going back and forth from Spain to France during glaciations.  We finally beat the Neanderthals because our tight fitting clothes were better than their natural physical advantage against the cold.
            Tribes that survived did so through adaption to climate change, finding new sources of food, keeping good relations with extended kin and just making good decisions. Not adapting to changing game migration routes or not developing new sources of food, like fishing, agriculture was a disaster.  Following a false prophet or staying with old ways could result in the end of the tribe.  A failed mammoth hunt could result in starvation and reduced population rates.  The mammoth hunt had to planned, practiced and timed to get the number of hunters, weapons and food processors together at the right place.  This required a sophisticated process that could end badly in a number of ways if technological, procedural, physical or ceremonial barriers were violated.
            Jim

            From: Michael Mulligan <steamshovel2002@...>
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Sent: Wed, December 29, 2010 9:43:37 PM
            Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

            I just think these organization are too mono culture and not diverse thinkers, they are stoved piped...most of the employees' have the self interest of the American consumer dream...they have squeezed the independent mind right out of us. '

             

            This is a deep spiritual problem, how we related to each other, it is systemic in our nation...it is the matter of the heart...it is not going to be fixed by some mechanical process.

             

            We are in a deep national and planetary development crisis...and everything is interrelated.

             

            It is fundamentally a communication problem...it is spiritual in nature in that we don't value each other adequately because of the massive amount of dishonest, inaccurate and shallow communication between us...fundamentally honest and true relationship between us is the weak link in planetary development. We value each other us in a money or trading relationship...we have lost track how spectacular and miraculous our humanity is in each other.

             

            We have all become fallen angels! It is always in my highest interest to talk to you honestly, accurately and deeply to another human. It is contrary to all our interest not to.

             

            It says a lot about the free market, if I gain the most by miscommunication to you? If I value you that least.




            From: "Brown, Robert L" <robert_l_brown@...>
            To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
            Sent: Wed, December 29, 2010 3:54:40 PM
            Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

             

            Sustainable, without getting into the morass that involves culture means recognizing the following:  Note, I prepared this based on borrowing from Bill.   Memos have a half life that is real short.  Briefings are almost always ceremonial.  Changing procedures can be fundamental if the changes are tied to commitments.  Lacking any way of citing the procedure change as a commitment means you only have a slightly longer half life than a memo because the next guy that changes the procedure won’t know why the text is there unless it is annotated.

            Bob Brown, CHP

            Contractor Assurance

            Washington River Protection Solutions

            Contractor to DOE

            (509) 372-2932

            Cell 438-1286

             

            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
            Sent: Wednesday, December 29, 2010 11:42 AM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

             

            I don’t know of any specific links offhand, but a quick opinion:  In a nutshell, for administrative type corrective actions (vs. engineered ones), it’s important to embed it into a process.  (Even engineered fixes can be undone or be replaced with something else unless something administratively accompanies it to document why it is so and a process exists to control engineering change.)  Counseling/reprimands, briefings/E-mails/required reading, issuing lessons learned documents, one time training, etc., are not at all sustainable yet are the most common corrective actions I see.  If it’s worth fixing, improve the process(es), establish/ensure oversight, and proceduralize both, and maintain a requirements tracking system that documents why that item is in the procedure or other supporting documents so if anyone in the future wants to change it they can find out what’s driving it to be done that way.  The same applies to lesson plans and schedules.  Anything short of that doesn’t pass muster.

             

            Weakness in requirements tracking is a common malady.  It’s often seen as too labor intensive so is not done and companies end up paying dearly for it over the long term.

             

            Note: A risk assessment as part of a corrective action plan can help put some focus on long term sustainability.  I don’t see that in reports very often.

             

            Scott

             

            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
            Sent: Wednesday, December 29, 2010 10:43 AM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

             

            Scott and Tedd,

            What attributes of a corrective action tend to make it sustainable?

            Do you have a link to a discussion or examples?

             

            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.
            Method: Mastering Investigative Technology
             
            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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            From: "Noga, Scott T" <scott_t_noga@...>
            To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
            Sent: Wed, December 29, 2010 11:53:05 AM
            Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

             

            Tedd,

             

            Yes, I had assumed you were referring to the costly window dressing that later catches fire.  I was supporting your point, but stated it differently.

             

            It could be argued, somewhat cynically though I don’t believe it’s intentional, a lack of sustainability is what keeps rooticians generally employed (and very busy).

             

            Scott

             

            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
            Sent: Wednesday, December 29, 2010 8:22 AM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

             

            

            Scott,

            I did not mean that we should not do any causal investigation, clearly we need to determine what actually caused each event in order to be sure that we have effective corrective action in the first place.

            But I have seen, and for the reasons that you state, effective corrective action degrade or disappear and the event repeats.

            As far as I know that effect has not been investigated and corrective action developed.

            Tedd

             


            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
            Sent: Wednesday, December 29, 2010 10:51 AM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

            It looks like sustainability could be a new topic of discussion.  Lessons learned may well have been learned at the time but are inherently transitory.  Competing interests come along, people come and go, and memories fade.  It’s why I’ve made it a point to include sustainability as a corrective action plan quality criterion during initial review and in subsequent effectiveness evaluations.

            Causal investigation and analysis is definitely not a waste of time if performed adequately and efficiently, but it certainly can be very costly window dressing if not.

            Scott Noga

            Risk Management Program

            WRPS - Hanford, USDOE contractor

            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 Salot, William
            Sent: Wednesday, December 29, 2010 4:54 AM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

            Lessons learned that don’t stay learned were never learned in the first place (LLTDSLWNLITFP) ☺☺  


            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
            Sent: Tuesday, December 28, 2010 4:55 PM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

            Bill,

            You are absolutely correct.

            I still think that we are wasting our time on causal investigation anyway.

            We keep having the same things happen, multiple times, after we have learned the supposedly lessons to be learned.

            What we need to be studying is why lessons learned don't stay learned.

            Tedd 


            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of william.rigot@...
            Sent: Tuesday, December 28, 2010 9:38 AM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

            Dr. Bill,

            My concern with this line of questioning is that the initial premise is that BP is guilty of something at the onset of the investigation.  When the entering argument is that "something bad happened, ergo criminal activity must have initiated it", then participants in the investigation are treated as criminals.  How does this inspire trust, openness and learning?  If you believe that What You Look For is What You Find (WYLFIWYF), then if you are looking for criminal activity, you're going to find it.  This notion that blaming people or even organizations for having bad things happen to them is comforting in hindsight, I suppose, but not particularly helpful in addressing what actually happened.  So if your causal analysis doesn't recognize the principle of WYLFIWYF, then WYFIWYF (what you find is what you fix).

            So, to answer your question, do you need to preserve evidence in a way that preserves fidelity to investigators?  Of course.  Do you need to ensure that the organization under investigation is separated from that evidence?  I don't think so.  After all, only that organization understands the context of the evidence.  The independent investigators certainly don't understand the context, without the willing participation of those decision makers whose bad decisions (in hindsight) led to the event.  It's a tricky balance, but I think it must be addressed up front in the investigation.  The number of times I've seen actual criminal activity in an accident investigation you could count on the fingers of one hand.  And when it happens, it's pretty obvious, and you need to stop what you're doing and get criminal investigators in quickly.  If you have properly preserved the fidelity of the evidence, you should be able to meet any challenges from a criminal investigation.  

            In this case, the CSB has got its panties in a wad over the wrong issue.  Why are there so many overlapping Federal investigations?  How is adding more complexity in the investigation process going to assure a better output?  And what would a better output look like?

            Just my opinions,

            Bill
            William L. Rigot
            Human Performance SME
            Savannah River Nuclear Solutions
            Aiken, SC  29808
            (O) 803.208.8673
            (C) 803.507.8144
            Strengths Finder:  Strategic/Positivity/Communication/Arranger/Connectedness




          • Jim Bryant
            Bill, I m a bit distracted getting ready for an Elk hunting trip to New Mexico, but I wanted to respond to your comments 1. Mental content: how people think,
            Message 5 of 24 , Jan 2, 2011
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              Bill,
                I'm a bit distracted getting ready for an Elk hunting trip to New Mexico, but I wanted to respond to your comments"
                1. Mental content: how people think, their beliefs, values, priorities, mores, mental models, shared stories, etc?

              The Aztec's decided to base their political, religious and economics upon massive human sacrifice, that exceeded any other culture in  I know about.  They got the slaves for sacrifice through military campaigns that kept their military tactics and technology on the edge.

                1. Norms: what people usually do in situations that repeat?

              The arrival of the Spaniards was new and their communications with the island tribes either poor or they didn't believe it.  They choose to treat them as Gods instead of invaders.  When they got around to mounting a defense, including making the right weapons such as pikes with obsidian tips, they were overcome by small pox.  That is once story of why they failed.

                1. Institutions: how people get things done, ceremonies, "sacraments", committees, programs, etc?

              The rules were religious ones.  Religious ceremony was used to prevent over fishing and hunting, while it was clearly scientific observation that determined the need for rules. 

                1. Artifacts: physical objects that are the result of or are used to support the above?

              Weapons and tactics were developed to counter the enemy, but the communications between cultures was not fast enough.  Pizarro read the book printed in Mexico City on how the Aztec's were defeated, but Incas were slow to learn to ambush the mounted Spaniards in canyons and passes and to use pikes.


                 


                From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Cc: HPI_SC_RCA HPI_SC_RCA <HPI_SC_RCA@yahoogroups.com>
                Sent: Sat, January 1, 2011 7:20:16 AM
                Subject: Re: [Root_Cause_State_of_the_Practice]Culture

                Captain Jim,

                Thanks. That is very helpful.

                The books "The History of the Conquest of Mexico" and "The History of the Conquest of Peru", though history, read like fiction.

                (For those who have not yet read Prescott see the following for a start: http://en.wikipedia.org/wiki/William_H._Prescott )


                Did those books remind you of "The Rise and Fall of the Third Reich?"

                (For those who have not yet read Shirer see the following for a start: http://en.wikipedia.org/wiki/The_Rise_and_Fall_of_the_Third_Reich )


                Certainly with our current views on culture, it would be easy to a make a case for "Culture was a set-up factor for disaster."

                You said:


                By culture I mean every aspect of their life, including their technology and decision making process.


                Do you have any links that would elaborate on your statement?

                Would you include in "culture":
                1. Mental content: how people think, their beliefs, values, priorities, mores, mental models, shared stories, etc?
                2. Norms: what people usually do in situations that repeat?
                3. Institutions: how people get things done, ceremonies, "sacraments", committees, programs, etc?
                4. Artifacts: physical objects that are the result of or are used to support the above?




                 
                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.
                Method: Mastering Investigative Technology
                 
                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.



                From: Jim Bryant <captjim1971@...>
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Sent: Fri, December 31, 2010 11:52:47 AM
                Subject: Re: [Root_Cause_State_of_the_Practice]Culture

                Bill, Happy New Year back to you.
                By culture I mean every aspect of their life, including their technology and decision making process.  This is a snapshot as these things are always in motion.  Anthropologists look for trends in tools, weapons, textiles, pottery and art to define a particulate period.  All the major cultures in South America left written records, so understanding them is easier.  At the time of the Spanish Conquest collecting slaves for sacrifice helped with population control and kept conquered tribes under control by fear.  This regulatory system worked well for them until Cortez became a rally point for subjugated tribes/city states.
                When Cortez arrived the Aztecs thought they were Gods, and treated them like guests.  It sounds like the spiritual policy over rode the piratical and military observations on what was reality.  I think we see that today.  It was obvious that Cortez was using the subjugated tribes as allies, but the "feel good, I believe folks" were in control.  They needed a regulatory policy change and they stayed with the old  ways when things were changing.  It was no surprise that there was a new technology and new people in their world.  They could have beat the Spanish if they had fought them on their own terms.
                As for references there are many.  The Discovery Channel and progressive writing likes to treat the Incas, Aztecs, etc as superior to Europeans.  The book Germs, Guns and Steel explains why they weren't.  Broken Spears is supposedly an eye witness account, but it is filled with agenda, including some Cuban Communist influences.
                When Cortez was treated like a God it violated military, ceremonial and common sense regulatory barriers.  The results can be debated for days.
                Jim
                 


                From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Cc: HPI_SC_RCA HPI_SC_RCA <HPI_SC_RCA@yahoogroups.com>
                Sent: Thu, December 30, 2010 5:14:06 PM
                Subject: Re: [Root_Cause_State_of_the_Practice]Culture

                Captain Jim,

                Happy New Year and thanks for your input.

                When you say "cultures like the Mayans and Aztecs" what do you mean by "culture?"

                How would I distinguish between something that was part of the "culture" and something that was not part of it?

                Do you have any links to articles that would help answer the questions?
                 
                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.
                Method: Mastering Investigative Technology
                 
                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.



                From: Jim Bryant <captjim1971@...>
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Sent: Thu, December 30, 2010 12:37:54 PM
                Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                Mike,
                I enjoy your comments, although like a lay person listening to a Persian Period Jewish Prophet, I don't always understand how you come to your conclusion.  One of my hobbies is Paleo Anthropology and my study suggests that only technology changes changes.  Early man had false Prophets, used ceremony instead of science to control over hunting and fishing.  There were religions that brought down cultures like the Mayans and Aztecs through internal wars and taking too many slaves from neighbors for sacrifice.  Cortez had no problems finding allies to fight against the Aztecs.
                Climate change had early man going back and forth from Spain to France during glaciations.  We finally beat the Neanderthals because our tight fitting clothes were better than their natural physical advantage against the cold.
                Tribes that survived did so through adaption to climate change, finding new sources of food, keeping good relations with extended kin and just making good decisions. Not adapting to changing game migration routes or not developing new sources of food, like fishing, agriculture was a disaster.  Following a false prophet or staying with old ways could result in the end of the tribe.  A failed mammoth hunt could result in starvation and reduced population rates.  The mammoth hunt had to planned, practiced and timed to get the number of hunters, weapons and food processors together at the right place.  This required a sophisticated process that could end badly in a number of ways if technological, procedural, physical or ceremonial barriers were violated.
                Jim

                From: Michael Mulligan <steamshovel2002@...>
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Sent: Wed, December 29, 2010 9:43:37 PM
                Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                I just think these organization are too mono culture and not diverse thinkers, they are stoved piped...most of the employees' have the self interest of the American consumer dream...they have squeezed the independent mind right out of us. '

                 

                This is a deep spiritual problem, how we related to each other, it is systemic in our nation...it is the matter of the heart...it is not going to be fixed by some mechanical process.

                 

                We are in a deep national and planetary development crisis...and everything is interrelated.

                 

                It is fundamentally a communication problem...it is spiritual in nature in that we don't value each other adequately because of the massive amount of dishonest, inaccurate and shallow communication between us...fundamentally honest and true relationship between us is the weak link in planetary development. We value each other us in a money or trading relationship...we have lost track how spectacular and miraculous our humanity is in each other.

                 

                We have all become fallen angels! It is always in my highest interest to talk to you honestly, accurately and deeply to another human. It is contrary to all our interest not to.

                 

                It says a lot about the free market, if I gain the most by miscommunication to you? If I value you that least.




                From: "Brown, Robert L" <robert_l_brown@...>
                To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                Sent: Wed, December 29, 2010 3:54:40 PM
                Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                 

                Sustainable, without getting into the morass that involves culture means recognizing the following:  Note, I prepared this based on borrowing from Bill.   Memos have a half life that is real short.  Briefings are almost always ceremonial.  Changing procedures can be fundamental if the changes are tied to commitments.  Lacking any way of citing the procedure change as a commitment means you only have a slightly longer half life than a memo because the next guy that changes the procedure won’t know why the text is there unless it is annotated.

                Bob Brown, CHP

                Contractor Assurance

                Washington River Protection Solutions

                Contractor to DOE

                (509) 372-2932

                Cell 438-1286

                 

                From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
                Sent: Wednesday, December 29, 2010 11:42 AM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                 

                 

                I don’t know of any specific links offhand, but a quick opinion:  In a nutshell, for administrative type corrective actions (vs. engineered ones), it’s important to embed it into a process.  (Even engineered fixes can be undone or be replaced with something else unless something administratively accompanies it to document why it is so and a process exists to control engineering change.)  Counseling/reprimands, briefings/E-mails/required reading, issuing lessons learned documents, one time training, etc., are not at all sustainable yet are the most common corrective actions I see.  If it’s worth fixing, improve the process(es), establish/ensure oversight, and proceduralize both, and maintain a requirements tracking system that documents why that item is in the procedure or other supporting documents so if anyone in the future wants to change it they can find out what’s driving it to be done that way.  The same applies to lesson plans and schedules.  Anything short of that doesn’t pass muster.

                 

                Weakness in requirements tracking is a common malady.  It’s often seen as too labor intensive so is not done and companies end up paying dearly for it over the long term.

                 

                Note: A risk assessment as part of a corrective action plan can help put some focus on long term sustainability.  I don’t see that in reports very often.

                 

                Scott

                 

                From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                Sent: Wednesday, December 29, 2010 10:43 AM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                 

                 

                Scott and Tedd,

                What attributes of a corrective action tend to make it sustainable?

                Do you have a link to a discussion or examples?

                 

                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.
                Method: Mastering Investigative Technology
                 
                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.

                 

                 


                From: "Noga, Scott T" <scott_t_noga@...>
                To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                Sent: Wed, December 29, 2010 11:53:05 AM
                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                 

                Tedd,

                 

                Yes, I had assumed you were referring to the costly window dressing that later catches fire.  I was supporting your point, but stated it differently.

                 

                It could be argued, somewhat cynically though I don’t believe it’s intentional, a lack of sustainability is what keeps rooticians generally employed (and very busy).

                 

                Scott

                 

                From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
                Sent: Wednesday, December 29, 2010 8:22 AM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                 

                 

                

                Scott,

                I did not mean that we should not do any causal investigation, clearly we need to determine what actually caused each event in order to be sure that we have effective corrective action in the first place.

                But I have seen, and for the reasons that you state, effective corrective action degrade or disappear and the event repeats.

                As far as I know that effect has not been investigated and corrective action developed.

                Tedd

                 


                From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
                Sent: Wednesday, December 29, 2010 10:51 AM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                 

                It looks like sustainability could be a new topic of discussion.  Lessons learned may well have been learned at the time but are inherently transitory.  Competing interests come along, people come and go, and memories fade.  It’s why I’ve made it a point to include sustainability as a corrective action plan quality criterion during initial review and in subsequent effectiveness evaluations.

                Causal investigation and analysis is definitely not a waste of time if performed adequately and efficiently, but it certainly can be very costly window dressing if not.

                Scott Noga

                Risk Management Program

                WRPS - Hanford, USDOE contractor

                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 Salot, William
                Sent: Wednesday, December 29, 2010 4:54 AM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                 

                Lessons learned that don’t stay learned were never learned in the first place (LLTDSLWNLITFP) ☺☺  


                From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
                Sent: Tuesday, December 28, 2010 4:55 PM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                 

                Bill,

                You are absolutely correct.

                I still think that we are wasting our time on causal investigation anyway.

                We keep having the same things happen, multiple times, after we have learned the supposedly lessons to be learned.

                What we need to be studying is why lessons learned don't stay learned.

                Tedd 


                From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of william.rigot@...
                Sent: Tuesday, December 28, 2010 9:38 AM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                 

                Dr. Bill,

                My concern with this line of questioning is that the initial premise is that BP is guilty of something at the onset of the investigation.  When the entering argument is that "something bad happened, ergo criminal activity must have initiated it", then participants in the investigation are treated as criminals.  How does this inspire trust, openness and learning?  If you believe that What You Look For is What You Find (WYLFIWYF), then if you are looking for criminal activity, you're going to find it.  This notion that blaming people or even organizations for having bad things happen to them is comforting in hindsight, I suppose, but not particularly helpful in addressing what actually happened.  So if your causal analysis doesn't recognize the principle of WYLFIWYF, then WYFIWYF (what you find is what you fix).

                So, to answer your question, do you need to preserve evidence in a way that preserves fidelity to investigators?  Of course.  Do you need to ensure that the organization under investigation is separated from that evidence?  I don't think so.  After all, only that organization understands the context of the evidence.  The independent investigators certainly don't understand the context, without the willing participation of those decision makers whose bad decisions (in hindsight) led to the event.  It's a tricky balance, but I think it must be addressed up front in the investigation.  The number of times I've seen actual criminal activity in an accident investigation you could count on the fingers of one hand.  And when it happens, it's pretty obvious, and you need to stop what you're doing and get criminal investigators in quickly.  If you have properly preserved the fidelity of the evidence, you should be able to meet any challenges from a criminal investigation.  

                In this case, the CSB has got its panties in a wad over the wrong issue.  Why are there so many overlapping Federal investigations?  How is adding more complexity in the investigation process going to assure a better output?  And what would a better output look like?

                Just my opinions,

                Bill
                William L. Rigot
                Human Performance SME
                Savannah River Nuclear Solutions
                Aiken, SC  29808
                (O) 803.208.8673
                (C) 803.507.8144
                Strengths Finder:  Strategic/Positivity/Communication/Arranger/Connectedness





              1. Michael Mulligan
                Jim,  So who is the false prophet in the Deepwater Horizon and all our institutional accidents? They were mostly our educated engineers and scientist.
                Message 6 of 24 , Jan 3, 2011
                • 0 Attachment
                  Jim,
                   
                   So who is the false prophet in the Deepwater Horizon and all our institutional accidents? They were mostly our educated engineers and scientist. They weren't the gas station attendants or spear chuckers.  Our scientist of today provide a similar role of our old prophets of generation past...the majority of them operate under a profit motive.
                   
                  Honestly, in our environment, with massive altruism abuse, how do we know anything we hear today is the truth. Somebody is trying sell us a gadget, look at all this expensive environmental crap, it is all wrapped up in the language of a crisis and if you purchase it it will save you and the earth. Everything is about doing so call good and altruism today, and never has the world been in this much turmoil and insecurity. You think being good leads to all this insanity?  We just got no independent authority to enforce truth telling. Just spew out anything you want independent of truth...and don't tell me there is no such thing as truth, it is situational. It is simple, we got no institutional truth guardians anymore...they been all stripped away from us by the politicians and businesse.     
                   
                  "There were religions that brought down cultures like the Mayans and Aztecs through internal wars and taking too many slaves from neighbors for sacrifice. Cortez had no problems finding allies to fight against the Aztecs."
                   
                  I could make a case you are talking about a addiction, a organizational virus, thrill seeking...seeking too much serotonin and other happy neurotransmitters. Apparent altruism is extraordinarily addictive.  The problem with early age technological innovation that was never recorded. It is more some inventions worked slightly better than the inventions and new ideas that harmed us. We seem to don't count the inventions that damaged us, after all, writing and documentation wasn't evented then.      
                   
                  I think technological innovation and new inventions is the only thing that is going to solve global warning ...this lying green environmental energy is only bringing the cliff closer to us. We will be voluntarily jumping off the cliff before the weather gets us the way it is being set up for is now...I think GW is real. 2010 was the warmest year yet for Massachusetts.  
                   
                  Either we got to invent a new cheap source of energy, we got the technology today, but with this current generation of technology we don't have the income to support it and us. Either we invent a new cheap energy source, or we have to invent a new style of economy that can support the current technology..and a decent standard of living for us all. Solving Global Warming is only an issue of adequate income for the bottom half of us...science is secondary.
                   
                  The commonality of all our crisis, it is not a technological or an invention fix. It is more a sociological or societal organization or cohesion problem. It is a spiritual, communication, it is what is the meaning of human life, it is what is the value of human life, it is we are all one, and not them and us...our eduaction, food, water, infrastructure, education, the military, all the other shortages, education again ...we just have to invent a increase income for the bottom half, and a new income stream to support all of our needs. We just have to have the freedom to spend a lot of time in seemingly non productive education...we have to incentivise education. That is the real problem behind GW curtain...it is income, it is about the creation of new ideas and invention on a mass scale, and without sending us all into the poor house....that is the problem behind it all. It is the tide rising all ships!  
                   
                  You basically gave me a model, created a model with how the world worked way back when, and I suspect how the world works today.   

                   

                  "This required a sophisticated process that could end badly in a number of ways if technological, procedure physical or ceremonial barriers were violated."

                   

                  Throughout history following the rules and barriers was always tricky business. The trouble is most of our modernity comes about by breaking through barriers and violating rules...least it looks like that when it occurs. The USS Nautilus SSN 571 is a example of that. It broke every rule in the book and it was a threat to the fossil fuel fleet. The word processor was threat to the typewriter, it was considered rule breaking. The biggest and most useful inventions and discoveries come about by breaking the rules or customs. It is tricky business knowing when it is important to follow the rule, when it is necessary to smash right through the rules. Many accident disruptor's such a whistle-blowers depend on breaking the rules. We have the CPU in our brain to know when we have to follow rules and when it is required to break the rules.  

                   

                  All of our prophets and our towering political prophets were grand barrier and rules violators. If you really want to get philosophical, most of the false prophets and trouble maker taught us more good stuff than any of the lily white traditional good Prophets. The lot of Prophets are again tricky business.  I would be very careful ignoring or discounting the lessens of a false prophet. I think all the prophits are sent by god as a teaching tool. i think god rains on the good and bad people alike...we all have a lessen to teach each other. Most really good prophets comes from a life of sinning, and god or the cosmos chose them all. 

                   

                  Aand after all, god or the cosmos chose us to be exactly right here!   

                   

                  Thanks,

                   

                  mike 

                   




                  From: Jim Bryant <captjim1971@...>
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Sent: Thu, December 30, 2010 12:37:54 PM
                  Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                  Mike,
                  I enjoy your comments, although like a lay person listening to a Persian Period Jewish Prophet, I don't always understand how you come to your conclusion.  One of my hobbies is Paleo Anthropology and my study suggests that only technology changes changes.  Early man had false Prophets, used ceremony instead of science to control over hunting and fishing.  There were religions that brought down cultures like the Mayans and Aztecs through internal wars and taking too many slaves from neighbors for sacrifice.  Cortez had no problems finding allies to fight against the Aztecs.
                  Climate change had early man going back and forth from Spain to France during glaciations.  We finally beat the Neanderthals because our tight fitting clothes were better than their natural physical advantage against the cold.
                  Tribes that survived did so through adaption to climate change, finding new sources of food, keeping good relations with extended kin and just making good decisions. Not adapting to changing game migration routes or not developing new sources of food, like fishing, agriculture was a disaster.  Following a false prophet or staying with old ways could result in the end of the tribe.  A failed mammoth hunt could result in starvation and reduced population rates.  The mammoth hunt had to planned, practiced and timed to get the number of hunters, weapons and food processors together at the right place.  This required a sophisticated process that could end badly in a number of ways if technological, procedural, physical or ceremonial barriers were violated.
                  Jim

                  From: Michael Mulligan <steamshovel2002@...>
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Sent: Wed, December 29, 2010 9:43:37 PM
                  Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                  I just think these organization are too mono culture and not diverse thinkers, they are stoved piped...most of the employees' have the self interest of the American consumer dream...they have squeezed the independent mind right out of us. '

                   

                  This is a deep spiritual problem, how we related to each other, it is systemic in our nation...it is the matter of the heart...it is not going to be fixed by some mechanical process.

                   

                  We are in a deep national and planetary development crisis...and everything is interrelated.

                   

                  It is fundamentally a communication problem...it is spiritual in nature in that we don't value each other adequately because of the massive amount of dishonest, inaccurate and shallow communication between us...fundamentally honest and true relationship between us is the weak link in planetary development. We value each other us in a money or trading relationship...we have lost track how spectacular and miraculous our humanity is in each other.

                   

                  We have all become fallen angels! It is always in my highest interest to talk to you honestly, accurately and deeply to another human. It is contrary to all our interest not to.

                   

                  It says a lot about the free market, if I gain the most by miscommunication to you? If I value you that least.




                  From: "Brown, Robert L" <robert_l_brown@...>
                  To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                  Sent: Wed, December 29, 2010 3:54:40 PM
                  Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                   

                  Sustainable, without getting into the morass that involves culture means recognizing the following:  Note, I prepared this based on borrowing from Bill.   Memos have a half life that is real short.  Briefings are almost always ceremonial.  Changing procedures can be fundamental if the changes are tied to commitments.  Lacking any way of citing the procedure change as a commitment means you only have a slightly longer half life than a memo because the next guy that changes the procedure won’t know why the text is there unless it is annotated.

                  Bob Brown, CHP

                  Contractor Assurance

                  Washington River Protection Solutions

                  Contractor to DOE

                  (509) 372-2932

                  Cell 438-1286

                   

                  From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
                  Sent: Wednesday, December 29, 2010 11:42 AM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: RE: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                   

                   

                  I don’t know of any specific links offhand, but a quick opinion:  In a nutshell, for administrative type corrective actions (vs. engineered ones), it’s important to embed it into a process.  (Even engineered fixes can be undone or be replaced with something else unless something administratively accompanies it to document why it is so and a process exists to control engineering change.)  Counseling/reprimands, briefings/E-mails/required reading, issuing lessons learned documents, one time training, etc., are not at all sustainable yet are the most common corrective actions I see.  If it’s worth fixing, improve the process(es), establish/ensure oversight, and proceduralize both, and maintain a requirements tracking system that documents why that item is in the procedure or other supporting documents so if anyone in the future wants to change it they can find out what’s driving it to be done that way.  The same applies to lesson plans and schedules.  Anything short of that doesn’t pass muster.

                   

                  Weakness in requirements tracking is a common malady.  It’s often seen as too labor intensive so is not done and companies end up paying dearly for it over the long term.

                   

                  Note: A risk assessment as part of a corrective action plan can help put some focus on long term sustainability.  I don’t see that in reports very often.

                   

                  Scott

                   

                  From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                  Sent: Wednesday, December 29, 2010 10:43 AM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions

                   

                   

                  Scott and Tedd,

                  What attributes of a corrective action tend to make it sustainable?

                  Do you have a link to a discussion or examples?

                   

                  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.
                  Method: Mastering Investigative Technology
                   
                  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.

                   

                   


                  From: "Noga, Scott T" <scott_t_noga@...>
                  To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                  Sent: Wed, December 29, 2010 11:53:05 AM
                  Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                   

                  Tedd,

                   

                  Yes, I had assumed you were referring to the costly window dressing that later catches fire.  I was supporting your point, but stated it differently.

                   

                  It could be argued, somewhat cynically though I don’t believe it’s intentional, a lack of sustainability is what keeps rooticians generally employed (and very busy).

                   

                  Scott

                   

                  From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
                  Sent: Wednesday, December 29, 2010 8:22 AM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                   

                   

                  

                  Scott,

                  I did not mean that we should not do any causal investigation, clearly we need to determine what actually caused each event in order to be sure that we have effective corrective action in the first place.

                  But I have seen, and for the reasons that you state, effective corrective action degrade or disappear and the event repeats.

                  As far as I know that effect has not been investigated and corrective action developed.

                  Tedd

                   


                  From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
                  Sent: Wednesday, December 29, 2010 10:51 AM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                   

                  It looks like sustainability could be a new topic of discussion.  Lessons learned may well have been learned at the time but are inherently transitory.  Competing interests come along, people come and go, and memories fade.  It’s why I’ve made it a point to include sustainability as a corrective action plan quality criterion during initial review and in subsequent effectiveness evaluations.

                  Causal investigation and analysis is definitely not a waste of time if performed adequately and efficiently, but it certainly can be very costly window dressing if not.

                  Scott Noga

                  Risk Management Program

                  WRPS - Hanford, USDOE contractor

                  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 Salot, William
                  Sent: Wednesday, December 29, 2010 4:54 AM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                   

                  Lessons learned that don’t stay learned were never learned in the first place (LLTDSLWNLITFP) ☺☺  


                  From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
                  Sent: Tuesday, December 28, 2010 4:55 PM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                   

                  Bill,

                  You are absolutely correct.

                  I still think that we are wasting our time on causal investigation anyway.

                  We keep having the same things happen, multiple times, after we have learned the supposedly lessons to be learned.

                  What we need to be studying is why lessons learned don't stay learned.

                  Tedd 


                  From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of william.rigot@...
                  Sent: Tuesday, December 28, 2010 9:38 AM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?

                   

                  Dr. Bill,

                  My concern with this line of questioning is that the initial premise is that BP is guilty of something at the onset of the investigation.  When the entering argument is that "something bad happened, ergo criminal activity must have initiated it", then participants in the investigation are treated as criminals.  How does this inspire trust, openness and learning?  If you believe that What You Look For is What You Find (WYLFIWYF), then if you are looking for criminal activity, you're going to find it.  This notion that blaming people or even organizations for having bad things happen to them is comforting in hindsight, I suppose, but not particularly helpful in addressing what actually happened.  So if your causal analysis doesn't recognize the principle of WYLFIWYF, then WYFIWYF (what you find is what you fix).

                  So, to answer your question, do you need to preserve evidence in a way that preserves fidelity to investigators?  Of course.  Do you need to ensure that the organization under investigation is separated from that evidence?  I don't think so.  After all, only that organization understands the context of the evidence.  The independent investigators certainly don't understand the context, without the willing participation of those decision makers whose bad decisions (in hindsight) led to the event.  It's a tricky balance, but I think it must be addressed up front in the investigation.  The number of times I've seen actual criminal activity in an accident investigation you could count on the fingers of one hand.  And when it happens, it's pretty obvious, and you need to stop what you're doing and get criminal investigators in quickly.  If you have properly preserved the fidelity of the evidence, you should be able to meet any challenges from a criminal investigation.  

                  In this case, the CSB has got its panties in a wad over the wrong issue.  Why are there so many overlapping Federal investigations?  How is adding more complexity in the investigation process going to assure a better output?  And what would a better output look like?

                  Just my opinions,

                  Bill
                  William L. Rigot
                  Human Performance SME
                  Savannah River Nuclear Solutions
                  Aiken, SC  29808
                  (O) 803.208.8673
                  (C) 803.507.8144
                  Strengths Finder:  Strategic/Positivity/Communication/Arranger/Connectedness




                • rey_cloutier@yahoo.com
                  If I can repeat a previous post: I ve learned from an organizational development specialist to develop solutions with multiple legs to add *robustness* (and
                  Message 7 of 24 , Jan 6, 2011
                  • 0 Attachment
                    If I can repeat a previous post:

                    I've learned from an organizational development specialist to develop solutions
                    with multiple legs to add robustness (and resilience?).

                    The typical "legs" or barriers (?) used are:

                    * Technical i.e. are the new tools and processes suitable for high performance.
                    * Structure i.e. does the organization structure facilitate or hinder
                    coordination and flow of information?
                    * Decision Making i.e.does the solution includes information that permits good
                    decision making at the right level?
                    * People i.e. does the solution includes people with the technical and social
                    skills necessary to excel at their job?
                    * Reward i.e. does the organization reward or discourage the proper behaviors
                    and attitudes?
                    * Renewal i.e. does the solution maximize the learning of the organization, i.e
                    is energy spent doing or on understanding? Those elements put together define
                    the Culture of the organization i.e. the way new members are taught what is the
                    correct way to behave.

                    I believe solutions that have three or more of the above attributes (or "legs") are more likely to be sustainable.

                    Regards,
                    Rey

                    On 10-12-29 2:42 PM, Noga, Scott T wrote:
                    I don’t know of any specific links offhand, but a quick opinion:  In a nutshell, for administrative type corrective actions (vs. engineered ones), it’s important to embed it into a process.  (Even engineered fixes can be undone or be replaced with something else unless something administratively accompanies it to document why it is so and a process exists to control engineering change.)  Counseling/reprimands, briefings/E-mails/required reading, issuing lessons learned documents, one time training, etc., are not at all sustainable yet are the most common corrective actions I see.  If it’s worth fixing, improve the process(es), establish/ensure oversight, and proceduralize both, and maintain a requirements tracking system that documents why that item is in the procedure or other supporting documents so if anyone in the future wants to change it they can find out what’s driving it to be done that way.  The same applies to lesson plans and schedules.  
                    Anything short of that doesn’t pass muster.
                    
                    Weakness in requirements tracking is a common malady.  It’s often seen as too labor intensive so is not done and companies end up paying dearly for it over the long term.
                    
                    Note: A risk assessment as part of a corrective action plan can help put some focus on long term sustainability.  I don’t see that in reports very often.
                    
                    Scott
                    
                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                    Sent: Wednesday, December 29, 2010 10:43 AM
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Subject: Re: [Root_Cause_State_of_the_Practice] Re:Sustainability of Corrective Actions
                    
                    
                    Scott and Tedd,
                    
                    What attributes of a corrective action tend to make it sustainable?
                    
                    Do you have a link to a discussion or examples?
                    
                    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.
                    Method: Mastering Investigative Technology
                    
                    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<mailto:TheFirebirdForum-subscribe@yahoogroups.com>
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                    ________________________________
                    From: "Noga, Scott T" <scott_t_noga@...>
                    To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                    Sent: Wed, December 29, 2010 11:53:05 AM
                    Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?
                    
                    
                    Tedd,
                    
                    Yes, I had assumed you were referring to the costly window dressing that later catches fire.  I was supporting your point, but stated it differently.
                    
                    It could be argued, somewhat cynically though I don’t believe it’s intentional, a lack of sustainability is what keeps rooticians generally employed (and very busy).
                    
                    Scott
                    
                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
                    Sent: Wednesday, December 29, 2010 8:22 AM
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?
                    
                    
                    
                    
                    Scott,
                    I did not mean that we should not do any causal investigation, clearly we need to determine what actually caused each event in order to be sure that we have effective corrective action in the first place.
                    But I have seen, and for the reasons that you state, effective corrective action degrade or disappear and the event repeats.
                    As far as I know that effect has not been investigated and corrective action developed.
                    Tedd
                    
                    ________________________________
                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Noga, Scott T
                    Sent: Wednesday, December 29, 2010 10:51 AM
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?
                    
                    It looks like sustainability could be a new topic of discussion.  Lessons learned may well have been learned at the time but are inherently transitory.  Competing interests come along, people come and go, and memories fade.  It’s why I’ve made it a point to include sustainability as a corrective action plan quality criterion during initial review and in subsequent effectiveness evaluations.
                    Causal investigation and analysis is definitely not a waste of time if performed adequately and efficiently, but it certainly can be very costly window dressing if not.
                    Scott Noga
                    Risk Management Program
                    WRPS - Hanford, USDOE contractor
                    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 Salot, William
                    Sent: Wednesday, December 29, 2010 4:54 AM
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?
                    
                    Lessons learned that don’t stay learned were never learned in the first place (LLTDSLWNLITFP) ☺☺
                    ________________________________
                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
                    Sent: Tuesday, December 28, 2010 4:55 PM
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?
                    
                    Bill,
                    You are absolutely correct.
                    I still think that we are wasting our time on causal investigation anyway.
                    We keep having the same things happen, multiple times, after we have learned the supposedly lessons to be learned.
                    What we need to be studying is why lessons learned don't stay learned.
                    Tedd
                    ________________________________
                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of william.rigot@...
                    Sent: Tuesday, December 28, 2010 9:38 AM
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Subject: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?
                    
                    
                    Dr. Bill,
                    
                    My concern with this line of questioning is that the initial premise is that BP is guilty of something at the onset of the investigation.  When the entering argument is that "something bad happened, ergo criminal activity must have initiated it", then participants in the investigation are treated as criminals.  How does this inspire trust, openness and learning?  If you believe that What You Look For is What You Find (WYLFIWYF), then if you are looking for criminal activity, you're going to find it.  This notion that blaming people or even organizations for having bad things happen to them is comforting in hindsight, I suppose, but not particularly helpful in addressing what actually happened.  So if your causal analysis doesn't recognize the principle of WYLFIWYF, then WYFIWYF (what you find is what you fix).
                    
                    So, to answer your question, do you need to preserve evidence in a way that preserves fidelity to investigators?  Of course.  Do you need to ensure that the organization under investigation is separated from that evidence?  I don't think so.  After all, only that organization understands the context of the evidence.  The independent investigators certainly don't understand the context, without the willing participation of those decision makers whose bad decisions (in hindsight) led to the event.  It's a tricky balance, but I think it must be addressed up front in the investigation.  The number of times I've seen actual criminal activity in an accident investigation you could count on the fingers of one hand.  And when it happens, it's pretty obvious, and you need to stop what you're doing and get criminal investigators in quickly.  If you have properly preserved the fidelity of the evidence, you should be able to meet any challenges from a criminal investigation.
                    
                    In this case, the CSB has got its panties in a wad over the wrong issue.  Why are there so many overlapping Federal investigations?  How is adding more complexity in the investigation process going to assure a better output?  And what would a better output look like?
                    
                    Just my opinions,
                    
                    Bill
                    William L. Rigot
                    Human Performance SME
                    Savannah River Nuclear Solutions
                    Aiken, SC  29808
                    (O) 803.208.8673
                    (C) 803.507.8144
                    Strengths Finder:  Strategic/Positivity/Communication/Arranger/Connectedness
                    
                    
                  • rey_cloutier@yahoo.com
                    Fully agree! Sustainability is a hot topic for many fields. I like the idea of including sustainability as a criteria for corrective action to prevent
                    Message 8 of 24 , Jan 6, 2011
                    • 0 Attachment
                      Fully agree!

                      Sustainability is a hot topic for many fields.

                      I like the idea of including sustainability as a criteria for corrective
                      action to prevent recurrence (CAPR) and effectiveness check.

                      Any other idea/area where sustainability may be considered in problem
                      solving and root cause analysis?

                      Rey

                      On 10-12-29 10:51 AM, Noga, Scott T wrote:
                      > It looks like sustainability could be a new topic of discussion. Lessons learned may well have been learned at the time but are inherently transitory. Competing interests come along, people come and go, and memories fade. It’s why I’ve made it a point to include sustainability as a corrective action plan quality criterion during initial review and in subsequent effectiveness evaluations.
                      >
                      > Causal investigation and analysis is definitely not a waste of time if performed adequately and efficiently, but it certainly can be very costly window dressing if not.
                      >
                      > Scott Noga
                      > Risk Management Program
                      > WRPS - Hanford, USDOE contractor
                      > 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 Salot, William
                      > Sent: Wednesday, December 29, 2010 4:54 AM
                      > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                      > Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?
                      >
                      >
                      > Lessons learned that don’t stay learned were never learned in the first place (LLTDSLWNLITFP) ☺☺
                      >
                      > ________________________________
                      > From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Dillard, Tedd A (E S SF RNA FS 1 1 E)
                      > Sent: Tuesday, December 28, 2010 4:55 PM
                      > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                      > Subject: RE: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?
                      >
                      >
                      > Bill,
                      > You are absolutely correct.
                      > I still think that we are wasting our time on causal investigation anyway.
                      > We keep having the same things happen, multiple times, after we have learned the supposedly lessons to be learned.
                      > What we need to be studying is why lessons learned don't stay learned.
                      > Tedd
                      >
                      > ________________________________
                      > From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of william.rigot@...
                      > Sent: Tuesday, December 28, 2010 9:38 AM
                      > To: Root_Cause_State_of_the_Practice@yahoogroups.com
                      > Subject: [Root_Cause_State_of_the_Practice] Re: Evidence Preservation or Evidence Management?
                      >
                      >
                      > Dr. Bill,
                      >
                      > My concern with this line of questioning is that the initial premise is that BP is guilty of something at the onset of the investigation. When the entering argument is that "something bad happened, ergo criminal activity must have initiated it", then participants in the investigation are treated as criminals. How does this inspire trust, openness and learning? If you believe that What You Look For is What You Find (WYLFIWYF), then if you are looking for criminal activity, you're going to find it. This notion that blaming people or even organizations for having bad things happen to them is comforting in hindsight, I suppose, but not particularly helpful in addressing what actually happened. So if your causal analysis doesn't recognize the principle of WYLFIWYF, then WYFIWYF (what you find is what you fix).
                      >
                      > So, to answer your question, do you need to preserve evidence in a way that preserves fidelity to investigators? Of course. Do you need to ensure that the organization under investigation is separated from that evidence? I don't think so. After all, only that organization understands the context of the evidence. The independent investigators certainly don't understand the context, without the willing participation of those decision makers whose bad decisions (in hindsight) led to the event. It's a tricky balance, but I think it must be addressed up front in the investigation. The number of times I've seen actual criminal activity in an accident investigation you could count on the fingers of one hand. And when it happens, it's pretty obvious, and you need to stop what you're doing and get criminal investigators in quickly. If you have properly preserved the fidelity of the evidence, you should be able to meet any challenges from a criminal investigation.
                      >
                      > In this case, the CSB has got its panties in a wad over the wrong issue. Why are there so many overlapping Federal investigations? How is adding more complexity in the investigation process going to assure a better output? And what would a better output look like?
                      >
                      > Just my opinions,
                      >
                      > Bill
                      > William L. Rigot
                      > Human Performance SME
                      > Savannah River Nuclear Solutions
                      > Aiken, SC 29808
                      > (O) 803.208.8673
                      > (C) 803.507.8144
                      > Strengths Finder: Strategic/Positivity/Communication/Arranger/Connectedness
                      >
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