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RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

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  • Hobbs, Andrew F (HBS)
    Before we get into what a precursor is, I would suggest that we discuss for a moment the circumstances in which things labeled as “precursors” are
    Message 1 of 17 , Mar 1, 2011

      Before we get into what a precursor is, I would suggest that we discuss for a moment the circumstances in which things labeled as “precursors” are generated or identified.

       

      It seems to me that there are two:

       

      -          a retrospective observation made with the benefit of hindsight

      -          a forecasting prediction made (mostly) based on experience and (perceived) understanding of the system and its current state

       

      It is obvious that the first has the greatest probability of being “right.”  The downside from the perspective of truth is that we probably didn’t know then what we know now when tagging something in the past as a precursor to what we now know has happened.  Dekker speaks of “data availability” vs. “data observability,” and the two are obviously not the same.  In my experience regulators have a tendency to point to things in the past after an accident and find “precursors” and thus chastise the operator/contractor for not having realized that they were such and thus prevented the accident from occurring.

       

      The second circumstance is the one in which we strive to be “proactive” and take action based on what we do know now and try to prevent something we believe will occur if we otherwise take no action to prevent it.  Though well-meaning and perhaps even necessary, this approach usually forgets that our understanding of the current state of the system is incomplete.  By making changes to the system in order to prevent one bad outcome, may very well result in another bad or even worse outcome because we didn’t fully understand how our changes would affect the entire system.  That doesn’t mean that we shouldn’t try to be proactive (even though we are really being reactive, just sooner in terms of the projected worse outcome), but we should do so with caution lest we think ourselves omniscient and become overconfident in our understanding of the complex socio-technical systems we have created.

       

      Thoughts?

       

      Andy Hobbs

      Y12 National Security Complex

      Issues Management Specialist for UPF Project

      Root Cause Analyst / HPI Practicioner

      office: 574-0812

       

      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
      Sent: Monday, February 28, 2011 5:14 PM
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

       

       

      Mike,

      Good point.

      What do you call a precursor if the next event hasn't happened?

      We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

      And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

       

      Take care,
       
      Bill Corcoran
      Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
      Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
      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: Michael Mulligan <steamshovel2002@...>
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Sent: Mon, February 28, 2011 11:21:32 AM
      Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

       

      Bill,

       

      Well, the Deepwater Horizon and the Presidential National Commission on the blow out of the Macondo well in the Gulf Of Mexico is a type 6 precursor?

       

      I suppose you can't call it a precursor if the next event hasn't happened?

       

      Mike 

       


      From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Sent: Mon, February 28, 2011 6:14:37 AM
      Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

       

      Mike,

      I agree on your choice.

      "The Rootician's Dictionary" defines a Type 6 Precursor thus:


      A consequential event that gets root cause analysis and corrective action and precedes another event whose causal factors include ones that were part of the previous event but were not identified and/or fixed.


      Does any one have other examples of Type 6 Precursors?

      Was the sinking of the USS Squalus (SS 192) a precursor to the sinking of the USS Thresher (SSN 593)? Which type of precursor? How did you decide?

      Useful links

      http://en.wikipedia.org/wiki/USS_Sailfish_%28SS-192%29

      http://en.wikipedia.org/wiki/USS_Thresher_%28SSN-593%29

       

      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: Michael Mulligan <steamshovel2002@...>
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Sent: Sun, February 27, 2011 1:02:24 PM
      Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

       

      Bill,

       

      Type 6

       

      I wonder if all the actions coming out of 1993 and 9/11 are reversible? Is all the stuff we did to enhance our protection against terrorism...if the terrorism threat ended...could we return to our pre 1993 state?  Would all the increased secrecy over the last two decades to protect ourselves end?

       

      When it is over, what is going to be the countervailing force to return us to our pre 1993 state?

       

      My life has been touched through these chain of events over the terrorism issue beginning before 1993...A FBI JTTF investigation of me last year. Has your life been directly touched?  

       

      We are still not getting to the source of this...all that is causing it.

       

      I think the most dangerous thing in the USA, say with the nuclear industry, is to withdrawal the public oversight of security related issues. This idea that in order to protect us we got to let people who have a vested interest in minimizing security to be exclusively in charge of terrorism related protection activities. Only people with a certain ideology are qualified to hold the secrets of nuclear industry...is that is what we have become. The most damaging thing to our society is to create a small exclusive cadre of experts being only in charge of our security and they only having transparency of the system... thinking their corporatism knows what is best for us with terrorism. Now does Israel knows this truth beyond anyone.   

       

      In our latest Saudi near miss it was the "us" of us all that unidentified this threat. The so called experts were helpless at the emergent level. Our security depends on the good people of our society always being in the front lines of all our wars...the eyes, ears and brains behind our national security stance. We are strongest when we all act together as one against the forces that are out to destroy us. We sink or swim, rich or poor, together. It utterly repugnant when a facility thinks the community are the first terrorist. Put a severe secrecy shield up, so the community can't see the sins of security system and their managers. The gaming of societal protection is unbelievable at this stage of the game. It is all about the power system trying to protect themselves from the cost and shortcomings of the protecting the community....It is about if the terrorist gets through their thin arrogant defenses and they being not held accountable...    

       

      If we as a community member become interested in the quality of security around a facility...the first thing they do is call you a terrorist sympathizer and call in the Feds.

       

      It is this continuous thing in our society where we split our community into the "them" and "us"...the privileged and the used.

       

      If a facility is floundering around near death will they show their security secrets as a public relation stunt in a quest for survival?  Would you?

       

      Does al-Qaeda and these well financed wild eyed Saudis engineering students think a dying facility is more vulnerable to terrorism than a thriving facility? I am getting close to those three words the FBI JTTF warned me to never use together ever again in one message.  

       

      I will just say it straight out, talking about that part 26 fatigue NRC commissioner meeting. The ghost stories.  I hope budget issues nationwide are not degrading the terrorism protections at nuclear power plants? I sense a lot of employee frustrations over the security related employee fatigue issues. The idea that a security officer would disclose to the commissioners that he has to seek a outside second job in order to support his family is very troubling. The idea that outside working hours maliciously not be reported as fatigue or regulated working hours because a security manager is upset with not getting enough income at a facility. Is morale and income troubles...security related budget problems...is that degrading the security related stance at our nuclear plants.     

       

       

      Mike     

       

       

        

       


      From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
      To: RCSOTP1 <Root_Cause_State_of_the_Practice@yahoogroups.com>
      Sent: Sat, February 26, 2011 5:03:29 AM
      Subject: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

       

      On Feb. 26, 1993, a bomb exploded in the garage of New York's World Trade Center, killing six people and injuring more

       

       

      than 1,000 others.

       

       

       

      What type of a precursor was this? What are the lessons to be learned?

       

       

       

       

      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.

       

       

       

    • DR WILLIAM CORCORAN
      Andy, Thanks ever so much for weighing in on this one. Would you be so kind as to give some real life examples of the two dysfunctional approaches to
      Message 2 of 17 , Mar 1, 2011
        Andy,

        Thanks ever so much for weighing in on this one.

        Would you be so kind as to give some real life examples of the two dysfunctional approaches to precursors?

        OBTW: "The Rootician's Dictionary" currently gives the following definition for "precursor."

        A precursor is a situation that has some, but usually not all, of the ingredients of a subsequent highly consequential situation.

        Do you have a better definition?

        For a somewhat dated approach to precursors visit page79 at:

        http://books.google.com/books?id=96JEnmy3H2YC&pg=PA79&dq=corcoran+precursor&hl=en&ei=U-tsTcHCKoLJgQf44dT6Aw&sa=X&oi=book_result&ct=result&resnum=1&ved=0CCwQ6AEwAA#v=onepage&q=corcoran%20precursor&f=false




         
        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: "Hobbs, Andrew F (HBS)" <afhobbs@...>
        To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
        Sent: Tue, March 1, 2011 7:20:38 AM
        Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

         

        Before we get into what a precursor is, I would suggest that we discuss for a moment the circumstances in which things labeled as “precursors” are generated or identified.

         

        It seems to me that there are two:

         

        -          a retrospective observation made with the benefit of hindsight

        -          a forecasting prediction made (mostly) based on experience and (perceived) understanding of the system and its current state

         

        It is obvious that the first has the greatest probability of being “right.”  The downside from the perspective of truth is that we probably didn’t know then what we know now when tagging something in the past as a precursor to what we now know has happened.  Dekker speaks of “data availability” vs. “data observability,” and the two are obviously not the same.  In my experience regulators have a tendency to point to things in the past after an accident and find “precursors” and thus chastise the operator/contractor for not having realized that they were such and thus prevented the accident from occurring.

         

        The second circumstance is the one in which we strive to be “proactive” and take action based on what we do know now and try to prevent something we believe will occur if we otherwise take no action to prevent it.  Though well-meaning and perhaps even necessary, this approach usually forgets that our understanding of the current state of the system is incomplete.  By making changes to the system in order to prevent one bad outcome, may very well result in another bad or even worse outcome because we didn’t fully understand how our changes would affect the entire system.  That doesn’t mean that we shouldn’t try to be proactive (even though we are really being reactive, just sooner in terms of the projected worse outcome), but we should do so with caution lest we think ourselves omniscient and become overconfident in our understanding of the complex socio-technical systems we have created.

         

        Thoughts?

         

        Andy Hobbs

        Y12 National Security Complex

        Issues Management Specialist for UPF Project

        Root Cause Analyst / HPI Practicioner

        office: 574-0812

         

        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
        Sent: Monday, February 28, 2011 5:14 PM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

         

         

        Mike,

        Good point.

        What do you call a precursor if the next event hasn't happened?

        We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

        And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

         

        Take care,
         
        Bill Corcoran
        Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
        Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
        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: Michael Mulligan <steamshovel2002@...>
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Sent: Mon, February 28, 2011 11:21:32 AM
        Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

         

        Bill,

         

        Well, the Deepwater Horizon and the Presidential National Commission on the blow out of the Macondo well in the Gulf Of Mexico is a type 6 precursor?

         

        I suppose you can't call it a precursor if the next event hasn't happened?

         

        Mike 

         


        From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Sent: Mon, February 28, 2011 6:14:37 AM
        Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

         

        Mike,

        I agree on your choice.

        "The Rootician's Dictionary" defines a Type 6 Precursor thus:


        A consequential event that gets root cause analysis and corrective action and precedes another event whose causal factors include ones that were part of the previous event but were not identified and/or fixed.


        Does any one have other examples of Type 6 Precursors?

        Was the sinking of the USS Squalus (SS 192) a precursor to the sinking of the USS Thresher (SSN 593)? Which type of precursor? How did you decide?

        Useful links

        http://en.wikipedia.org/wiki/USS_Sailfish_%28SS-192%29

        http://en.wikipedia.org/wiki/USS_Thresher_%28SSN-593%29

         

        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: Michael Mulligan <steamshovel2002@...>
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Sent: Sun, February 27, 2011 1:02:24 PM
        Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

         

        Bill,

         

        Type 6

         

        I wonder if all the actions coming out of 1993 and 9/11 are reversible? Is all the stuff we did to enhance our protection against terrorism...if the terrorism threat ended...could we return to our pre 1993 state?  Would all the increased secrecy over the last two decades to protect ourselves end?

         

        When it is over, what is going to be the countervailing force to return us to our pre 1993 state?

         

        My life has been touched through these chain of events over the terrorism issue beginning before 1993...A FBI JTTF investigation of me last year. Has your life been directly touched?  

         

        We are still not getting to the source of this...all that is causing it.

         

        I think the most dangerous thing in the USA, say with the nuclear industry, is to withdrawal the public oversight of security related issues. This idea that in order to protect us we got to let people who have a vested interest in minimizing security to be exclusively in charge of terrorism related protection activities. Only people with a certain ideology are qualified to hold the secrets of nuclear industry...is that is what we have become. The most damaging thing to our society is to create a small exclusive cadre of experts being only in charge of our security and they only having transparency of the system... thinking their corporatism knows what is best for us with terrorism. Now does Israel knows this truth beyond anyone.   

         

        In our latest Saudi near miss it was the "us" of us all that unidentified this threat. The so called experts were helpless at the emergent level. Our security depends on the good people of our society always being in the front lines of all our wars...the eyes, ears and brains behind our national security stance. We are strongest when we all act together as one against the forces that are out to destroy us. We sink or swim, rich or poor, together. It utterly repugnant when a facility thinks the community are the first terrorist. Put a severe secrecy shield up, so the community can't see the sins of security system and their managers. The gaming of societal protection is unbelievable at this stage of the game. It is all about the power system trying to protect themselves from the cost and shortcomings of the protecting the community....It is about if the terrorist gets through their thin arrogant defenses and they being not held accountable...    

         

        If we as a community member become interested in the quality of security around a facility...the first thing they do is call you a terrorist sympathizer and call in the Feds.

         

        It is this continuous thing in our society where we split our community into the "them" and "us"...the privileged and the used.

         

        If a facility is floundering around near death will they show their security secrets as a public relation stunt in a quest for survival?  Would you?

         

        Does al-Qaeda and these well financed wild eyed Saudis engineering students think a dying facility is more vulnerable to terrorism than a thriving facility? I am getting close to those three words the FBI JTTF warned me to never use together ever again in one message.  

         

        I will just say it straight out, talking about that part 26 fatigue NRC commissioner meeting. The ghost stories.  I hope budget issues nationwide are not degrading the terrorism protections at nuclear power plants? I sense a lot of employee frustrations over the security related employee fatigue issues. The idea that a security officer would disclose to the commissioners that he has to seek a outside second job in order to support his family is very troubling. The idea that outside working hours maliciously not be reported as fatigue or regulated working hours because a security manager is upset with not getting enough income at a facility. Is morale and income troubles...security related budget problems...is that degrading the security related stance at our nuclear plants.     

         

         

        Mike     

         

         

          

         


        From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
        To: RCSOTP1 <Root_Cause_State_of_the_Practice@yahoogroups.com>
        Sent: Sat, February 26, 2011 5:03:29 AM
        Subject: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

         

        On Feb. 26, 1993, a bomb exploded in the garage of New York's World Trade Center, killing six people and injuring more

         

         

        than 1,000 others.

         

         

         

        What type of a precursor was this? What are the lessons to be learned?

         

         

         

         

        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.

         

         

         

      • Sam Hobbs
        Dr. Bill, Why do you refer to the paper as a “somewhat” dated view? Introductory or preliminary perhaps, but not necessarily “dated.” Sam From:
        Message 3 of 17 , Mar 1, 2011

          Dr. Bill,

           

          Why do you refer to the paper as a “somewhat” dated view? Introductory or preliminary perhaps, but not necessarily “dated.”

           

          Sam

           

          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
          Sent: Tuesday, March 01, 2011 7:51 AM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: Re: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

           

           

          Andy,

          Thanks ever so much for weighing in on this one.

          Would you be so kind as to give some real life examples of the two dysfunctional approaches to precursors?

          OBTW: "The Rootician's Dictionary" currently gives the following definition for "precursor."


          A precursor is a situation that has some, but usually not all, of the ingredients of a subsequent highly consequential situation.



          Do you have a better definition?

          For a somewhat dated approach to precursors visit page79 at:


          http://books.google.com/books?id=96JEnmy3H2YC&pg=PA79&dq=corcoran+precursor&hl=en&ei=U-tsTcHCKoLJgQf44dT6Aw&sa=X&oi=book_result&ct=result&resnum=1&ved=0CCwQ6AEwAA#v=onepage&q=corcoran%20precursor&f=false


           

           

           

          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: "Hobbs, Andrew F (HBS)" <afhobbs@...>
          To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
          Sent: Tue, March 1, 2011 7:20:38 AM
          Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

           

          Before we get into what a precursor is, I would suggest that we discuss for a moment the circumstances in which things labeled as “precursors” are generated or identified.

           

          It seems to me that there are two:

           

          -          a retrospective observation made with the benefit of hindsight

          -          a forecasting prediction made (mostly) based on experience and (perceived) understanding of the system and its current state

           

          It is obvious that the first has the greatest probability of being “right.”  The downside from the perspective of truth is that we probably didn’t know then what we know now when tagging something in the past as a precursor to what we now know has happened.  Dekker speaks of “data availability” vs. “data observability,” and the two are obviously not the same.  In my experience regulators have a tendency to point to things in the past after an accident and find “precursors” and thus chastise the operator/contractor for not having realized that they were such and thus prevented the accident from occurring.

           

          The second circumstance is the one in which we strive to be “proactive” and take action based on what we do know now and try to prevent something we believe will occur if we otherwise take no action to prevent it.  Though well-meaning and perhaps even necessary, this approach usually forgets that our understanding of the current state of the system is incomplete.  By making changes to the system in order to prevent one bad outcome, may very well result in another bad or even worse outcome because we didn’t fully understand how our changes would affect the entire system.  That doesn’t mean that we shouldn’t try to be proactive (even though we are really being reactive, just sooner in terms of the projected worse outcome), but we should do so with caution lest we think ourselves omniscient and become overconfident in our understanding of the complex socio-technical systems we have created.

           

          Thoughts?

           

          Andy Hobbs

          Y12 National Security Complex

          Issues Management Specialist for UPF Project

          Root Cause Analyst / HPI Practicioner

          office: 574-0812

           

          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
          Sent: Monday, February 28, 2011 5:14 PM
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

           

           

          Mike,

          Good point.

          What do you call a precursor if the next event hasn't happened?

          We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

          And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

           

          Take care,
           
          Bill Corcoran
          Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
          Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
          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: Michael Mulligan <steamshovel2002@...>
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Sent: Mon, February 28, 2011 11:21:32 AM
          Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

           

          Bill,

           

          Well, the Deepwater Horizon and the Presidential National Commission on the blow out of the Macondo well in the Gulf Of Mexico is a type 6 precursor?

           

          I suppose you can't call it a precursor if the next event hasn't happened?

           

          Mike 

           


          From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Sent: Mon, February 28, 2011 6:14:37 AM
          Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

           

          Mike,

          I agree on your choice.

          "The Rootician's Dictionary" defines a Type 6 Precursor thus:


          A consequential event that gets root cause analysis and corrective action and precedes another event whose causal factors include ones that were part of the previous event but were not identified and/or fixed.


          Does any one have other examples of Type 6 Precursors?

          Was the sinking of the USS Squalus (SS 192) a precursor to the sinking of the USS Thresher (SSN 593)? Which type of precursor? How did you decide?

          Useful links

          http://en.wikipedia.org/wiki/USS_Sailfish_%28SS-192%29

          http://en.wikipedia.org/wiki/USS_Thresher_%28SSN-593%29

           

          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: Michael Mulligan <steamshovel2002@...>
          To: Root_Cause_State_of_the_Practice@yahoogroups.com
          Sent: Sun, February 27, 2011 1:02:24 PM
          Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

           

          Bill,

           

          Type 6

           

          I wonder if all the actions coming out of 1993 and 9/11 are reversible? Is all the stuff we did to enhance our protection against terrorism...if the terrorism threat ended...could we return to our pre 1993 state?  Would all the increased secrecy over the last two decades to protect ourselves end?

           

          When it is over, what is going to be the countervailing force to return us to our pre 1993 state?

           

          My life has been touched through these chain of events over the terrorism issue beginning before 1993...A FBI JTTF investigation of me last year. Has your life been directly touched?  

           

          We are still not getting to the source of this...all that is causing it.

           

          I think the most dangerous thing in the USA, say with the nuclear industry, is to withdrawal the public oversight of security related issues. This idea that in order to protect us we got to let people who have a vested interest in minimizing security to be exclusively in charge of terrorism related protection activities. Only people with a certain ideology are qualified to hold the secrets of nuclear industry...is that is what we have become. The most damaging thing to our society is to create a small exclusive cadre of experts being only in charge of our security and they only having transparency of the system... thinking their corporatism knows what is best for us with terrorism. Now does Israel knows this truth beyond anyone.   

           

          In our latest Saudi near miss it was the "us" of us all that unidentified this threat. The so called experts were helpless at the emergent level. Our security depends on the good people of our society always being in the front lines of all our wars...the eyes, ears and brains behind our national security stance. We are strongest when we all act together as one against the forces that are out to destroy us. We sink or swim, rich or poor, together. It utterly repugnant when a facility thinks the community are the first terrorist. Put a severe secrecy shield up, so the community can't see the sins of security system and their managers. The gaming of societal protection is unbelievable at this stage of the game. It is all about the power system trying to protect themselves from the cost and shortcomings of the protecting the community....It is about if the terrorist gets through their thin arrogant defenses and they being not held accountable...    

           

          If we as a community member become interested in the quality of security around a facility...the first thing they do is call you a terrorist sympathizer and call in the Feds.

           

          It is this continuous thing in our society where we split our community into the "them" and "us"...the privileged and the used.

           

          If a facility is floundering around near death will they show their security secrets as a public relation stunt in a quest for survival?  Would you?

           

          Does al-Qaeda and these well financed wild eyed Saudis engineering students think a dying facility is more vulnerable to terrorism than a thriving facility? I am getting close to those three words the FBI JTTF warned me to never use together ever again in one message.  

           

          I will just say it straight out, talking about that part 26 fatigue NRC commissioner meeting. The ghost stories.  I hope budget issues nationwide are not degrading the terrorism protections at nuclear power plants? I sense a lot of employee frustrations over the security related employee fatigue issues. The idea that a security officer would disclose to the commissioners that he has to seek a outside second job in order to support his family is very troubling. The idea that outside working hours maliciously not be reported as fatigue or regulated working hours because a security manager is upset with not getting enough income at a facility. Is morale and income troubles...security related budget problems...is that degrading the security related stance at our nuclear plants.     

           

           

          Mike     

           

           

            

           


          From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
          To: RCSOTP1 <Root_Cause_State_of_the_Practice@yahoogroups.com>
          Sent: Sat, February 26, 2011 5:03:29 AM
          Subject: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

           

          On Feb. 26, 1993, a bomb exploded in the garage of New York's World Trade Center, killing six people and injuring more

           

           

          than 1,000 others.

           

           

           

          What type of a precursor was this? What are the lessons to be learned?

           

           

           

           

          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.

           

           

           

        • DR WILLIAM CORCORAN
          Sam, Thanks. There are more precursor types in The Rootician s Dictionary. Take care, Bill Corcoran Mission: Saving lives, pain, assets, and careers through
          Message 4 of 17 , Mar 1, 2011
            Sam,

            Thanks.

            There are more precursor types in "The Rootician's Dictionary."
             
            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: Sam Hobbs <sam.h.hobbs@...>
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Sent: Tue, March 1, 2011 8:32:51 AM
            Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

             

            Dr. Bill,

             

            Why do you refer to the paper as a “somewhat” dated view? Introductory or preliminary perhaps, but not necessarily “dated.”

             

            Sam

             

            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
            Sent: Tuesday, March 01, 2011 7:51 AM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: Re: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

             

             

            Andy,

            Thanks ever so much for weighing in on this one.

            Would you be so kind as to give some real life examples of the two dysfunctional approaches to precursors?

            OBTW: "The Rootician's Dictionary" currently gives the following definition for "precursor."


            A precursor is a situation that has some, but usually not all, of the ingredients of a subsequent highly consequential situation.



            Do you have a better definition?

            For a somewhat dated approach to precursors visit page79 at:


            http://books.google.com/books?id=96JEnmy3H2YC&pg=PA79&dq=corcoran+precursor&hl=en&ei=U-tsTcHCKoLJgQf44dT6Aw&sa=X&oi=book_result&ct=result&resnum=1&ved=0CCwQ6AEwAA#v=onepage&q=corcoran%20precursor&f=false


             

             

             

            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: "Hobbs, Andrew F (HBS)" <afhobbs@...>
            To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
            Sent: Tue, March 1, 2011 7:20:38 AM
            Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

             

            Before we get into what a precursor is, I would suggest that we discuss for a moment the circumstances in which things labeled as “precursors” are generated or identified.

             

            It seems to me that there are two:

             

            -          a retrospective observation made with the benefit of hindsight

            -          a forecasting prediction made (mostly) based on experience and (perceived) understanding of the system and its current state

             

            It is obvious that the first has the greatest probability of being “right.”  The downside from the perspective of truth is that we probably didn’t know then what we know now when tagging something in the past as a precursor to what we now know has happened.  Dekker speaks of “data availability” vs. “data observability,” and the two are obviously not the same.  In my experience regulators have a tendency to point to things in the past after an accident and find “precursors” and thus chastise the operator/contractor for not having realized that they were such and thus prevented the accident from occurring.

             

            The second circumstance is the one in which we strive to be “proactive” and take action based on what we do know now and try to prevent something we believe will occur if we otherwise take no action to prevent it.  Though well-meaning and perhaps even necessary, this approach usually forgets that our understanding of the current state of the system is incomplete.  By making changes to the system in order to prevent one bad outcome, may very well result in another bad or even worse outcome because we didn’t fully understand how our changes would affect the entire system.  That doesn’t mean that we shouldn’t try to be proactive (even though we are really being reactive, just sooner in terms of the projected worse outcome), but we should do so with caution lest we think ourselves omniscient and become overconfident in our understanding of the complex socio-technical systems we have created.

             

            Thoughts?

             

            Andy Hobbs

            Y12 National Security Complex

            Issues Management Specialist for UPF Project

            Root Cause Analyst / HPI Practicioner

            office: 574-0812

             

            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
            Sent: Monday, February 28, 2011 5:14 PM
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

             

             

            Mike,

            Good point.

            What do you call a precursor if the next event hasn't happened?

            We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

            And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

             

            Take care,
             
            Bill Corcoran
            Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
            Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
            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: Michael Mulligan <steamshovel2002@...>
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Sent: Mon, February 28, 2011 11:21:32 AM
            Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

             

            Bill,

             

            Well, the Deepwater Horizon and the Presidential National Commission on the blow out of the Macondo well in the Gulf Of Mexico is a type 6 precursor?

             

            I suppose you can't call it a precursor if the next event hasn't happened?

             

            Mike 

             


            From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Sent: Mon, February 28, 2011 6:14:37 AM
            Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

             

            Mike,

            I agree on your choice.

            "The Rootician's Dictionary" defines a Type 6 Precursor thus:


            A consequential event that gets root cause analysis and corrective action and precedes another event whose causal factors include ones that were part of the previous event but were not identified and/or fixed.


            Does any one have other examples of Type 6 Precursors?

            Was the sinking of the USS Squalus (SS 192) a precursor to the sinking of the USS Thresher (SSN 593)? Which type of precursor? How did you decide?

            Useful links

            http://en.wikipedia.org/wiki/USS_Sailfish_%28SS-192%29

            http://en.wikipedia.org/wiki/USS_Thresher_%28SSN-593%29

             

            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: Michael Mulligan <steamshovel2002@...>
            To: Root_Cause_State_of_the_Practice@yahoogroups.com
            Sent: Sun, February 27, 2011 1:02:24 PM
            Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

             

            Bill,

             

            Type 6

             

            I wonder if all the actions coming out of 1993 and 9/11 are reversible? Is all the stuff we did to enhance our protection against terrorism...if the terrorism threat ended...could we return to our pre 1993 state?  Would all the increased secrecy over the last two decades to protect ourselves end?

             

            When it is over, what is going to be the countervailing force to return us to our pre 1993 state?

             

            My life has been touched through these chain of events over the terrorism issue beginning before 1993...A FBI JTTF investigation of me last year. Has your life been directly touched?  

             

            We are still not getting to the source of this...all that is causing it.

             

            I think the most dangerous thing in the USA, say with the nuclear industry, is to withdrawal the public oversight of security related issues. This idea that in order to protect us we got to let people who have a vested interest in minimizing security to be exclusively in charge of terrorism related protection activities. Only people with a certain ideology are qualified to hold the secrets of nuclear industry...is that is what we have become. The most damaging thing to our society is to create a small exclusive cadre of experts being only in charge of our security and they only having transparency of the system... thinking their corporatism knows what is best for us with terrorism. Now does Israel knows this truth beyond anyone.   

             

            In our latest Saudi near miss it was the "us" of us all that unidentified this threat. The so called experts were helpless at the emergent level. Our security depends on the good people of our society always being in the front lines of all our wars...the eyes, ears and brains behind our national security stance. We are strongest when we all act together as one against the forces that are out to destroy us. We sink or swim, rich or poor, together. It utterly repugnant when a facility thinks the community are the first terrorist. Put a severe secrecy shield up, so the community can't see the sins of security system and their managers. The gaming of societal protection is unbelievable at this stage of the game. It is all about the power system trying to protect themselves from the cost and shortcomings of the protecting the community....It is about if the terrorist gets through their thin arrogant defenses and they being not held accountable...    

             

            If we as a community member become interested in the quality of security around a facility...the first thing they do is call you a terrorist sympathizer and call in the Feds.

             

            It is this continuous thing in our society where we split our community into the "them" and "us"...the privileged and the used.

             

            If a facility is floundering around near death will they show their security secrets as a public relation stunt in a quest for survival?  Would you?

             

            Does al-Qaeda and these well financed wild eyed Saudis engineering students think a dying facility is more vulnerable to terrorism than a thriving facility? I am getting close to those three words the FBI JTTF warned me to never use together ever again in one message.  

             

            I will just say it straight out, talking about that part 26 fatigue NRC commissioner meeting. The ghost stories.  I hope budget issues nationwide are not degrading the terrorism protections at nuclear power plants? I sense a lot of employee frustrations over the security related employee fatigue issues. The idea that a security officer would disclose to the commissioners that he has to seek a outside second job in order to support his family is very troubling. The idea that outside working hours maliciously not be reported as fatigue or regulated working hours because a security manager is upset with not getting enough income at a facility. Is morale and income troubles...security related budget problems...is that degrading the security related stance at our nuclear plants.     

             

             

            Mike     

             

             

              

             


            From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
            To: RCSOTP1 <Root_Cause_State_of_the_Practice@yahoogroups.com>
            Sent: Sat, February 26, 2011 5:03:29 AM
            Subject: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

             

            On Feb. 26, 1993, a bomb exploded in the garage of New York's World Trade Center, killing six people and injuring more

             

             

            than 1,000 others.

             

             

             

            What type of a precursor was this? What are the lessons to be learned?

             

             

             

             

            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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          • Michael Mulligan
            Hmm, how do you weight the risk of the results of action and inaction?   I can think of a host of cascade accidents...TMI being one of our tiny examples.
            Message 5 of 17 , Mar 1, 2011

              Hmm, how do you weight the risk of the results of action and inaction?

               

              I can think of a host of cascade accidents...TMI being one of our "tiny" examples. You had a equipment failure...then a sequential set of operational and organization failures...the media and political system going haywire...what do we think of all the excesses as the energy of the cascade is expended? What do we think of initial weak signal and then the humongous amplification? These cascades accidents that develop slowly and with blatant symptoms right in front of our eyes. I don't understand why we aren't more terrified of all the energy they slowly collect. The core damage ended up being insignificant compared to the existent threat to the whole industry and our national energy security. You can make a case this threw them into a later protective and secrecy model where growth and technological advancement was impossible.

               

              Wall Street and our economy is an example of a another cascade accident...Certainly Egypt and the Middle East is about a system becoming more brittle and more closely coupled. More coupled through the continued pain and injustice of a increasing population of restless young people. The idea that the suffering and powerlessness is what we got in common, then lessening dictatorship opacity though facebook, cell phones and technological advancement melting away communication barriers and decades of dictatorships. Don't forget Chaos theory and the flapping of a butterfly's wing causing a catastrophe a continent away.

               

              You rattle and shake these complex socio-technical systems...the end result is you can see a new facet of the system, than when it wasn't stressed. Are we better not knowing what is going on behind the curtains? I think we live better when we risk understanding the system, than in the risk of accepting the stable system...or the unnaturally quiet system.

               

              I have been there wondering what this switch does and then flipping it...with astonishing unbelievable things happening that has affected many people. I discovered a lot from it, I am certain we as a nation missed the clear signals this event gave us.

               

              "we think ourselves omniscient and become overconfident in our understanding of the complex socio-technical systems we have create"...Remember we can become omniscient and overconfident though our human relationships and incentives in complex socio-technical systems, and this distances us from wanting to understand the complex systems. So what are the motives with not understanding why we don't understand complex socio-technical systems...

               

              Isn't that the ultimate root cause of all our troubles in the complex systems, in that we don't have the instincts to be vigilant with the changes that are occurring. Why are we even running these systems without the proper understanding of the complex socio-technical systems?

               

              And yet another problem, sometimes we are incentivized to not know what the complex socio-technical systems are doing or changing...




              From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Sent: Tue, March 1, 2011 8:38:56 AM
              Subject: Re: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

               

              Sam,

              Thanks.

              There are more precursor types in "The Rootician's Dictionary."
               
              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: Sam Hobbs <sam.h.hobbs@...>
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Sent: Tue, March 1, 2011 8:32:51 AM
              Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

               

              Dr. Bill,

               

              Why do you refer to the paper as a “somewhat” dated view? Introductory or preliminary perhaps, but not necessarily “dated.”

               

              Sam

               

              From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
              Sent: Tuesday, March 01, 2011 7:51 AM
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Subject: Re: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

               

               

              Andy,

              Thanks ever so much for weighing in on this one.

              Would you be so kind as to give some real life examples of the two dysfunctional approaches to precursors?

              OBTW: "The Rootician's Dictionary" currently gives the following definition for "precursor."


              A precursor is a situation that has some, but usually not all, of the ingredients of a subsequent highly consequential situation.



              Do you have a better definition?

              For a somewhat dated approach to precursors visit page79 at:


              http://books.google.com/books?id=96JEnmy3H2YC&pg=PA79&dq=corcoran+precursor&hl=en&ei=U-tsTcHCKoLJgQf44dT6Aw&sa=X&oi=book_result&ct=result&resnum=1&ved=0CCwQ6AEwAA#v=onepage&q=corcoran%20precursor&f=false


               

               

               

              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: "Hobbs, Andrew F (HBS)" <afhobbs@...>
              To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
              Sent: Tue, March 1, 2011 7:20:38 AM
              Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

               

              Before we get into what a precursor is, I would suggest that we discuss for a moment the circumstances in which things labeled as “precursors” are generated or identified.

               

              It seems to me that there are two:

               

              -          a retrospective observation made with the benefit of hindsight

              -          a forecasting prediction made (mostly) based on experience and (perceived) understanding of the system and its current state

               

              It is obvious that the first has the greatest probability of being “right.”  The downside from the perspective of truth is that we probably didn’t know then what we know now when tagging something in the past as a precursor to what we now know has happened.  Dekker speaks of “data availability” vs. “data observability,” and the two are obviously not the same.  In my experience regulators have a tendency to point to things in the past after an accident and find “precursors” and thus chastise the operator/contractor for not having realized that they were such and thus prevented the accident from occurring.

               

              The second circumstance is the one in which we strive to be “proactive” and take action based on what we do know now and try to prevent something we believe will occur if we otherwise take no action to prevent it.  Though well-meaning and perhaps even necessary, this approach usually forgets that our understanding of the current state of the system is incomplete.  By making changes to the system in order to prevent one bad outcome, may very well result in another bad or even worse outcome because we didn’t fully understand how our changes would affect the entire system.  That doesn’t mean that we shouldn’t try to be proactive (even though we are really being reactive, just sooner in terms of the projected worse outcome), but we should do so with caution lest we think ourselves omniscient and become overconfident in our understanding of the complex socio-technical systems we have created.

               

              Thoughts?

               

              Andy Hobbs

              Y12 National Security Complex

              Issues Management Specialist for UPF Project

              Root Cause Analyst / HPI Practicioner

              office: 574-0812

               

              From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
              Sent: Monday, February 28, 2011 5:14 PM
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

               

               

              Mike,

              Good point.

              What do you call a precursor if the next event hasn't happened?

              We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

              And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

               

              Take care,
               
              Bill Corcoran
              Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
              Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
              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: Michael Mulligan <steamshovel2002@...>
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Sent: Mon, February 28, 2011 11:21:32 AM
              Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

               

              Bill,

               

              Well, the Deepwater Horizon and the Presidential National Commission on the blow out of the Macondo well in the Gulf Of Mexico is a type 6 precursor?

               

              I suppose you can't call it a precursor if the next event hasn't happened?

               

              Mike 

               


              From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Sent: Mon, February 28, 2011 6:14:37 AM
              Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

               

              Mike,

              I agree on your choice.

              "The Rootician's Dictionary" defines a Type 6 Precursor thus:


              A consequential event that gets root cause analysis and corrective action and precedes another event whose causal factors include ones that were part of the previous event but were not identified and/or fixed.


              Does any one have other examples of Type 6 Precursors?

              Was the sinking of the USS Squalus (SS 192) a precursor to the sinking of the USS Thresher (SSN 593)? Which type of precursor? How did you decide?

              Useful links

              http://en.wikipedia.org/wiki/USS_Sailfish_%28SS-192%29

              http://en.wikipedia.org/wiki/USS_Thresher_%28SSN-593%29

               

              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: Michael Mulligan <steamshovel2002@...>
              To: Root_Cause_State_of_the_Practice@yahoogroups.com
              Sent: Sun, February 27, 2011 1:02:24 PM
              Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

               

              Bill,

               

              Type 6

               

              I wonder if all the actions coming out of 1993 and 9/11 are reversible? Is all the stuff we did to enhance our protection against terrorism...if the terrorism threat ended...could we return to our pre 1993 state?  Would all the increased secrecy over the last two decades to protect ourselves end?

               

              When it is over, what is going to be the countervailing force to return us to our pre 1993 state?

               

              My life has been touched through these chain of events over the terrorism issue beginning before 1993...A FBI JTTF investigation of me last year. Has your life been directly touched?  

               

              We are still not getting to the source of this...all that is causing it.

               

              I think the most dangerous thing in the USA, say with the nuclear industry, is to withdrawal the public oversight of security related issues. This idea that in order to protect us we got to let people who have a vested interest in minimizing security to be exclusively in charge of terrorism related protection activities. Only people with a certain ideology are qualified to hold the secrets of nuclear industry...is that is what we have become. The most damaging thing to our society is to create a small exclusive cadre of experts being only in charge of our security and they only having transparency of the system... thinking their corporatism knows what is best for us with terrorism. Now does Israel knows this truth beyond anyone.   

               

              In our latest Saudi near miss it was the "us" of us all that unidentified this threat. The so called experts were helpless at the emergent level. Our security depends on the good people of our society always being in the front lines of all our wars...the eyes, ears and brains behind our national security stance. We are strongest when we all act together as one against the forces that are out to destroy us. We sink or swim, rich or poor, together. It utterly repugnant when a facility thinks the community are the first terrorist. Put a severe secrecy shield up, so the community can't see the sins of security system and their managers. The gaming of societal protection is unbelievable at this stage of the game. It is all about the power system trying to protect themselves from the cost and shortcomings of the protecting the community....It is about if the terrorist gets through their thin arrogant defenses and they being not held accountable...    

               

              If we as a community member become interested in the quality of security around a facility...the first thing they do is call you a terrorist sympathizer and call in the Feds.

               

              It is this continuous thing in our society where we split our community into the "them" and "us"...the privileged and the used.

               

              If a facility is floundering around near death will they show their security secrets as a public relation stunt in a quest for survival?  Would you?

               

              Does al-Qaeda and these well financed wild eyed Saudis engineering students think a dying facility is more vulnerable to terrorism than a thriving facility? I am getting close to those three words the FBI JTTF warned me to never use together ever again in one message.  

               

              I will just say it straight out, talking about that part 26 fatigue NRC commissioner meeting. The ghost stories.  I hope budget issues nationwide are not degrading the terrorism protections at nuclear power plants? I sense a lot of employee frustrations over the security related employee fatigue issues. The idea that a security officer would disclose to the commissioners that he has to seek a outside second job in order to support his family is very troubling. The idea that outside working hours maliciously not be reported as fatigue or regulated working hours because a security manager is upset with not getting enough income at a facility. Is morale and income troubles...security related budget problems...is that degrading the security related stance at our nuclear plants.     

               

               

              Mike     

               

               

                

               


              From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
              To: RCSOTP1 <Root_Cause_State_of_the_Practice@yahoogroups.com>
              Sent: Sat, February 26, 2011 5:03:29 AM
              Subject: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

               

              On Feb. 26, 1993, a bomb exploded in the garage of New York's World Trade Center, killing six people and injuring more

               

               

              than 1,000 others.

               

               

               

              What type of a precursor was this? What are the lessons to be learned?

               

               

               

               

              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.

               

               

               


            • Mitchell, Glen
              Aren’t we really looking in hindsight even in the preemptive mode? It seems to me the precursors “forecasted” in even a new process/design are only
              Message 6 of 17 , Mar 1, 2011

                Aren’t we really looking in hindsight even in the preemptive mode? It seems to me the precursors “forecasted” in even a new process/design are only recognized from someone’s past experience we are applying to a current situation.

                Also, there is a danger in creating new precursors by trying to prevent/mitigate from another seen in hindsight.

                Example: Creating time pressure by adding review/ verifications to an already time-stressed resource or task. 

                Also, any change should be identified as a precursor needing prevention/mitigation.

                 

                glen

                806-477-4953

                 

                From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of Hobbs, Andrew F (HBS)
                Sent: Tuesday, March 01, 2011 6:21 AM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                 

                 

                Before we get into what a precursor is, I would suggest that we discuss for a moment the circumstances in which things labeled as “precursors” are generated or identified.

                 

                It seems to me that there are two:

                 

                -          a retrospective observation made with the benefit of hindsight

                -          a forecasting prediction made (mostly) based on experience and (perceived) understanding of the system and its current state

                 

                It is obvious that the first has the greatest probability of being “right.”  The downside from the perspective of truth is that we probably didn’t know then what we know now when tagging something in the past as a precursor to what we now know has happened.  Dekker speaks of “data availability” vs. “data observability,” and the two are obviously not the same.  In my experience regulators have a tendency to point to things in the past after an accident and find “precursors” and thus chastise the operator/contractor for not having realized that they were such and thus prevented the accident from occurring.

                 

                The second circumstance is the one in which we strive to be “proactive” and take action based on what we do know now and try to prevent something we believe will occur if we otherwise take no action to prevent it.  Though well-meaning and perhaps even necessary, this approach usually forgets that our understanding of the current state of the system is incomplete.  By making changes to the system in order to prevent one bad outcome, may very well result in another bad or even worse outcome because we didn’t fully understand how our changes would affect the entire system.  That doesn’t mean that we shouldn’t try to be proactive (even though we are really being reactive, just sooner in terms of the projected worse outcome), but we should do so with caution lest we think ourselves omniscient and become overconfident in our understanding of the complex socio-technical systems we have created.

                 

                Thoughts?

                 

                Andy Hobbs

                Y12 National Security Complex

                Issues Management Specialist for UPF Project

                Root Cause Analyst / HPI Practicioner

                office: 574-0812

                 

                From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                Sent: Monday, February 28, 2011 5:14 PM
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                 

                 

                Mike,

                Good point.

                What do you call a precursor if the next event hasn't happened?

                We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

                And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

                 

                Take care,
                 
                Bill Corcoran
                Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                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: Michael Mulligan <steamshovel2002@...>
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Sent: Mon, February 28, 2011 11:21:32 AM
                Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                 

                Bill,

                 

                Well, the Deepwater Horizon and the Presidential National Commission on the blow out of the Macondo well in the Gulf Of Mexico is a type 6 precursor?

                 

                I suppose you can't call it a precursor if the next event hasn't happened?

                 

                Mike 

                 


                From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Sent: Mon, February 28, 2011 6:14:37 AM
                Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                 

                Mike,

                I agree on your choice.

                "The Rootician's Dictionary" defines a Type 6 Precursor thus:


                A consequential event that gets root cause analysis and corrective action and precedes another event whose causal factors include ones that were part of the previous event but were not identified and/or fixed.


                Does any one have other examples of Type 6 Precursors?

                Was the sinking of the USS Squalus (SS 192) a precursor to the sinking of the USS Thresher (SSN 593)? Which type of precursor? How did you decide?

                Useful links

                http://en.wikipedia.org/wiki/USS_Sailfish_%28SS-192%29

                http://en.wikipedia.org/wiki/USS_Thresher_%28SSN-593%29

                 

                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: Michael Mulligan <steamshovel2002@...>
                To: Root_Cause_State_of_the_Practice@yahoogroups.com
                Sent: Sun, February 27, 2011 1:02:24 PM
                Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                 

                Bill,

                 

                Type 6

                 

                I wonder if all the actions coming out of 1993 and 9/11 are reversible? Is all the stuff we did to enhance our protection against terrorism...if the terrorism threat ended...could we return to our pre 1993 state?  Would all the increased secrecy over the last two decades to protect ourselves end?

                 

                When it is over, what is going to be the countervailing force to return us to our pre 1993 state?

                 

                My life has been touched through these chain of events over the terrorism issue beginning before 1993...A FBI JTTF investigation of me last year. Has your life been directly touched?  

                 

                We are still not getting to the source of this...all that is causing it.

                 

                I think the most dangerous thing in the USA, say with the nuclear industry, is to withdrawal the public oversight of security related issues. This idea that in order to protect us we got to let people who have a vested interest in minimizing security to be exclusively in charge of terrorism related protection activities. Only people with a certain ideology are qualified to hold the secrets of nuclear industry...is that is what we have become. The most damaging thing to our society is to create a small exclusive cadre of experts being only in charge of our security and they only having transparency of the system... thinking their corporatism knows what is best for us with terrorism. Now does Israel knows this truth beyond anyone.   

                 

                In our latest Saudi near miss it was the "us" of us all that unidentified this threat. The so called experts were helpless at the emergent level. Our security depends on the good people of our society always being in the front lines of all our wars...the eyes, ears and brains behind our national security stance. We are strongest when we all act together as one against the forces that are out to destroy us. We sink or swim, rich or poor, together. It utterly repugnant when a facility thinks the community are the first terrorist. Put a severe secrecy shield up, so the community can't see the sins of security system and their managers. The gaming of societal protection is unbelievable at this stage of the game. It is all about the power system trying to protect themselves from the cost and shortcomings of the protecting the community....It is about if the terrorist gets through their thin arrogant defenses and they being not held accountable...    

                 

                If we as a community member become interested in the quality of security around a facility...the first thing they do is call you a terrorist sympathizer and call in the Feds.

                 

                It is this continuous thing in our society where we split our community into the "them" and "us"...the privileged and the used.

                 

                If a facility is floundering around near death will they show their security secrets as a public relation stunt in a quest for survival?  Would you?

                 

                Does al-Qaeda and these well financed wild eyed Saudis engineering students think a dying facility is more vulnerable to terrorism than a thriving facility? I am getting close to those three words the FBI JTTF warned me to never use together ever again in one message.  

                 

                I will just say it straight out, talking about that part 26 fatigue NRC commissioner meeting. The ghost stories.  I hope budget issues nationwide are not degrading the terrorism protections at nuclear power plants? I sense a lot of employee frustrations over the security related employee fatigue issues. The idea that a security officer would disclose to the commissioners that he has to seek a outside second job in order to support his family is very troubling. The idea that outside working hours maliciously not be reported as fatigue or regulated working hours because a security manager is upset with not getting enough income at a facility. Is morale and income troubles...security related budget problems...is that degrading the security related stance at our nuclear plants.     

                 

                 

                Mike     

                 

                 

                  

                 


                From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                To: RCSOTP1 <Root_Cause_State_of_the_Practice@yahoogroups.com>
                Sent: Sat, February 26, 2011 5:03:29 AM
                Subject: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                 

                On Feb. 26, 1993, a bomb exploded in the garage of New York's World Trade Center, killing six people and injuring more

                 

                 

                than 1,000 others.

                 

                 

                 

                What type of a precursor was this? What are the lessons to be learned?

                 

                 

                 

                 

                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.

                 

                 

                 

              • Mitchell, Glen
                We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions ☺ glen 806-477-4953 From:
                Message 7 of 17 , Mar 1, 2011

                  We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions J

                   

                  glen

                  806-477-4953

                   

                  From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                  Sent: Monday, February 28, 2011 4:14 PM
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                   

                   

                  Mike,

                  Good point.

                  What do you call a precursor if the next event hasn't happened?

                  We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

                  And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

                   

                  Take care,
                   
                  Bill Corcoran
                  Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
                  Motto: If you want safety, peace, or justice, then work for competency, integrity, and transparency.
                  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: Michael Mulligan <steamshovel2002@...>
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Sent: Mon, February 28, 2011 11:21:32 AM
                  Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                   

                  Bill,

                   

                  Well, the Deepwater Horizon and the Presidential National Commission on the blow out of the Macondo well in the Gulf Of Mexico is a type 6 precursor?

                   

                  I suppose you can't call it a precursor if the next event hasn't happened?

                   

                  Mike 

                   


                  From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Sent: Mon, February 28, 2011 6:14:37 AM
                  Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                   

                  Mike,

                  I agree on your choice.

                  "The Rootician's Dictionary" defines a Type 6 Precursor thus:


                  A consequential event that gets root cause analysis and corrective action and precedes another event whose causal factors include ones that were part of the previous event but were not identified and/or fixed.


                  Does any one have other examples of Type 6 Precursors?

                  Was the sinking of the USS Squalus (SS 192) a precursor to the sinking of the USS Thresher (SSN 593)? Which type of precursor? How did you decide?

                  Useful links

                  http://en.wikipedia.org/wiki/USS_Sailfish_%28SS-192%29

                  http://en.wikipedia.org/wiki/USS_Thresher_%28SSN-593%29

                   

                  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: Michael Mulligan <steamshovel2002@...>
                  To: Root_Cause_State_of_the_Practice@yahoogroups.com
                  Sent: Sun, February 27, 2011 1:02:24 PM
                  Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                   

                  Bill,

                   

                  Type 6

                   

                  I wonder if all the actions coming out of 1993 and 9/11 are reversible? Is all the stuff we did to enhance our protection against terrorism...if the terrorism threat ended...could we return to our pre 1993 state?  Would all the increased secrecy over the last two decades to protect ourselves end?

                   

                  When it is over, what is going to be the countervailing force to return us to our pre 1993 state?

                   

                  My life has been touched through these chain of events over the terrorism issue beginning before 1993...A FBI JTTF investigation of me last year. Has your life been directly touched?  

                   

                  We are still not getting to the source of this...all that is causing it.

                   

                  I think the most dangerous thing in the USA, say with the nuclear industry, is to withdrawal the public oversight of security related issues. This idea that in order to protect us we got to let people who have a vested interest in minimizing security to be exclusively in charge of terrorism related protection activities. Only people with a certain ideology are qualified to hold the secrets of nuclear industry...is that is what we have become. The most damaging thing to our society is to create a small exclusive cadre of experts being only in charge of our security and they only having transparency of the system... thinking their corporatism knows what is best for us with terrorism. Now does Israel knows this truth beyond anyone.   

                   

                  In our latest Saudi near miss it was the "us" of us all that unidentified this threat. The so called experts were helpless at the emergent level. Our security depends on the good people of our society always being in the front lines of all our wars...the eyes, ears and brains behind our national security stance. We are strongest when we all act together as one against the forces that are out to destroy us. We sink or swim, rich or poor, together. It utterly repugnant when a facility thinks the community are the first terrorist. Put a severe secrecy shield up, so the community can't see the sins of security system and their managers. The gaming of societal protection is unbelievable at this stage of the game. It is all about the power system trying to protect themselves from the cost and shortcomings of the protecting the community....It is about if the terrorist gets through their thin arrogant defenses and they being not held accountable...    

                   

                  If we as a community member become interested in the quality of security around a facility...the first thing they do is call you a terrorist sympathizer and call in the Feds.

                   

                  It is this continuous thing in our society where we split our community into the "them" and "us"...the privileged and the used.

                   

                  If a facility is floundering around near death will they show their security secrets as a public relation stunt in a quest for survival?  Would you?

                   

                  Does al-Qaeda and these well financed wild eyed Saudis engineering students think a dying facility is more vulnerable to terrorism than a thriving facility? I am getting close to those three words the FBI JTTF warned me to never use together ever again in one message.  

                   

                  I will just say it straight out, talking about that part 26 fatigue NRC commissioner meeting. The ghost stories.  I hope budget issues nationwide are not degrading the terrorism protections at nuclear power plants? I sense a lot of employee frustrations over the security related employee fatigue issues. The idea that a security officer would disclose to the commissioners that he has to seek a outside second job in order to support his family is very troubling. The idea that outside working hours maliciously not be reported as fatigue or regulated working hours because a security manager is upset with not getting enough income at a facility. Is morale and income troubles...security related budget problems...is that degrading the security related stance at our nuclear plants.     

                   

                   

                  Mike     

                   

                   

                    

                   


                  From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                  To: RCSOTP1 <Root_Cause_State_of_the_Practice@yahoogroups.com>
                  Sent: Sat, February 26, 2011 5:03:29 AM
                  Subject: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                   

                  On Feb. 26, 1993, a bomb exploded in the garage of New York's World Trade Center, killing six people and injuring more

                   

                   

                  than 1,000 others.

                   

                   

                   

                  What type of a precursor was this? What are the lessons to be learned?

                   

                   

                   

                   

                  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.

                   

                   

                   

                • DR WILLIAM CORCORAN
                  Glen, You said: ________________________________ We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions
                  Message 8 of 17 , Mar 2, 2011
                    Glen,

                    You said:


                      We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions
                    Are all CATSs and PUCs precursors?
                     
                    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: "Mitchell, Glen" <gmitchel@...>
                    To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                    Sent: Tue, March 1, 2011 12:34:48 PM
                    Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                     

                    We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions J

                     

                    glen

                    806-477-4953

                     

                    From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                    Sent: Monday, February ! 28, 2011 4:14 PM
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                     

                     

                    Mike,

                    Good point.

                    What do you call a precursor if the next event hasn't happened?

                    We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

                    And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

                     

                    Take care,
                     
                    Bill Corcoran
                    Mission: Saving lives, pain, assets, and careers through thou! ghtful 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. sha! ll be understood as neither given nor endorsed by it.

                     

                     


                    From: Michael Mulligan <steamshovel2002@...>
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Sent: Mon, February 28, 2011 11:21:32 AM
                    Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                     

                    Bill,

                     

                    We! ll, the Deepwater Horizon and the Presidential National Commission on the blow out of the Macondo well in the Gulf Of Mexico is a type 6 precursor?

                     

                    I suppose you can't call it a precursor if the next event hasn't happened?

                     

                    Mike 

                     


                    From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Sen! t: Mon, February 28, 2011 6:14:37 AM
                    Subject: Re: [Root_ Cause_State_of_the_Practice] WTC 1993 a Precursor?

                     

                    Mike,

                    I agree on your choice.

                    "The Rootician's Dictionary" defines a Type 6 Precursor thus:


                    A consequential event that gets root cause analysis and corrective action and precedes another event whose causal factors include ones that were part of the previous event but were not identified and/or fixed.


                    Does any one have other examples of Type 6 Precursors?
                    Was the sinking of the USS Squalus (SS 192) a precursor to the sinking of the USS Thresher (SSN 593)? Which type of precursor? How did you decide?

                    Useful links

                    http://en.wikipedia.org/wiki/USS_Sailfish_%28SS-192%29

                    http://en.wikipedia.org/wiki/USS_Thresher_%28SSN-593%29

                     

                    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: Michael Mulligan <steamshovel2002@...>
                    To: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Sent: Sun, February 27, 2011 1:02:24 PM
                    Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                     

                    Bill,

                     

                    Type 6

                     

                    I wonder if all the actions coming out of 1993 and 9/11 are reversible? Is all the stuff we did to enhance our protection against terrorism...if the terrorism threat ended...! could we return to our pre 1993 state?  Would all the increased secrecy over the last two decades to protect ourselves end?

                     

                    When it is over, what is going to be the countervailing force to return us to our pre 1993 state?

                     

                    My life has been touched through these chain of events over the terrorism issue beginning before 1993...A FBI JTTF investigation of me last year. Has your life been directly touched?  

                     

                    We are still not getting to the source of this...all that is causing it.

                     

                    I think the most dangerous thing in the USA, say with the nucl ear industry, is to withdrawal the public oversight of security related issues. This idea that in order to protect us we got to let people who have a vested interest in minimizing security to be exclusively in charge of terrorism related protection activities. Only people with a certain ideology are qualified to hold the secrets of nuclear industry...is that is what we have become. The most damaging thing to our society is to create a small exclusive cadre of experts being only in charge of our security and they only having transparency of the system... thinking their corporatism knows what is best for us with terrorism. Now does Israel knows this truth beyond anyone.   

                     

                    In our latest Saudi near miss it was the "us" of us all t! hat unidentified this threat. The so called experts were helpless at the emergent level. Our security depends on the good people of our society always being in the front lines of all our wars...the eyes, ears and brains behind our national security stance. We are strongest when we all act together as one against the forces that are out to destroy us. We sink or swim, rich or poor, together. It utterly repugnant when a facility thinks the community are the first terrorist. Put a severe secrecy shield up, so the community can't see the sins of security system and their managers. The gaming of societal protection is unbelievable at this stage of the game. It is all about the power system trying to protect themselves from the cost and shortcomings of the protecting the community....It is about if the terrorist gets through their thin arrogant defenses and they being not held accountable...!    

                    < span> 

                    If we as a community member become interested in the quality of security around a facility...the first thing they do is call you a terrorist sympathizer and call in the Feds.

                     

                    It is this continuous thing in our society where we split our community into the "them" and "us"...the privileged and the used.

                     

                    If a facility is floundering around near death will they show their security secrets as a public relation stunt in a quest for survival?  Would you?

                     

                    Does al-Qaeda and ! these well financed wild eyed Saudis engineering students think a dying facility is more vulnerable to terrorism than a thriving facility? I am getting close to those three words the FBI JTTF warned me to never use together ever again in one message.  

                     

                    I will just say it straight out, talking about that part 26 fatigue NRC commissioner meeting. The ghost stories.  I hope budget issues nationwide are not degrading the terrorism protections at nuclear power plants? I sense a lot of employee frustrations over the security related employee fatigue issues. The idea that a security officer would disclose to the commissioners that he has to seek a outside second job in order to support his family is very troubling. The idea that!  outside working hours maliciously not be reported as f atigue or regulated working hours because a security manager is upset with not getting enough income at a facility. Is morale and income troubles...security related budget problems...is that degrading the security related stance at our nuclear plants.     

                     

                     

                    Mike     

                     

                     

                      

                     


                    !

                    From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                    To: RCSOTP1 <Root_Cause_State_of_the_Practice@yahoogroups.com>
                    Sent: Sat, February 26, 2011 5:03:29 AM
                    Subject: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                     

                    On Feb. 26, 1993, a bomb exploded in the garage of New York's World Trade Center, killing six people and injuring more

                     

                     

                    than 1,000 others.

                    &nbs! p;

                    &nbs p;

                     

                    What type of a precursor was this? What are the lessons to be learned?

                     

                     

                     

                     

                    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.

                     

                     

                     

                  • Salot, William
                    They are PP s: potential precursors ________________________________ From: Root_Cause_State_of_the_Practice@yahoogroups.com
                    Message 9 of 17 , Mar 2, 2011

                      They are PP’s: potential precursors

                       


                      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, March 02, 2011 10:11 AM
                      To: Root_Cause_State_of_the_Practice@yahoogroups.com
                      Subject: Re: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                       

                       

                      Glen,

                      You said:



                        We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions


                      Are all CATSs and PUCs precursors?

                       

                      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: "Mitchell, Glen" <gmitchel@...>
                      To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                      Sent: Tue, March 1, 2011 12:34:48 PM
                      Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                       

                      We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions J

                       

                      glen

                      806-477-4953

                       

                      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                      Sent: Monday, February ! 28, 2011 4:14 PM
                      To: Root_Cause_State_of_the_Practice@yahoogroups.com
                      Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                       

                       

                      Mike,

                      Good point.

                      What do you call a precursor if the next event hasn't happened?

                      We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

                      And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

                       

                      Take care,
                       
                      Bill Corcoran
                      Mission : Saving lives, pain, assets, and careers through thou! ghtful 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

                       

                    • Dillard, Tedd A (E S SF RNA FS 1 1 E)
                      It seems to me that the use of the word precursor is so dependent on the understanding of the listener that it is unhelpful to have so many different
                      Message 10 of 17 , Mar 2, 2011
                        It seems to me that the use of the word precursor is so dependent on the understanding of the listener that it is unhelpful to have so many different definitions of the word.
                        Especially definitions that are only relevant to our little part of the world.
                        The best description I found in the Rooticians Dictionary  was a comment in elaboration 1 of the type 2 precursor definition, "Comment: The same precursor can be classified in more than one way, so that the actual classification of a precursor is not all that important."
                        Looking at definitions in the wider view it appears that there are really only two, 1. A thing is a necessary contributor of a specific following event to happen, or 2. A thing is only an indicator of a following event but not a causal factor.
                        Tedd


                        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, March 02, 2011 12:48 PM
                        To: Root_Cause_State_of_the_Practice@yahoogroups.com
                        Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                         

                        They are PP’s: potential precursors


                        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, March 02, 2011 10:11 AM
                        To: Root_Cause_State_of_the_Practice@yahoogroups.com
                        Subject: Re: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                         

                        Glen,

                        You said:



                          We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions


                        Are all CATSs and PUCs precursors?

                        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: "Mitchell, Glen" <gmitchel@...>
                        To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                        Sent: Tue, March 1, 2011 12:34:48 PM
                        Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                         

                        We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions J

                        glen

                        806-477-4953

                        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                        Sent: Monday, February ! 28, 2011 4:14 PM
                        To: Root_Cause_State_of_the_Practice@yahoogroups.com
                        Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                         

                        Mike,

                        Good point.

                        What do you call a precursor if the next event hasn't happened?

                        We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

                        And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

                        Take care,
                         
                        Bill Corcoran
                        Mission : Saving lives, pain, assets, and careers through thou! ghtful 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

                      • Michael Mulligan
                        potential precursors   Why isn t their a value judgment on it like a class 1, 2, or 3 potential precursors...like the consequences could be $1000, $10
                        Message 11 of 17 , Mar 2, 2011
                          potential precursors

                           

                          Why isn't their a value judgment on it like a class 1, 2, or 3 potential precursors...like the consequences could be $1000, $10 million dollars, injury or loss of life, and then maybe loss of business.

                           

                           




                          From: "Dillard, Tedd A (E S SF RNA FS 1 1 E)" <tedd.dillard@...>
                          To: Root_Cause_State_of_the_Practice@yahoogroups.com
                          Sent: Wed, March 2, 2011 1:08:43 PM
                          Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                           

                          It seems to me that the use of the word precursor is so dependent on the understanding of the listener that it is unhelpful to have so many different definitions of the word.
                          Especially definitions that are only relevant to our little part of the world.
                          The best description I found in the Rooticians Dictionary  was a comment in elaboration 1 of the type 2 precursor definition, "Comment: The same precursor can be classified in more than one way, so that the actual classification of a precursor is not all that important."
                          Looking at definitions in the wider view it appears that there are really only two, 1. A thing is a necessary contributor of a specific following event to happen, or 2. A thing is only an indicator of a following event but not a causal factor.
                          Tedd


                          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, March 02, 2011 12:48 PM
                          To: Root_Cause_State_of_the_Practice@yahoogroups.com
                          Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                           

                          They are PP’s: potential precursors


                          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, March 02, 2011 10:11 AM
                          To: Root_Cause_State_of_the_Practice@yahoogroups.com
                          Subject: Re: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                           

                          Glen,

                          You said:



                            We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions


                          Are all CATSs and PUCs precursors?

                          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: "Mitchell, Glen" <gmitchel@...>
                          To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                          Sent: Tue, March 1, 2011 12:34:48 PM
                          Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                           

                          We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions J

                          glen

                          806-477-4953

                          From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                          Sent: Monday, February ! 28, 2011 4:14 PM
                          To: Root_Cause_State_of_the_Practice@yahoogroups.com
                          Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                           

                          Mike,

                          Good point.

                          What do you call a precursor if the next event hasn't happened?

                          We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

                          And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

                          Take care,
                           
                          Bill Corcoran
                          Mission : Saving lives, pain, assets, and careers through thou! ghtful 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


                        • Mitchell, Glen
                          My tongue was actually in my cheek with those suggestions. I was just taken with multiple definitions and types and etc. Question: When we do a process
                          Message 12 of 17 , Mar 2, 2011

                            My tongue was actually in my cheek with those suggestions.

                             

                            I was just taken with multiple definitions and types and etc.

                             

                            Question:

                            When we do a process development (or plan a maintenance task, etc) around here, we identify all the hazards we can think of first and some barriers to them next.  

                            A precursor is treated just like any other hazard and is not specifically identified as a precursor. I am trying to think where a separate precursor category of hazard would be helpful.

                            I can quickly see where it might pull someone’s thinking back in the box, which I would see as a negative, rather than a positive effect.

                            Anyone have thoughts on that?

                             

                            glen

                            806-477-4953

                             

                            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, March 02, 2011 9:11 AM
                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            Subject: Re: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                             

                             

                            Glen,

                            You said:



                              We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions


                            Are all CATSs and PUCs precursors?

                             

                            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: "Mitchell, Glen" <gmitchel@...>
                            To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
                            Sent: Tue, March 1, 2011 12:34:48 PM
                            Subject: RE: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                             

                            We could call them CATS- Conditions Adverse to Safety- or PUCs Potentially Unsafe Conditions J

                             

                            glen

                            806-477-4953

                             

                            From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
                            Sent: Monday, February ! 28, 2011 4:14 PM
                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            Subject: [Root_Cause_State_of_the_Practice] What do you call a precursor if the next event hasn't happened?

                             

                             

                            Mike,

                            Good point.

                            What do you call a precursor if the next event hasn't happened?

                            We usually call them "precursors" anyway, but it's a little fuzzy what they ought to be called.

                            And to make it fuzzier, if the right corrective actions are taken it is not a precursor any more, is it?

                             

                            Take care,
                             
                            Bill Corcoran
                            Mission: Saving lives, pain, assets, and careers through thou! ghtful 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. sha! ll be understood as neither given nor endorsed by it.

                             

                             


                            From: Michael Mulligan <steamshovel2002@...>
                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            Sent: Mon, February 28, 2011 11:21:32 AM
                            Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                             

                            Bill,

                             

                            We! ll, the Deepwater Horizon and the Presidential National Commission on the blow out of the Macondo well in the Gulf Of Mexico is a type 6 precursor?

                             

                            I suppose you can't call it a precursor if the next event hasn't happened?

                             

                            Mike 

                             


                            From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            Sen! t: Mon, February 28, 2011 6:14:37 AM
                            Subject: Re: [Root_ Cause_State_of_the_Practice] WTC 1993 a Precursor?

                             

                            Mike,

                            I agree on your choice.

                            "The Rootician's Dictionary" defines a Type 6 Precursor thus:


                            A consequential event that gets root cause analysis and corrective action and precedes another event whose causal factors include ones that were part of the previous event but were not identified and/or fixed.


                            Does any one have other examples of Type 6 Precursors?
                            Was the sinking of the USS Squalus (SS 192) a precursor to the sinking of the USS Thresher (SSN 593)? Which type of precursor? How did you decide?

                            Useful links

                            http://en.wikipedia.org/wiki/USS_Sailfish_%28SS-192%29

                            http://en.wikipedia.org/wiki/USS_Thresher_%28SSN-593%29

                             

                            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: Michael Mulligan <steamshovel2002@...>
                            To: Root_Cause_State_of_the_Practice@yahoogroups.com
                            Sent: Sun, February 27, 2011 1:02:24 PM
                            Subject: Re: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                             

                            Bill,

                             

                            Type 6

                             

                            I wonder if all the actions coming out of 1993 and 9/11 are reversible? Is all the stuff we did to enhance our protection against terrorism...if the terrorism threat ended...! could we return to our pre 1993 state?  Would all the increased secrecy over the last two decades to protect ourselves end?

                             

                            When it is over, what is going to be the countervailing force to return us to our pre 1993 state?

                             

                            My life has been touched through these chain of events over the terrorism issue beginning before 1993...A FBI JTTF investigation of me last year. Has your life been directly touched?  

                             

                            We are still not getting to the source of this...all that is causing it.

                             

                            I think the most dangerous thing in the USA, say with the nucl ear industry, is to withdrawal the public oversight of security related issues. This idea that in order to protect us we got to let people who have a vested interest in minimizing security to be exclusively in charge of terrorism related protection activities. Only people with a certain ideology are qualified to hold the secrets of nuclear industry...is that is what we have become. The most damaging thing to our society is to create a small exclusive cadre of experts being only in charge of our security and they only having transparency of the system... thinking their corporatism knows what is best for us with terrorism. Now does Israel knows this truth beyond anyone.   

                             

                            In our latest Saudi near miss it was the "us" of us all t! hat unidentified this threat. The so called experts were helpless at the emergent level. Our security depends on the good people of our society always being in the front lines of all our wars...the eyes, ears and brains behind our national security stance. We are strongest when we all act together as one against the forces that are out to destroy us. We sink or swim, rich or poor, together. It utterly repugnant when a facility thinks the community are the first terrorist. Put a severe secrecy shield up, so the community can't see the sins of security system and their managers. The gaming of societal protection is unbelievable at this stage of the game. It is all about the power system trying to protect themselves from the cost and shortcomings of the protecting the community....It is about if the terrorist gets through their thin arrogant defenses and they being not held accountable...!    

                            < span> 

                            If we as a community member become interested in the quality of security around a facility...the first thing they do is call you a terrorist sympathizer and call in the Feds.

                             

                            It is this continuous thing in our society where we split our community into the "them" and "us"...the privileged and the used.

                             

                            If a facility is floundering around near death will they show their security secrets as a public relation stunt in a quest for survival?  Would you?

                             

                            Does al-Qaeda and ! these well financed wild eyed Saudis engineering students think a dying facility is more vulnerable to terrorism than a thriving facility? I am getting close to those three words the FBI JTTF warned me to never use together ever again in one message.  

                             

                            I will just say it straight out, talking about that part 26 fatigue NRC commissioner meeting. The ghost stories.  I hope budget issues nationwide are not degrading the terrorism protections at nuclear power plants? I sense a lot of employee frustrations over the security related employee fatigue issues. The idea that a security officer would disclose to the commissioners that he has to seek a outside second job in order to support his family is very troubling. The idea that!  outside working hours maliciously not be reported as f atigue or regulated working hours because a security manager is upset with not getting enough income at a facility. Is morale and income troubles...security related budget problems...is that degrading the security related stance at our nuclear plants.     

                             

                             

                            Mike     

                             

                             

                              

                             


                            !

                            From: DR WILLIAM CORCORAN <William.R.Corcoran@...>
                            To: RCSOTP1 <Root_Cause_State_of_the_Practice@yahoogroups.com>
                            Sent: Sat, February 26, 2011 5:03:29 AM
                            Subject: [Root_Cause_State_of_the_Practice] WTC 1993 a Precursor?

                             

                            On Feb. 26, 1993, a bomb exploded in the garage of New York's World Trade Center, killing six people and injuring more

                             

                             

                            than 1,000 others.

                            &nbs! p;

                            &nbs p;

                             

                            What type of a precursor was this? What are the lessons to be learned?

                             

                             

                             

                             

                            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

                             

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