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RE: [Spam] RE: [Root_Cause_State_of_the_Practice] Critical Parameter Events

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  • MARRS, STEPHEN C
    After refreshing from the Roger s Commission report, the following was listed in Chapter 4: The investigation has shown that the joint sealing performance is
    Message 1 of 7 , Aug 1, 2011
    • 0 Attachment
      After refreshing from the Roger's Commission report, the following was listed in Chapter 4:
       
      "The investigation has shown that the joint sealing performance is sensitive to the following factors, either independently or in combination:

      (a) Damage to the joints/seals or generation of contaminants as joints are assembled as influenced by:

      (1) Manufacturing tolerances.
      (2) Out of round due to handling.
      (3) Effects of reuse.

      (b) Tang/clevis gap opening due to motor pressure and other loads.

      (c) Static O-ring compression.

      (d) Joint temperature as it affects O-ring response under dynamic conditions (resiliency) and hardness.

      (e) Joint temperature as it relates to forming ice from water intrusion in the joint.

      (f) Putty performance effects on:

      (1) O-ring pressure actuation timing.
      (2) O-ring erosion."
      There were 2 temperature effects listed (italics above...).
       
       


      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
      Sent: Saturday, July 30, 2011 8:04 PM
      To: Root_Cause_State_of_the_Practice@yahoogroups.com
      Subject: Re: [Spam] RE: [Root_Cause_State_of_the_Practice] Critical Parameter Events

       

      Thanks, Tedd.

      I'd like to hear from others.

      Needless to say, I find your posting to be baffling.  I'll think about 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


      One-day RCA Training on August 18,2011 at ANS Utility Working Conference.  http://secure.ans.org/meetings/uwc/registration/

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


      --- On Sat, 7/30/11, Dillard, Tedd A (E S SF RNA FS 1 1 E) <tedd.dillard@...> wrote:

      From: Dillard, Tedd A (E S SF RNA FS 1 1 E) <tedd.dillard@...>
      Subject: [Spam] RE: [Root_Cause_State_of_the_Practice] Critical Parameter Events
      To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
      Date: Saturday, July 30, 2011, 9:44 AM

       

      Dr. Bill,
      I have real problems with this list, at least with the specific comments, the general idea that there are lessons to be learned from events I do agree with.
      The Challenger did not explode because the temperature was outside the design limit. There had never been a flight that did not have O ring failure at any temperature!
      The joint design was known to be defective. The O ring manufactor told NASA that the O ring was not intended to work in the application they had.
      The explosion could have happened at a higher temperature if some other factor had been different other than temperature.
      The lesson to be learned is why the joint was designed the way it was in the first place, what other better designs were there and why the joint design was not changed when repeat failures of O rings on all flights made it clear that there was a problem, what is it about the way decisions were made in the design, testing and qualification of the components before production?
      Based on what little I have seen on the Byron service water issue, which is only the NRC report, it is not clear to me just what was done or not done. As stated in the report the plant replaced all of the piping above the flange with stainless steel. That had to be a significant cost. The question then must be what was it about the way decisions were made that allowed the significant project to be implemented but not include the short section of pipe from the concrete floor to the flange? Was the replacement of that less than one foot of pipe never considered? Was it considered and rejected because to some factor not identified in the NRC report? Did the engineering management say "yeah we see this very important section of pipe but we are not going to do anything about it because it is just too hard or expensive, we are willing to spend a great deal of money on replacing the other 20 or 30 feet of pipe but not this less than one foot"?
      As for the repeated reduction of allowable wall thickness, it must have made sense at the time each evaluation was done? What were the questions that were ask and answered to allow each evaluation to be accepted? What was the limiting basis for the pipe wall thickness? It likely was not based on pressure as the pressure would have been almost atmospheric at that point in the system. 
      In my view one of the issues that is missing in the Davis Besse event is the fact there had been several previous events in the industry and that the industry, NRC, INPO, NEI all failed to learn from them. That is a true statement about TMI as I recall that the industry knew there had been previous event of the PROV sticking open.
      The vertical stabilizer breaking off seems to me to be because the plane was designed and known to be designed to fail if over loaded and yet still built that way. I can understand that every device will fail if operated outside it's design base like the wings will fail if they are reverse .loaded but to me to allow the rudder to break off if a little too much force is applied is not something that should have been accepted.
      Tedd  
       


      From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
      Sent: Saturday, July 30, 2011 5:42 AM
      To: RCSOTP_23_CriticalParameters
      Cc: rootcauseconference@yahoogroups.com; RCSOTP1
      Subject: [Root_Cause_State_of_the_Practice] Critical Parameter Events

       

      Please scroll down for the link and the table.

      Every harmful event does not involve critical parameters, but many educational ones do.

      There seem to be some patterns emerging:
      1. Critical parameter events tend to involve the safe operating envelope.
      2. Critical parameter events tend to involve emergent/ emerging issues/ situations.
      3. Critical parameter events tend to involve cliff-edge effects.
      4. Critical parameter events tend to reveal system weaknesses and systemic weaknesses.

      What events should be added to this table?  What lessons to be learned are missing?

      To participate in building the critical parameter body of knowledge send an e-mail to RCSOTP_23_CriticalParameters-subscribe@yahoogroups.com
       
      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


      One-day RCA Training on August 18,2011 at ANS Utility Working Conference.  http://secure.ans.org/meetings/uwc/registration/

       
      ****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.


      http://tech.groups.yahoo.com/group/RCSOTP_23_CriticalPar ameters/database

      Yahoo! Groups

      Name:  Critical Parameter Events 2011.07.30

      Table Description:  Data describing important critical parameter events.
      Short name of event? Where and when ? vShort description of the event?The actual, expected, and/or potential harm?What was/were the critical parameter(s) involved?What critical parameters were not identified?What identified critical parameters were not monitored?Identified--monitored CPs not effectivly responded to?Impact on the harm had the CRs been responded to?What are the lessons to be learned?Internet links ? || Other comments?
      Challenger Explosion--Off Cape Canaveral, January 28, 1986Space shuttle explodes on launchLoss of crew and shuttle.Launch temperatureLaunch temperatureLaunch temperature Laundh would have been delayed until the air was warmer.1) The safe operating envelope of a system should not include parameter values outside the safe operating envelope of any critical component. 2) Equipment failure and degradation data should be plotted against critical parameters.http://en.wikipedia .org/wiki/ Space_Shuttle_ Challenger_ disaster ||
      Essential Service Water Wall Thinning and Pencil Whipping--Byron Station-2007Essential Service Water thinning was detected and repeatedly approved for continued operation.1) Ten gpm leak nessitating shutdown of two large nuclear units at the cost of $millions. 2) NRC White Finding resulting in increaed inspection paid for by ownerESW integrity (pipe wall thichness).  ESW integrity (pipe wall thichness). 1) Unmovable action values should be established for all critical parameters. 2) All engineers should be trained in "Engineering 101" and refresher training should be mandatory. 3) Engineering output should be subject to adult supervision. 4) All technical personnel should be trained in "Frog Boiling" and speaking up.The nuclear safety culture in this event is mind boggling.|| NRC Report Numbers 05000454/2007009 and 05000455/2007009
      Foreign Material Injection into Service Water: LaSalle-1996( ?)Worker injected furmanite into service water trunk for several months until NRC Sr RI requested a dive.$600,000 or so civil penalty. Potential meltdown (?)Service water foreign material collection device pressure drops plus others.Service water foreign material collection device pressure drops plus others Service water foreign material collection device pressure drops plus othersEarlier detection and correction.Have a central location where all abnormal information is aggregated and assessed. Connect the dots. 
      Fuel Oil Spill--Salem Harbor Station--May 2005230 bbl of #6 FO spilled into berm while taking fuel from barge.Minimal soil contamination. Could have been thousands of barrels of oil released to bare soil.Reconciliation difference, i.e., the difference between the volume pumped and the volume received.None.The reconciliation difference was not monitored often enough.The pumping was not immediately terminated when the reconciliation difference anomaly was first identified.No spill1) Monitor critical parameters often enough to detect serious abnormatities promptly.2) Take immediate action on verified critical parameterabnormalit ies.No links known. ||
      Fuel Oil Spill--Salem Harbor Station--May 2005--Elaboration 1  Tank levels in the tanks not intended to be filled.Tank levels in the tanks not intended to be filled.Tank levels in the tanks not intended to be filled. Early identification of the erroneous line-up. No spill.l(This needs some thought.) 
      MS Royal Majesty--Rose and Crown Shoal near Nantucket Island, MA, USACruise ship groundsLoss of use of ship, inconvenience to passengers, minor fuel spilll. Could have been a disaster.Difference between plotted position and GPS position.Difference between plotted position and GPS positionDifference between plotted position and GPS positionDifference between plotted position and GPS positionNo grounding.1) Identify and monitor critical parameters systematically. 2) Make critical parameter monitoring part of the core business.There are many good links, e.g., http://ti.arc. nasa.gov/ m/profile/ adegani/Groundin g%20of%20the% 20Royal%20Majest y.pdf || Critical parameter management should be part of safety culture.
      Near Miss LOCA with Recirc Failure--Davis- Besse (1996?-2002)Control rod drive nozzle leakage continuation results in severe weakening of reactor coolant pressure boundary.About $2Billion in costs. Near miss LOCA. Potential fule damage.Reactor coolant leakage, emergency heat removal capability,, radiation monitor flow  Reactor coolant leakage, emergency heat removal capability,, radiation monitor flow1) Earlier detection and correction. 2) Much less expensive and disruptive corrective actions.1) Have a central location where all abnormal information is aggregated and assessed. Connect the dots. 2) Complete all root cause analyses related to critical parameters. 3) Don't equate specification compliance with safety. 
      Service Water Fouling--Calvert Cliffs--1999( ?)Gradual, but exponential fouling of new plate and frame heat exchanges was not noted until it affected plant operation.Expensive and disruptive actions to keep service water operable.Service water heat exchanger heat differntial temperature. .Service water heat exchanger heat differntial temperature. .  Much less expensive and disruptive corrective actions.1) Before putting new equipment into service identify and plan for the monitoring and response to critical parameters. 2) Equipment failure and degradation data should be plotted against critical parameters. 
      Vertical stabilizer snapped off (aka American Airlines Flight 587) Queens, Long Island, NY 2001First officer snaps off vertical stabilizer by overstressing it.265 fatalities, destruction of aircraft, ground property losses.Stress on vertical stabilizerStress on vertical stabilizer  If the first officer had known that he was going outside the safe operating envelope he could have eased off on the rudder controls.1) Operators must be able to tell when they are approching the limits of the safe operating envelope.http://en.wikipedia .org/wiki/ American_ Airlines_ Flight_587 ||

    • Dillard, Tedd A (E S SF RNA FS 1 1 E)
      Steve, Thank you for your information. I appreciate the details but they are as I remembered them. I agree that the temperature was a factor in the failure and
      Message 2 of 7 , Aug 1, 2011
      • 0 Attachment
        Steve,
        Thank you for your information. I appreciate the details but they are as I remembered them.
        I agree that the temperature was a factor in the failure and I agree that there is a limit to what temperature the joint can tolerate.
        On the issue of the O ring failure it is my point that item (c) was the critical factor that was exceeded. and that was due mostly to item (b).
        If the joint had been designed to provide the proper static compression at motor pressure then it is very unlikely that the joint would have failed.
        It apparently had proper static compression before the engine fires but the gap opening up when the engine did fire was what unloaded the O ring and allowed the leakage.
        They knew this before the failure, they had tried several fixes for it short of a new joint design.
        Knowing that the joint is defective and hoping that the O ring is resilent enough to recover from being de-compressed at ignition is not a good way to do business...at any temperature.
        On the issue of Bill's list I believe the critical factor or factors that should be listed would be the ones that allowed the poor design in the first place and failed to correct it later.
        Tedd

        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of MARRS, STEPHEN C
        Sent: Monday, August 01, 2011 1:06 PM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: RE: [Spam] RE: [Root_Cause_State_of_the_Practice] Critical Parameter Events

         

        After refreshing from the Roger's Commission report, the following was listed in Chapter 4:
         
        "The investigation has shown that the joint sealing performance is sensitive to the following factors, either independently or in combination:

        (a) Damage to the joints/seals or generation of contaminants as joints are assembled as influenced by:

        (1) Manufacturing tolerances.
        (2) Out of round due to handling.
        (3) Effects of reuse.

        (b) Tang/clevis gap opening due to motor pressure and other loads.

        (c) Static O-ring compression.

        (d) Joint temperature as it affects O-ring response under dynamic conditions (resiliency) and hardness.

        (e) Joint temperature as it relates to forming ice from water intrusion in the joint.

        (f) Putty performance effects on:

        (1) O-ring pressure actuation timing.
        (2) O-ring erosion."
        There were 2 temperature effects listed (italics above...).
         
         


        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
        Sent: Saturday, July 30, 2011 8:04 PM
        To: Root_Cause_State_of_the_Practice@yahoogroups.com
        Subject: Re: [Spam] RE: [Root_Cause_State_of_the_Practice] Critical Parameter Events

         

        Thanks, Tedd.

        I'd like to hear from others.

        Needless to say, I find your posting to be baffling.  I'll think about 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


        One-day RCA Training on August 18,2011 at ANS Utility Working Conference.  http://secure.ans.org/meetings/uwc/registration/

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


        --- On Sat, 7/30/11, Dillard, Tedd A (E S SF RNA FS 1 1 E) <tedd.dillard@...> wrote:

        From: Dillard, Tedd A (E S SF RNA FS 1 1 E) <tedd.dillard@...>
        Subject: [Spam] RE: [Root_Cause_State_of_the_Practice] Critical Parameter Events
        To: "Root_Cause_State_of_the_Practice@yahoogroups.com" <Root_Cause_State_of_the_Practice@yahoogroups.com>
        Date: Saturday, July 30, 2011, 9:44 AM

         

        Dr. Bill,
        I have real problems with this list, at least with the specific comments, the general idea that there are lessons to be learned from events I do agree with.
        The Challenger did not explode because the temperature was outside the design limit. There had never been a flight that did not have O ring failure at any temperature!
        The joint design was known to be defective. The O ring manufactor told NASA that the O ring was not intended to work in the application they had.
        The explosion could have happened at a higher temperature if some other factor had been different other than temperature.
        The lesson to be learned is why the joint was designed the way it was in the first place, what other better designs were there and why the joint design was not changed when repeat failures of O rings on all flights made it clear that there was a problem, what is it about the way decisions were made in the design, testing and qualification of the components before production?
        Based on what little I have seen on the Byron service water issue, which is only the NRC report, it is not clear to me just what was done or not done. As stated in the report the plant replaced all of the piping above the flange with stainless steel. That had to be a significant cost. The question then must be what was it about the way decisions were made that allowed the significant project to be implemented but not include the short section of pipe from the concrete floor to the flange? Was the replacement of that less than one foot of pipe never considered? Was it considered and rejected because to some factor not identified in the NRC report? Did the engineering management say "yeah we see this very important section of pipe but we are not going to do anything about it because it is just too hard or expensive, we are willing to spend a great deal of money on replacing the other 20 or 30 feet of pipe but not this less than one foot"?
        As for the repeated reduction of allowable wall thickness, it must have made sense at the time each evaluation was done? What were the questions that were ask and answered to allow each evaluation to be accepted? What was the limiting basis for the pipe wall thickness? It likely was not based on pressure as the pressure would have been almost atmospheric at that point in the system. 
        In my view one of the issues that is missing in the Davis Besse event is the fact there had been several previous events in the industry and that the industry, NRC, INPO, NEI all failed to learn from them. That is a true statement about TMI as I recall that the industry knew there had been previous event of the PROV sticking open.
        The vertical stabilizer breaking off seems to me to be because the plane was designed and known to be designed to fail if over loaded and yet still built that way. I can understand that every device will fail if operated outside it's design base like the wings will fail if they are reverse .loaded but to me to allow the rudder to break off if a little too much force is applied is not something that should have been accepted.
        Tedd  
         


        From: Root_Cause_State_of_the_Practice@yahoogroups.com [mailto:Root_Cause_State_of_the_Practice@yahoogroups.com] On Behalf Of DR WILLIAM CORCORAN
        Sent: Saturday, July 30, 2011 5:42 AM
        To: RCSOTP_23_CriticalParameters
        Cc: rootcauseconference@yahoogroups.com; RCSOTP1
        Subject: [Root_Cause_State_of_the_Practice] Critical Parameter Events

         

        Please scroll down for the link and the table.

        Every harmful event does not involve critical parameters, but many educational ones do.

        There seem to be some patterns emerging:
        1. Critical parameter events tend to involve the safe operating envelope.
        2. Critical parameter events tend to involve emergent/ emerging issues/ situations.
        3. Critical parameter events tend to involve cliff-edge effects.
        4. Critical parameter events tend to reveal system weaknesses and systemic weaknesses.

        What events should be added to this table?  What lessons to be learned are missing?

        To participate in building the critical parameter body of knowledge send an e-mail to RCSOTP_23_CriticalParameters-subscribe@yahoogroups.com
         
        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


        One-day RCA Training on August 18,2011 at ANS Utility Working Conference.  http://secure.ans.org/meetings/uwc/registration/

         
        ****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.


        http://tech.groups.yahoo.com/group/RCSOTP_23_CriticalPar ameters/database

        Yahoo! Groups

        Name:  Critical Parameter Events 2011.07.30

        Table Description:  Data describing important critical parameter events.
        Short name of event? Where and when ? vShort description of the event?The actual, expected, and/or potential harm?What was/were the critical parameter(s) involved?What critical parameters were not identified?What identified critical parameters were not monitored?Identified--monitored CPs not effectivly responded to?Impact on the harm had the CRs been responded to?What are the lessons to be learned?Internet links ? || Other comments?
        Challenger Explosion--Off Cape Canaveral, January 28, 1986Space shuttle explodes on launchLoss of crew and shuttle.Launch temperatureLaunch temperatureLaunch temperature Laundh would have been delayed until the air was warmer.1) The safe operating envelope of a system should not include parameter values outside the safe operating envelope of any critical component. 2) Equipment failure and degradation data should be plotted against critical parameters.http://en.wikipedia .org/wiki/ Space_Shuttle_ Challenger_ disaster ||
        Essential Service Water Wall Thinning and Pencil Whipping--Byron Station-2007Essential Service Water thinning was detected and repeatedly approved for continued operation.1) Ten gpm leak nessitating shutdown of two large nuclear units at the cost of $millions. 2) NRC White Finding resulting in increaed inspection paid for by ownerESW integrity (pipe wall thichness).  ESW integrity (pipe wall thichness). 1) Unmovable action values should be established for all critical parameters. 2) All engineers should be trained in "Engineering 101" and refresher training should be mandatory. 3) Engineering output should be subject to adult supervision. 4) All technical personnel should be trained in "Frog Boiling" and speaking up.The nuclear safety culture in this event is mind boggling.|| NRC Report Numbers 05000454/2007009 and 05000455/2007009
        Foreign Material Injection into Service Water: LaSalle-1996( ?)Worker injected furmanite into service water trunk for several months until NRC Sr RI requested a dive.$600,000 or so civil penalty. Potential meltdown (?)Service water foreign material collection device pressure drops plus others.Service water foreign material collection device pressure drops plus others Service water foreign material collection device pressure drops plus othersEarlier detection and correction.Have a central location where all abnormal information is aggregated and assessed. Connect the dots. 
        Fuel Oil Spill--Salem Harbor Station--May 2005230 bbl of #6 FO spilled into berm while taking fuel from barge.Minimal soil contamination. Could have been thousands of barrels of oil released to bare soil.Reconciliation difference, i.e., the difference between the volume pumped and the volume received.None.The reconciliation difference was not monitored often enough.The pumping was not immediately terminated when the reconciliation difference anomaly was first identified.No spill1) Monitor critical parameters often enough to detect serious abnormatities promptly.2) Take immediate action on verified critical parameterabnormalit ies.No links known. ||
        Fuel Oil Spill--Salem Harbor Station--May 2005--Elaboration 1  Tank levels in the tanks not intended to be filled.Tank levels in the tanks not intended to be filled.Tank levels in the tanks not intended to be filled. Early identification of the erroneous line-up. No spill.l(This needs some thought.) 
        MS Royal Majesty--Rose and Crown Shoal near Nantucket Island, MA, USACruise ship groundsLoss of use of ship, inconvenience to passengers, minor fuel spilll. Could have been a disaster.Difference between plotted position and GPS position.Difference between plotted position and GPS positionDifference between plotted position and GPS positionDifference between plotted position and GPS positionNo grounding.1) Identify and monitor critical parameters systematically. 2) Make critical parameter monitoring part of the core business.There are many good links, e.g., http://ti.arc. nasa.gov/ m/profile/ adegani/Groundin g%20of%20the% 20Royal%20Majest y.pdf || Critical parameter management should be part of safety culture.
        Near Miss LOCA with Recirc Failure--Davis- Besse (1996?-2002)Control rod drive nozzle leakage continuation results in severe weakening of reactor coolant pressure boundary.About $2Billion in costs. Near miss LOCA. Potential fule damage.Reactor coolant leakage, emergency heat removal capability,, radiation monitor flow  Reactor coolant leakage, emergency heat removal capability,, radiation monitor flow1) Earlier detection and correction. 2) Much less expensive and disruptive corrective actions.1) Have a central location where all abnormal information is aggregated and assessed. Connect the dots. 2) Complete all root cause analyses related to critical parameters. 3) Don't equate specification compliance with safety. 
        Service Water Fouling--Calvert Cliffs--1999( ?)Gradual, but exponential fouling of new plate and frame heat exchanges was not noted until it affected plant operation.Expensive and disruptive actions to keep service water operable.Service water heat exchanger heat differntial temperature. .Service water heat exchanger heat differntial temperature. .  Much less expensive and disruptive corrective actions.1) Before putting new equipment into service identify and plan for the monitoring and response to critical parameters. 2) Equipment failure and degradation data should be plotted against critical parameters. 
        Vertical stabilizer snapped off (aka American Airlines Flight 587) Queens, Long Island, NY 2001First officer snaps off vertical stabilizer by overstressing it.265 fatalities, destruction of aircraft, ground property losses.Stress on vertical stabilizerStress on vertical stabilizer  If the first officer had known that he was going outside the safe operating envelope he could have eased off on the rudder controls.1) Operators must be able to tell when they are approching the limits of the safe operating envelope.http://en.wikipedia .org/wiki/ American_ Airlines_ Flight_587 ||

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