http://www.bill-wilson.net/b5.html Weblog focused on problem solving, root cause analysis, accident investigation, organizations, safety, and nuclear energy. Copyright 2004 Sat, 03 Mar 2007 16:14:56 GMT http://www.bill-wilson.net/b90.html Sat, 03 Mar 2007 16:14:56 GMT http://www.bill-wilson.net/b90.html Kathleen DeFilippo over at The AntiSyphus Effect has written a very nice collection of 10 articles on root cause analysis. I especially like how the articles flow from a logical starting point to a logical conclusion... something I've never really bothered to do. She's also developed a couple of nice little tools (FERCS and the PHaTS Domino) that should be useful to anyone trying to get started in root cause analysis.Below is a pointer to Ka... http://www.bill-wilson.net/b89.html Mon, 30 Oct 2006 12:46:25 GMT http://www.bill-wilson.net/b89.html Root cause analysis can be characterized in many ways. Some refer to it as a tool for continuous improvement. Others call it a method for finding performance problems. Those at the receiving end, however, often view root cause analysis as just a repackaged version of "the blame game". Who can blame them when operator error or lack of attention to detail are so often listed as causes?All too often during root cause investigations, a line of inquiry will end a... http://www.bill-wilson.net/b88.html Tue, 10 Oct 2006 05:57:40 GMT http://www.bill-wilson.net/b88.html There are many commonly held beliefs about root cause analysis that bother me. Perhaps the single most irksome to me is the statement "it's an art, not a science." I don't have anything against art, but I don't believe that this statement does justice to the practice of root cause analysis. In fact, I believe it is one of the most damaging perceptions that can be held by an investigator or be communicated to others.So, why do people believe this? One widely-held perception is... http://www.bill-wilson.net/b87.html Fri, 24 Mar 2006 06:16:07 GMT http://www.bill-wilson.net/b87.html Most problems and accidents involve human activity at some point or other. Often, this activity is right at the point of occurrence, and people at the sharp end are usually operating under difficult or confusing circumstances. They make decisions and take actions that, in hindsight, prove to be "wrong" in some way. Then, after something "bad" happens, we perform an investigation and find these "human err... http://www.bill-wilson.net/b86.html Mon, 13 Mar 2006 04:36:19 GMT http://www.bill-wilson.net/b86.html Problems come in all shapes and sizes. I've been involved in all kinds of investigations, from those dealing with something as mundane a chronic lack of hot water in a shower facility, to something as critical as a software error that caused non-conservative miscalculations of reactor operating limits. I've even been involved in a fairly significant event before, which my "friends" keep reminding me about even though such remembrances cause me great pain and embarrassment. Somet... http://www.bill-wilson.net/b82.html Wed, 15 Feb 2006 03:42:50 GMT http://www.bill-wilson.net/b82.html Problems happen all the time. How we choose to respond is a major factor in determining how badly we will be affected by any given problem. I would argue that a systematic response is best, and furthermore, I propose a 9-stage sequence as discussed in this article.If you are already familiar with other problem-solving methodologies, like 8D or DMAIC, some aspects of the recommended sequence may seem familiar to you. I believe the sequence proposed below is more com... http://www.bill-wilson.net/b81.html Mon, 14 Nov 2005 20:19:01 GMT http://www.bill-wilson.net/b81.html Root cause analysis has a fatal flaw -- if you can't convince people that change is necessary, they will not change.  Too many beautiful reports fail to make even a miniscule change in the course that an organization has already set for itself. The most thoroughly researched root cause analysis in the world is completely useless, if it fails to change anyone's mind. This is the second installment of my "cross-pollination" series. It focuses exlusively on a facet of root cause... http://www.bill-wilson.net/b80.html Tue, 08 Nov 2005 17:15:38 GMT http://www.bill-wilson.net/b80.html Wired News has a nice article on what they consider to be the 10 worst software bugs of all time (so far). I knew about a few of these, notably the Therac-25 fatalities and the Ariane-5 self-destruction. However, at least three of them were new to me.Here is a list of the bugs they describe:1962: Mariner 1 space probe destruction after launch1982: Soviet gas pipeline explosion1985-198...