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I did not
make any judging about the report, I did not read it, and I just make a comment
on your statement
In fact I do believe that
such report is very important toward safety performance and safety culture to
prevent accident (incident, failures and degradations).
In my point of view the
resume for all type of accident is:
What failed? (Personnel,
equipment, procedure)
Why did it fail? (Direct
causes)
Why was it not prevented?
(Root causes)
Lessons
to prevent recurrence (nevertheless many similar events were
reported)
Jose Julio
Rozental
Israel
----- Original Message -----
Sent: Monday, March 18, 2002 1:25
AM
Subject: Re: Criticality accident
I want
to point out that in my email on accidents I gave a VERY brief summary of the
Los Alamos report. the investigators investogated EVERY accident since
1943 VERY THOROUGHLY. Please don't judge their report by my superficial and
very brief summary. They have looked thoroughly at environmental and
public health effects. Again. the speaker was ONLY talking about
process accidents. The report of course includes other criticality
accidents. the others were not part of this particular talk.
Perhaps I dgould have been clearer that I was only giging a brief
summary and touching on points that happened to interest me, but PLEASE don't
jump to the conclusion that the report itself is superficial or lacking in any
way.,
Ruth Weiner, Ph. D.
ruthweiner@aol.com
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