Re: Re: TMI The Root Cause

["Sandy Perle" <sandyfl@earthlink.net>]

I am resending this post since it appears to have been lost in 
cyberspace.. I apologize if this eventually shows up as a duplicate. 
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The only issue I have with the entire discussion is the 
terminology used. In my opinion, the term Root Cause has been 
inappropriately used with respect to the TMI accident. Many have 
coined the various system malfunctions as the Root Cause of the 
accident. I see these as initiating events, not Root Causes. There 
were systems in place at the time of the accident that would have 
mitigated the sequence of events, if, certain actions were initiated, 
and if other actions were not initiated. The condensate system and 
relief valves were symptoms of the situation. While they were the 
initiating events, they were not the root cause.  To identify the 
Root Causes, TQM methods needed to be utilized. In all of the reports 
on the incident, this was done, and, the real Root Causes were in 
fact identified. They identified training, management and a lack of 
competency on the part of many. IF one truly believes that it was the 
hardware malfunctions that were the Root Causes, then one would 
expect that these malfunctions would always lead to the same 
consequences. This is obviously not the case. Equipment failures 
occur all the time. That is why we have procedures. That is why a 
plant can operate under an LCO. One does not expect that a system 
failure will lead to a TMI incident. 

An analogy ... accident occurs after the brakes on a car failed. One
could say that the Root Cause was a brake failure. On the other hand,
perhaps the Root Cause was the car owner NOT taking responsibility for
proper maintenance, NOT replacing the brakes knowing that they were
failing, NOT knowing how to handle the car when the situation arose.
My point being, Root Cause is the ultimate one or two items that led
to a problem. I too often see individuals calling the symptom the root
cause, when it alone can never prevent recurrence, when taken care of.
Only with root cause analysis, and identification of real root causes,
can recurrence be prevented.

------------------
Sandy Perle
Technical Director
ICN Dosimetry Division
Costa Mesa, CA 92626
Office: (800) 548-5100 x2306 
Fax:    (714) 668-3111
  
sandyfl@earthlink.net
sperle@icnpharm.com

ICN Dosimetry Website:
http://www.dosimetry.com

Personal Homepage:
http://www.geocities.com/CapeCanaveral/1205

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