Re: Re: TMI The Root Cause

["J. J. Rozental" <josrozen@netmedia.net.il>]

I believe that we can resume in this way:

1) What failed? --- Personnel, equipment, procedure

2) Why did it fail? -- Direct causes

3) Why was it not prevented? -- Root causes

J. J. Rozental <josrozen@netmedia.net.il>
Israel

At 06:14 PM 3/10/98 -0600, you wrote:
>I am resending this post since it appears to have been lost in 
>cyberspace.. I apologize if this eventually shows up as a duplicate. 
>---------
>
>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
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>