Common BlogarithmsWeblog focused on problem solving, root cause analysis, accident investigation, organizations, safety, and nuclear energy.Rockin' New Human Performance Investigation Tool- March 24, 2006 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/b87.html Optimization Is Not The Goal- March 13, 2006 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/b86.html |