Organizational/Systemic Failure: Large Organizations (February release)

I discussed previously regarding large organizations experiencing a failure, that meeting the Organizational Failure threshold depends on certain details. This development of ideas has become a long article or short book. The draft will be passed to a publisher for review in December. Long answer short: simply because large organizations (as defined by having a … More Organizational/Systemic Failure: Large Organizations (February release)

Organizational/Systemic Failure: Root Cause Analysis

The best case scenario for the Root Cause Analysis (RCA) approach to safety is when used to investigate a “close call”. In our experience, these are infrequently reported. Most commonly, an RCA is conducted when a fatality/injury/other significant damage has occurred, making it a posteriori. It is a necessary step to be taken to prevent … More Organizational/Systemic Failure: Root Cause Analysis

Organizational/Systemic Failure: Malignant/Dismissive Authority

In 1956, a handful of people died in the Arundel Park fire. “Several of the sample population indicated that when they entered the hall after observing the fire from outside the building, they warned their friends and suggested they leave but were laughed at, their warning apparently disregarded.” People have a difficult time interpreting indirect … More Organizational/Systemic Failure: Malignant/Dismissive Authority

Systemic Failure: The Ghost Report

A critical report was released April 1985 by the National Highway Traffic Safety Administration focused on reducing braking distances of heavy vehicles. Among the findings it states, “Complete removal or deactivation of the front brakes, a practice which is common among some trucker users, obviously degrades the [braking] situation…” At issue is a rumored report … More Systemic Failure: The Ghost Report

“Thermal Insulation for Buildings, Pipe and Mechanical Equipment”, a Complication

This month’s (February 2019) Plumbing Engineer magazine featured an article discussing insulation engineering considerations.  The general topics covered are the major points that need to be addressed: (a) the basics (b) history of thermal insulation (c) how heat transfer works and (d) applicable codes and standards.  This makes it a great reference article.  An expert … More “Thermal Insulation for Buildings, Pipe and Mechanical Equipment”, a Complication