Monday Accident & Lessons Learned: Is a leaking pipe a "root cause"?
Sometimes I think that people really don’t understand root cause analysis.
If you read this posting in the Vermont Digger, you’ll see what I mean …
First, consider this statement:
“Trask said the holes in the pipes were not the “root cause” of the leaks into the environment, but a “contributing cause.” The root cause, he said, was the pipe tunnel. Until the tunnel was breached, there was no leak outside the plant, according to Trask.”
Next, try this explanation:
“Smith accepted that this analogy explains Yankee’s concept of “root cause”: In a car crash where the brakes fail and then the air bag fails and the driver is injured, the root cause of the driver’s injury is the air bag failure, and the brake failure is a contributing cause.”
I think both of these explanations are misusing root cause analysis terminology.
Here is the TapRooT® defintion of “root cause”:
A Root Cause is the absence of a best practice
or the failure to apply knowledge
that would have prevented a problem.
Thus, none of the examples above would be root causes. They would all be Causal Factors that must be analyzed for their root causes.
A regulatory hearing with “intervenors” determined to shut down your plant can be a contentious environment to have a philosophical debate. I wish people would STOP trying to place blame and twist the meaning of words and put more effort into improving performance. Perhaps this statement by the Nuclear Regulatory Commission representative means that they think that vermont Yankee’s corrective actions are good enough even if their explanation of root cause leaves something to be desired:
“Neil Sheehan of the Nuclear Regulatory Commission said there was no one root cause, but a combination of problems—the holes in the pipes and the flaws in the pipe tunnel. He expressed confidence in Entergy’s root cause analysis.“