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	<title>Comments for Your Expert Root Cause Analysis Resource</title>
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	<link>http://root-cause-analysis.info</link>
	<description>Root Cause Analysis</description>
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		<title>Comment on Therac-25 Radiation Overdoses by Ksmiley</title>
		<link>http://root-cause-analysis.info/2010/08/08/therac-25-radiation-overdoses/#comment-1037</link>
		<dc:creator>Ksmiley</dc:creator>
		<pubDate>Thu, 02 Sep 2010 09:21:05 +0000</pubDate>
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		<description>The link will be fixed and a full size pdf will be available.  Thank you for letting us know.</description>
		<content:encoded><![CDATA[<p>The link will be fixed and a full size pdf will be available.  Thank you for letting us know.</p>
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		<title>Comment on Therac-25 Radiation Overdoses by dgunderud</title>
		<link>http://root-cause-analysis.info/2010/08/08/therac-25-radiation-overdoses/#comment-1036</link>
		<dc:creator>dgunderud</dc:creator>
		<pubDate>Wed, 01 Sep 2010 18:58:38 +0000</pubDate>
		<guid isPermaLink="false">http://root-cause-analysis.info/?p=264#comment-1036</guid>
		<description>Will there be a full sized pdf of the Cause Map linked to this post?  Right now, we only get the thumbnail view of it, as well as the Virginia Tech link.</description>
		<content:encoded><![CDATA[<p>Will there be a full sized pdf of the Cause Map linked to this post?  Right now, we only get the thumbnail view of it, as well as the Virginia Tech link.</p>
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		<title>Comment on Salmonella Recall by dplucky</title>
		<link>http://root-cause-analysis.info/2010/03/09/salmonella-recall/#comment-1035</link>
		<dc:creator>dplucky</dc:creator>
		<pubDate>Thu, 11 Mar 2010 03:58:47 +0000</pubDate>
		<guid isPermaLink="false">http://root-cause-analysis.info/?p=218#comment-1035</guid>
		<description>OK - Just why did they recall the Salmonella?  Was it ineffective salmonella?</description>
		<content:encoded><![CDATA[<p>OK &#8211; Just why did they recall the Salmonella?  Was it ineffective salmonella?</p>
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		<title>Comment on Death of Luger at 2010 Winter Olympics by Jim</title>
		<link>http://root-cause-analysis.info/2010/02/25/death-of-luger-at-2010-winter-olympics/#comment-1034</link>
		<dc:creator>Jim</dc:creator>
		<pubDate>Fri, 26 Feb 2010 00:21:43 +0000</pubDate>
		<guid isPermaLink="false">http://root-cause-analysis.info/?p=213#comment-1034</guid>
		<description>I am a failure analysis, forensic management expert and I thank you for your efforts in this analysis; it is haunting me that someone focus on these elements.

I wish to convey to the family what a horrible and seemingly avertable tragedy this has been for me and I&#039;m sure the rest of the world.  If there is anything we can do we are happy to help in any way.

My first thought, like everyone was disbelief and I never wish to view the incident again.

Since the incident burned a horrible image in my mind; I did give it a step by step thought as to how this young man; so full of life could have been killed by what first appeared as just an accident. 

It appears, as with all failures of this type that the Sun, Moon and Stars needed to line up for the end result to occur.  In this case it was more than three things.

When I had heard of the event a statement about him being an amateur seemed to brush off other factors.  If there is substance to this, let the authority claim this as contributory but I thought all Olympians were required to be amatures.  I would take issue with anyone claiming amateur to an Olympic Athelet; qualified by his country and countrymen and likely top of class.

When I heard that the track was faster by 6 to 9 miles an hour, at 90 miles per hour [40 m/s] he would be about 4&#039; beyond a point of his &quot;muscle/reactionary memory capability.&quot;  Any neurologist could easily explain better than I.  I do not believe this is contributory to a death as errors are to be expected and tracks, safety barriers, and management is expected to meet standards.

When I heard he was not given a chance to train as needed, I would bring this to a major contributory factor; not for his death as one should not die if making an error.  If this was out of standards then I would hold this more contributory to &quot;setting an increased risk factor&quot; because of failure to aid in the prevention or errors [a basic expected Olympian standard is to keep athletes safe].

When I saw that AFTER his error in missing the turn [due to the speed difference] he then ended up hitting the &quot;Inside Wall&quot; before he was catapulted outwardly beyond the plane of the track and into the pillar.  I felt that this wall could have been designed wider (inward away from his ricocheting body) by making it wider on the inside by perhaps a meter.  This would have prevented ricochet and simply would have resulted in sending down the track.  Because of the tight inside wall he was sent out toward the outside wall.  I see no reason for creating such a tight, narrow inside wall and using roller coaster technology may have shared that given a good ISO 9000 Design Process.  The Design Process may have missed this danger.

The final missing barrier was clearly the cause of death and therefore, to omit such a barrier in the face of all other elements, one would have to conclude culpability to the safety engineers responsible for checking design flaws.

If there was practice limitations then the root of those limitations should be investigated as a major contributory factor to the original error of going into the turn wrong.</description>
		<content:encoded><![CDATA[<p>I am a failure analysis, forensic management expert and I thank you for your efforts in this analysis; it is haunting me that someone focus on these elements.</p>
<p>I wish to convey to the family what a horrible and seemingly avertable tragedy this has been for me and I&#8217;m sure the rest of the world.  If there is anything we can do we are happy to help in any way.</p>
<p>My first thought, like everyone was disbelief and I never wish to view the incident again.</p>
<p>Since the incident burned a horrible image in my mind; I did give it a step by step thought as to how this young man; so full of life could have been killed by what first appeared as just an accident. </p>
<p>It appears, as with all failures of this type that the Sun, Moon and Stars needed to line up for the end result to occur.  In this case it was more than three things.</p>
<p>When I had heard of the event a statement about him being an amateur seemed to brush off other factors.  If there is substance to this, let the authority claim this as contributory but I thought all Olympians were required to be amatures.  I would take issue with anyone claiming amateur to an Olympic Athelet; qualified by his country and countrymen and likely top of class.</p>
<p>When I heard that the track was faster by 6 to 9 miles an hour, at 90 miles per hour [40 m/s] he would be about 4&#8242; beyond a point of his &#8220;muscle/reactionary memory capability.&#8221;  Any neurologist could easily explain better than I.  I do not believe this is contributory to a death as errors are to be expected and tracks, safety barriers, and management is expected to meet standards.</p>
<p>When I heard he was not given a chance to train as needed, I would bring this to a major contributory factor; not for his death as one should not die if making an error.  If this was out of standards then I would hold this more contributory to &#8220;setting an increased risk factor&#8221; because of failure to aid in the prevention or errors [a basic expected Olympian standard is to keep athletes safe].</p>
<p>When I saw that AFTER his error in missing the turn [due to the speed difference] he then ended up hitting the &#8220;Inside Wall&#8221; before he was catapulted outwardly beyond the plane of the track and into the pillar.  I felt that this wall could have been designed wider (inward away from his ricocheting body) by making it wider on the inside by perhaps a meter.  This would have prevented ricochet and simply would have resulted in sending down the track.  Because of the tight inside wall he was sent out toward the outside wall.  I see no reason for creating such a tight, narrow inside wall and using roller coaster technology may have shared that given a good ISO 9000 Design Process.  The Design Process may have missed this danger.</p>
<p>The final missing barrier was clearly the cause of death and therefore, to omit such a barrier in the face of all other elements, one would have to conclude culpability to the safety engineers responsible for checking design flaws.</p>
<p>If there was practice limitations then the root of those limitations should be investigated as a major contributory factor to the original error of going into the turn wrong.</p>
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		<title>Comment on When the Power Goes Out . . . by tburchill</title>
		<link>http://root-cause-analysis.info/2009/08/21/when-the-power-goes-out/#comment-1033</link>
		<dc:creator>tburchill</dc:creator>
		<pubDate>Fri, 21 Aug 2009 20:06:45 +0000</pubDate>
		<guid isPermaLink="false">http://root-cause-analysis.info/?p=123#comment-1033</guid>
		<description>Hi,

I believe I asked this question. Thank you very much for such a great and comprehensive answer. This is exactly what I am looking for. The webinars are excellent. I try not to miss any. Look forward to next week.</description>
		<content:encoded><![CDATA[<p>Hi,</p>
<p>I believe I asked this question. Thank you very much for such a great and comprehensive answer. This is exactly what I am looking for. The webinars are excellent. I try not to miss any. Look forward to next week.</p>
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