Hindsight not Always 20/20 with Problem Management: Page 2

Did something about the process change? Was it formally documented and adopted just prior to the incident?

What processes failed and why?

Are people bypassing the formal documented processes? Why?

Are there processes and/or controls that need to be added?

Are there processes and/or controls that need to be changed?

Did documentation exist?

Was the documentation readily available?

Was it understandable?

Could they find the needed topics in the manual?

How can the documentation be improved?

Were the operators trained appropriately?

Were they trained to handle the scenario that took place and if so, how similar was the training to reality?

How could training be improved?

Was fatigue a factor?

Were the operators angry, upset, anxious?

Were there corporate pressures, such as expense control or other financial constraints?

Were there pressures to meet unrealistic deadlines?

Was there failure in multiple subsystems or just one?

Was the failure, or sequence of failures, predictable?

Did the alarms work?

Were the parties involved experienced with the systems and subsystems in production or was there a new variable?

What testing was done prior to going into production?

It is always beneficial to learn from mistakes and outages. Problem review boards analyzing an incident after the fact need to beware of allowing their knowledge of outcomes to bias their examination of the steps that led up to the event. They must pay appropriate attention to the processes and human factors that could create fertile environments for failure, not just the technical elements.

In this age of ever increasing complexity, there will always be incidents and underlying problems that must be addressed with proper organizational learning and corrective actions to keep the problem from popping up again.