Well today it almost happened....someone almost lost their life at my workplace.  While my first post focused on my knowledge gained as a nuclear Quality Assurance professional, my job as Corrective Action Manager also takes me into realms beyond.  Today it was personnel safety.

Two men were working together changing out an anvil on a huge forge press.  One of the men had been doing the job alone since being trained by a long time employee who'd recently retired.  But this time there were two doing the job.  One of the men was in a control room looking through windows as the other man disconnected the anvil.  Someone came into the building on a forklift and dropped something off, causing the man in the control room to look away from his task.  When the control room operator returned his gaze to the task, he saw his own shadow in the windows of the control room and believed what he was seeing was the other man leaving the equipment, after which he activated the forge press toward the anvil.  He happened to look out at the equipment and was shocked to see the first man laying pinned between the press and the anvil.

HO-LEE-SHIT!!!!

The man who was pinned was OK it turned out but had injuries to his back and knee.

In the station meeting this morning attended by all management we talked about the event.  I was (but shouldn't have been) surprised some were trying to minimize the consequences of the event.  I thought our policy was clear:  personnel fatality or near miss needs a Root Cause Analysis (RCA).  Some argued a lower level investigation would be sufficient.  Finally the Engineering Manager stated the event should be classified higher and HR Manager read the policy aloud.  Most finally seemed to "get it" and the consensus was to perform the RCA.  The next topic was who should lead the RCA.  I was shocked when the managers of the next available analyst stated his department would be shut down if he did it.  HELL-O....why are we still reinforcing Production over Safety when someone was nearly killed today?

The whole thing made me cry, not because I felt responsibility but because I continue to see a management team who believes the corrective action program causes unnecessary work.  The ironic thing is the mister and I just this past weekend discussed how it was just a matter of time before something like this - or worse - happened.  Well, we've now had 4 RCAs this year - twice as many as last year, and it's only the middle of the year.  I pray the leaders of my company will wake up and get serious about determining *why* these events are happening and correcting same.    

Why This Blog?

My first post here I'll explain why I've decided to establish this blog.  I'm not really anyone noteworthy so it's not that I think I am.  I have, however, been employed by a supplier to the nuclear power industry since 1979 as a Quality Assurance professional so have learned a thing or two along the way.  Guess you could say this old dog wants to make sure all the bones don't stay burried after I'm gone.

While my work in nuclear QA has always been filled with chapter & verse quotations of requirements to explain why things could or could not be done, this blog will be more opinionated and informal in nature.......and I think that will be quite fun for a change!

So a quick bit about me before the opinions begin to roll.  I started my job in 1979 as a secretary in the QA department of a brand new plant built to supply raw material for nuclear fuel assemblies.  When I started my job I didn't know the first thing about quality assurance or the nuclear industry.  In fact I'm quite sure I had no idea the business even was part of the nuclear industry at first (ditto for most of the employees originally hired at the place - it just wasn't talked about much early on).  I did know good grammar, spelling and office procedures having had a business minor in college and a few years' experience as an executive secretary and assistant office manager.  I was only 25 - and female - but not about to let anyone bamboozle me with quality hocus pocus.  As I began to type up the zillions of procedures that were being written for how to do various tasks within the plant, I think I drove the engineers, managers and other authors quite crazy asking what unfamiliar words meant.  Then as I began to have to re-type (yes, this was in the days before word processing!) procedures that didn't get approved by management, I quickly began to understand the procedure topics so as to be able to help the authors avoid rejection.  It was interesting and fun learning.  Some authors did not appreciate my help, but most did.

As we started manufacturing product, our customers began to schedule quality assurance audits to make sure we were meeting their requirements.  Every audit involved whether we were working in compliance with the procedures I had been so dutifully typing up.  Soon, the Quality Assurance Manager found that no one could answer questions better than me about which procedure covered which topic, where and what it said specifically.  Thus, a year later I was promoted from Sr. Secretary to Audit Coordinator.

I met so many people from all over the world.  They all taught me things about the requirements of being a supplier to the nuclear industry.  Some became pretty good friends.    

Through answering audit findings, I fell into the world of corrective actions.  I first learned that it was required and expected that you could prove that you really did what you said you did when you explained how you fixed an audit finding.  Some sort of formal objective evidence had to be generated which would then be used as a defense by people to prevent the mistake from happeneing again.  After that I learned that if the fix wasn't good enough, the problem most likely would happen again.

I was a lead auditor for the corporation (not just my plant) for over 25 years.  I mostly audited sub-suppliers but eventually decided to let my qualification lapse because the corporate audits always seemed to conflict with something else that was a higher priority for me to get done at my plant.

About 10 years ago, a new electronic Corrective Action System (CAPs) was adopted by my corporation and I was appointed to be the manager of it at my plant simply because of my experience with nuclear QA audits.  However, the CAPs process involved all aspects of the business where an event needed correction.  My eyes were opened to the worlds of environment, health & safety; maintenance; accounting and so on.  I was soon trained as an Apparent Cause Analyst to lead investigations of events and then became an Apparent Cause Analyst trainer for the corporation.  I came to understand and enjoy the development of why trees as a pictorial flow of why an event occurred.

When I began my career in nuclear QA in 1979, the Three Mile Island nuclear accident occurred.  There were many years when we were not sure the nuclear industry would survive in part because of that accident.  We are now in the midst of the Fukushima Dai-Ichi power plant failure from a horrific earthquake and tsunami that occurred in March, 2011.  It will be interesting to see where that situation takes the nuclear industry next.