Fault escalating

Characteristic Assuming No Fault Escalation Solidly Grounded Ungrounded High Resistance... 

Thus, there are many factors which could justifiably trigger escalation and not just a potential impact on clinical risk. A fault can have little or no clinical risk at all and yet warrant the highest level of resolution priority on the basis that it has significant security, statutory reporting or financial consequences. 

Nevertheless, clinical risk is clearly a major contributor to the potential impact of a fault. Irrespective of other possible outcomes, an adverse effect on patient safety is likely to promote the priority level significantly. Healthcare organisations and manufacturers therefore need to assess reported faults to determine whether or not they are safety-related and, where they are, determine the level of clinical risk. This can be a challenge where large numbers of faults are reported and it may be necessary for filters to be put in place such that service desk staff can escalate faults of greatest concern for a formal risk assessment. 

A succinct and evidence-based account of the problem quickly becomes a mutual focus point of an investigation. Without this the concerns of the CRM team can become nothing more than a lone voice in a sea of fast-moving communications. Note that an issue assessment can be written at any time once the nature of the fault is at least partly understood. Should one wait until a fault is resolved before setting out the risk, the horse has bolted and the opportunity for escalation has essentially passed. 

Objectively documenting a CRM assessment for a significant fault is a powerful tool in gaining stakeholder buy-in and effecting its resolution. This is particularly the case when a healthcare organisations needs to escalate a fault to the manufacturer. 

Determine the hazards and hazardous events of the EUC and the EUC control system under all reasonably foreseeable circumstances (including fault conditions and misuse). This shall include all relevant human factor issues, and shall give particular attention to abnormal or A hazard is an incipient condition and a hazardous situation occurs only when the condition is manifested AND the various layers of protection are breached. The accident itself (the hazardous situation) with a balance of probability of escalating to a major or catastrophic outcome. The storm scenario presented here is infrequent. 

The role of the operator is to monitor that the nuclear safety functions are being successfiilly maintained by the various systems, diagnose the cause of the initiating fault, act to prevent any escalation of the situation and decide on the long term requirements, if any. In most cases there should be nothing preventing the return of the reactor to power. 

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