PHASE V—FOLLOW-UP

Determining facts related to any accident is the key to an accurate and effective analysis. Remember to 

Select the one (most) direct cause and the root (basic) cause (the one for which corrective action will prevent recurrence and have the greatest, most widespread effect). In cause selection, focus on programmatic and system deficiencies and avoid simple excuses such as blaming the employee. Note that the root (basic) canse mnst be an explanation (the why) of the direct cause, not a repeat of the direct canse. In addition, a cause description is not just a repeat of the category code description it is a description specific to the occurrence. Also, up to three (contributing or indirect) causes may be selected. Describe the corrective actions selected to prevent recurrence, including the reason why they were selected, and how they will prevent recurrence. Collect additional information as necessary. 

A Comprehensive Course in Root Cause Analysis and Corrective Action for Nuclear Power Plants (Workshop Manual). San Juan Capistrano Failure Prevention Inc., 1988. 

Root cause and how to find it. Nuclear News, August 1987. 

Nertney, R.J., J. D. Comelison, and W. A. Trost. Root Cause Analysis of Performance Indicators, (WP-21). System Safety Development Center, Idaho Falls, ID EG G Idaho, Inc., 1989. 

Comprehensive Course inRoot Cause Analysis andCorrective Action for Nuclear Power Plants, (Worktop Manual San Juan Capistrano  

United States Department of Energy, Office ofNuclear Energy. Root Cause Analysis Guidance Document. Washington February 1992. 

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Kopp, V.R., et al Test Fuel Blending and Analysis for Phase II Follow-Up Programs The Auto/Oil Air Quality Improvement Program, SAE Paper No. 952506, Society of Automotive Engineers, Warrendale, Pa., 1995. 

Bovine liver, rumen content (partially digested grain and vegetation mixture) Extraction of homogenized sample with methanol-dichloromethane (10-90, v/v) followed by gel permeation chromatography and silica gel solid phase extraction clean-up. GC/FPD 0.01-0.05 p/g using 5 g sample Rumen content 95 (3% RSD) at 0.1 pg/g liver 88 (5% RSD) at 0.05 / Holstege et al. 1991... 

Holmes C, Boche D, Wilkinson D, Yadegarfar G, Hopkins V, Bayer A, Jones RW, Bullock R, Love S, Neal JW, Zotova E, Nicoll JA (2008) Long-term effects of Abeta42 immunisation in Alzheimer s disease follow-up of a randomised, placebo-controlled phase I trial. Lancet... 

A solution of 0.96g (2.4mmol) of (4,V,5,V)-4,5-dicyclohexyl-2-[(.S )-(Z)-l-mcthyl-2-butcnyl]-l,3,2-dioxa-borolane [(S,5,S)-7] in 5 mL of petroleum ether (bp 40 - 60 C) is treated with 0.35 g (2.4 mmol) of benzaldehyde for 12 h at r.t. The solution is then concentrated and taken up in 10 mL of diethyl ether. 0.35 g (2.4 mmol) of triethanolamine is added and the mixture is heated to reflux for 4 h. The resulting boratrane is filtered and washed with three 20-mL portions of diethyl ether. The filtrate is stirred intensively with 50 mL of 20% aq NaHS03, then the aqueous phase is extracted with two 20-mL portions of diethyl ether. The combined extracts arc washed with water and brine and then dried over MgS04. Concentration of this solution ill vacuo is followed by short-path distillation at 60 X/0.1 Torr yield 0.30 g (71%) 99% ee [chiral capillary GC on a (5)-valine-(5)-a-phenylethylamide column]39. 

The plan of this chapter is the following. Section II gives a summary of the phenomenology of irreversible processes and set up the stage for the results of nonequilibrium statistical mechanics to follow. In Section III, it is explained that time asymmetry is compatible with microreversibility. In Section IV, the concept of Pollicott-Ruelle resonance is presented and shown to break the time-reversal symmetry in the statistical description of the time evolution of nonequilibrium relaxation toward the state of thermodynamic equilibrium. This concept is applied in Section V to the construction of the hydrodynamic modes of diffusion at the microscopic level of description in the phase space of Newton s equations. This framework allows us to derive ab initio entropy production as shown in Section VI. In Section VII, the concept of Pollicott-Ruelle resonance is also used to obtain the different transport coefficients, as well as the rates of various kinetic processes in the framework of the escape-rate theory. The time asymmetry in the dynamical randomness of nonequilibrium systems and the fluctuation theorem for the currents are presented in Section VIII. Conclusions and perspectives in biology are discussed in Section IX. 

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