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ADVERSE CONSEQUENCES ARE CAUSED BY BEHAVIORS AND CONDITIONS.
For example, the behavior of cutting into a pipe and the condition of the pipe being pressurized with hydrogen caused the hydrogen fire mentioned above. In order to prevent consequences or to make them less severe, the behaviors and conditions that caused them must be changed. The core melt at Three Mile Island was caused by the behavior of turning off the safety injection pump and the condition of the power operated relief valve being open. Again, these were not “root causes |
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