Incident investigation workshop


DETERMINE CAUSES FOR ALL OBSERVATIONS



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How to develop a Why Tree-2012 DHK

DETERMINE CAUSES FOR ALL OBSERVATIONS

  • DETERMINE CAUSES FOR ALL OBSERVATIONS
  • After determining key factors for one observation, go back and repeat the process for the other observations. Continue until you have explained all the observations to ensure you haven't overlooked some key factors.
  • In the Fuse case, finding the key factors of one observation explained the other three.
  • The fuse which failed and caused the 'Pop' was in the motor control centre that was being started.
  • When it failed, it took out several other fuses, interrupting power to the four drives.
  • When the drives lost power, the motors they were controlling stopped, which caused the faceplate rolls that the motors were turning to also stop.

DETERMINE CAUSES FOR ALL OBSERVATIONS

  • DETERMINE CAUSES FOR ALL OBSERVATIONS
  • DATE: 6/9/05
  • FAILURE CATEGORY: Drive Failure
  • WASTE: 1800 Ibs.
  • DOWNTIME: 2 hours
  • MACHINE: SM 310
  • INITIATING EVENT: Motor Drive Failure
  • PHYSICAL FACTOR: Too small a fuse was installed in an application, which resulted in the fuse blowing apart catastrophically. The explosion took out many other fuses in a domino effect, which left many functions inoperable.
  • HUMAN FACTOR: Did not know proper fuse rating. Fuse rating label not read.
  • SYSTEM FACTOR: Inadequate training, supervision and accountability.

WHEN BUILDING A WHY TREE

  • WHEN BUILDING A WHY TREE
  • People will tend to:
  • Inter: "This is a like that so they should react the same way."
  • Perceive: “I can't prove it but I just know it must be."
  • Assume: "We've seen this problem before. The same thing must be causing it."
  • Don't use someone else's subjective BELIEFS as objective FACTS.
  • Conventional wisdom can mislead you

TIPS FOR BUILDING GOOD WHY TREES

  • TIPS FOR BUILDING GOOD WHY TREES
  • ARE THE CAUSE and EFFECT STATEMENT CLEAR?
  • plus

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