Question
lesson 6
Lesson 6
Class,
This week we will look at discovering why incidents happen in the first place. If we are tasked with solving the problem, we need to make sure the solution actually solves the problem. All too often a solution is put into place that only addresses the symptoms and not the cause. Finding the actual cause is often referred to as the “root cause”. There are several ways to perform a root cause analysis; one of the simplest methods is using the “5 whys”. Please see the link below and read the article.http://www.lifetime-reliability.com/tutorials/lean-management-methods/How_to_Use_the_5-Whys_for_Root_Cause_Analysis.pdfOnce you have read the article, please go to this link: http://www.csb.gov/dupont-corporation-toxic-chemical-releases/Watch the video and do your best to auger down to the root cause of the incident in the video. The link has a written assessment of what went wrong and the video gives you all the answers, so this is not that difficult; however, there is a lot of information to sift through. Your assignment will be to put the findings into the “5 why” question table format. For the cost box; this will be the loss of life, business and reputation. If you follow the intent of the “5 why” article and present the facts, you will end up with about a page of information. Please follow the table format in the link; you can create one of these in MSWord.Feel free to add additional levels if you need to go deeper (hint-hint).
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Expert Solution
|
Why
1 |
Why
2 |
Why
3 |
Why
4 |
Why
5 |
|
Death
of Dupont employee |
Phosgene
intoxication |
Stainless
steel pipe burst |
Corrosion
of steel pipe |
Weak
material |
|
|
|
|
Lack
of regular planned maintenance |
Laxity
of staff. Lack
of follow-up on orders. Lack
of thorough monitoring system ("DuPont Corporation Toxic Chemical
Releases | CSB", 2011) |
|
A
leak of nitric acid |
The
nitric acid leaked due to a burst in one of the pipes that carry the nitric
acid during the process |
The
pipe burst due to Corrosion. The
pipe burst due to the use of pipes that are not strong to handle certain
chemicals |
Lack
of scheduled maintenance. Use
of cheaper pipes |
Miscommunication
of personnel leads to a lack of follow up in instructions and orders Desire
to cut costs |
|
|
The
nitric acid leaked due to a lack of follow up on alarms raised by the system |
The
workers are used to Many false alarms and have become a bit relaxed. ("DuPont Corporation Toxic
Chemical Releases | CSB", 2011)
|
The
monitoring systems are Sensitive systems and trip regularly |
Lack
of balance in the control systems
|
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