This webinar shows a simple way a complex incident can be broken down into its different contributing factors. Every investigation, regardless of severity, can begin with a few simple Why questions then expand as needed to thoroughly explain the issue.
On March 23, 2005, a massive explosion at the Texas City refinery 40 miles southeast of Houston resulted in 15 fatalities and over 180 injures. A summary of this incident provides some basic facts – too much liquid was added to a tower resulting in a release to atmosphere that ultimately ignited. As with any incident, key lessons about reducing operational risk are concealed within in the details. Discovering those details takes some digging, which is the intent of a root cause analysis.
The analysis of the Texas City disaster contains several different 5-Whys, depending on point of view, that will combine into a more complete 25-Why and eventually a detailed 125-Why.