Fishbone Diagram Project
Read the U.S. Chemical Safety Board investigation report of the 2007 propane explosion at the Little General Store in Ghent, WV. The final report can be read/downloaded at the following link:
https://www.csb.gov/assets/1/20/csbfinalreportlittlegeneral.pdf?13741
Additional information on the incident, including a video summary, can be found at the following link: http://www.csb.gov/littlegeneral-store-propane-explosion/
NOTE: This is the same investigation report used to complete the assignments in Units IV and V.
Complete the assignment as detailed below.
Part I: From the information in the report and from the information you developed for the assignments in Unit IV (events and
causal factors [ECF] chart) and Unit V (barrier analysis), create a fishbone diagram that illustrates the relationship between
the causal factors and the accident. In your diagram, the backbone of the fish should represent the accident, and the big
bones should represent the people, procedures, environment, equipment, and policies.
Part II: On a separate page, discuss what new information about the accident is revealed in the chart, and describe how that
information might be used to identify potential corrective actions. This part of the assignment should be a minimum of one
page in length.
Upload Parts I and II as a single document. For Part II of the assignment, you should use academic sources to support your
thoughts. Any outside sources used, including the sources mentioned in the assignment, must be cited using APA format
and must be included on a references page.
Fishbone Diagram Project
Student’s Name
Institutional Affiliation
Course
Instructor’s Name
Date
Fishbone Diagram Project
Part I
Part II
The fishbone diagram analyses the propane explosion incident. The fishbone diagram discovered new causal factors such as lack of leak detection, procedure remiss on trans loading tanks, negligence in various aspects of operation, and lack of proper policy to prevent hazards (CSB, 2008). In the analysis, there were no serious detectors that could sound an alarm or warn the technician that the matter was so serious. The Employees also did not know early that propane leakage was happening due to a lack of detectors. Also, carelessness in the loading procedure led to damages to the plug that in turn caused the problem. If the loading trans-loading process was effective, the plug would have not been damaged CSB, 2008). Operations were negligent, for instance, negligence in maintenance programs and negligence to look at the pre-job cycle checklist.
The information indicated in the fishbone diagram can be used to find a remedy to the problem to prevent future hazards. There are so many things that should be corrected regarding the issue CSB, 2008). For example, there should be proper training for all technicians and emergency response teams to ensure they are effective at work. A standard of practice procedure should be provided to all employees in all departments to follow to avoid hazards CSB, 2008). Another remedy is to provide safety education to all employees to ensure they protect themselves during problems like the one being discussed in this paper. All these measures are essential to enhance safety and efficiency at the workplace.
References
CSB. (2008). U.S. Chemical Safety and Hazard Investigation Board: Investigation report, Little General Store – Propane Explosion. https://www.csb.gov/assets/1/20/csbfinalreportlittlegeneral.pdf?13741