Events and Causal Factors Chart Project

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Student Name

Course Title

Lecturer’s Name

Date of Submission

Part 1:

Part II

The likely causal factors for the witnessed explosion include failure to satisfy the acceptable measures as well as the inability to ensure the installation of proper metrics. There was a dire need for the technician on call to fulfil the necessary standards and controls during the process of repairing the valves. This step could have prevented the occurrence of the explosion. The state of the appliances affected the overall performance of the propane system thereby resulting in a blast. Among the goals of the assessment of the effectiveness of any system is the need to ensure all the installed tools and equipment are appropriate as well as efficient for the work (Oakley, 2012). Failure to observe this vital requirement exposes the entire system to plenty of defects which could have severe effects.

Constant checking of the system is an essential prerequisite aimed at correcting defects such as leaks of the propane gas. The CSB report indicates clearly that the junior technician was incompetent to perform his duties. He lacked the necessary skills needed to effectively carry out repairs on the malfunctioning valves. This allowed for emission of the gas and its subsequent vaporization and explosion. Ensuring the valves are well fixed and that no amount of leakage is witnessed is a necessary step that the technician would have taken to avoid any uncertainty from occurring. Failure to observe this amount to negligence and must be punishable bearing in mind the fatality of the witnessed explosion.

The report by CSB has an intricate correlation to the identified causal factors. Both reflect that the unfortunate event was due to lack of proper inspection as well as audit programs that could have helped in the identification process of the defective tank. Proper controls and audits would have enhanced the transfer of the defective tanks from against the building thus mitigating any eventuality. The second causal factor identified revolves around the fact that the emergency responders lacked the necessary skills needed for them to effectively perform their roles. The respondents failed to act accordingly for fifteen minutes thus allowing the explosion to occur (Oakley, 2012). The respondents could have helped to prevent the explosion had they moved swiftly with speed in seizing the reported Propane leakage.

In conclusion, this occurrence implies that employee training initiatives are critical for the safety and efficiency of organizational processes. Moreover, organizations should establish adequate inspection procedures to ensure the existence of a friendly and less risky operational environment as well as the suitability of tools and equipment used. Such measures if implemented would help to identify and mitigate causal factors for various tragedies thus saving organizational resources.

REFERENCE

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and

applications (2nd ed.).Des Plaines, IL: American Society of Safety Engineers.

Employment; Junior Propane Service Technician employed for transfer liquid propane

Propane Gas released unexpectedly

Plug of Existing Tank Removed

10.50 am

Responders come but ignore the release of Propane.

10.00a.m

Plug of Existing Tank Removed

10:53 am; Huge explosion due Propane ignition

10:25 am

Propane Gas released unexpectedly

10:40 am

911 Called after 15 minutes of release

Gas Vapour forms due to release