Category
Incident Investigation
89 articles
San Bruno and the Leadership Test Hidden in Pipeline Records
The 2010 San Bruno pipeline rupture was not only a technical failure. The NTSB investigation showed how uncertain records, weak validation, and leadership decisions about risk can combine until a serious hazard becomes an irreversible event.
TapRooT vs ICAM vs Bow-Tie Reverse Analysis: Which Investigation Method Fits a Serious-Injury Exposure?
TapRooT, ICAM, and Bow-Tie Reverse Analysis answer different investigation questions. This comparison helps plant leaders choose the method that best matches task failure, organizational complexity, or critical-barrier verification.
Incident Investigation: 4 Assumptions That Weaken Action
Incident reports fail when they explain the last action but leave the operating conditions unchanged. Test four assumptions before approving corrective action.
Kleen Energy: How a Routine Pipe-Cleaning Method Became a Fatality Pathway
The 2010 Kleen Energy explosion killed six workers because a familiar natural-gas pipe-cleaning method created a major hazard that the project controls did not adequately challenge. The case shows why temporary work, shared contractor responsibility, and commissioning decisions require stronger ownership and field verification than routine paperwork can provide.
Incident Investigation: 5 Blind Spots That Keep Serious Causes Out of the Report
A serious incident investigation should explain more than the final action. This diagnostic guide shows five blind spots that hide system conditions, weaken corrective actions, and leave risk available for the next shift.
Timeline Reconstruction vs Witness Accounts vs Physical Evidence vs Digital Records: Which Should Lead an Incident Investigation?
Incident investigations become unreliable when the team treats every evidence source as equally complete. This comparison explains when timeline reconstruction, witness accounts, physical evidence, or digital records should lead the inquiry, and why the strongest conclusion usually comes from testing the gaps between them.
Piper Alpha: How a Permit Handoff Became a Catastrophic Loss
The Piper Alpha disaster shows why permit-to-work systems fail when handovers preserve paperwork but lose operational meaning. This case study connects the Cullen Report to restart decisions, barrier evidence, and practical control checks for high-hazard operations.
Incident Investigation: 4 Evidence Breaks That Let a Known Hazard Return
An incident investigation should do more than explain what happened. It should show which control failed, what decision allowed the exposure to remain, and what evidence proves the risk is different now. This F1 diagnostic helps EHS leaders and operations managers find four evidence breaks that make corrective action look complete while leaving the hazard in place.
Bhopal: How an Emergency Plan Became a Fatality Pathway
The Bhopal gas disaster was not only a chemical release. It was a governance failure in which warning evidence, degraded barriers, unclear authority, and emergency readiness failed to change the operating decision before exposure became harm.
Three Mile Island: How a Minor Malfunction Became a Safety Leadership Test
The Three Mile Island Unit 2 accident on March 28, 1979, was not a single operator mistake. It was a case in which equipment behavior, confusing indications, design weaknesses, training, and management assumptions combined faster than the organization could interpret them. This case study turns the NRC record into practical questions for safety leaders.