The Sydney Morning Herald reported:
“Failure to test a cement casing at an oil well in the Timor Sea was a root cause of a blowout that caused Australia’s worst offshore oil spill, an inquiry has heard.“
See the article at:
It sure seems like there were many more “root causes” to me and that the analysis should have led to root causes that were much more in-depth. And it would be a big help if there was a SnapCharT® to help identify all of the Causal Factors.
What do you think?
Here’s the March 15 meeting transcript:
And here’s the link to the Commission’s web site for more information:
http://www.montarainquiry.gov.au/index.html
In the report, after stating the “root cause” are the following questions… How and why did this occur? Why was the mistaken
calculation concerning the volume of cement not detected at
the time? What systems were in place to ensure that
correct volumes of cement would be used in order to achieve
top of cement above reservoir? What was the effect of
using the wrong volume of cement in terms of the integrity
of the cemented casing shoe as a barrier?
I suspect the real root cause lies in the answers to these questions. I was always taught to keep asking questions until the evidence confesses with something you could fix.
Hi Mark,
Failure to test is definetly not a Root Cause. I guess I can only give them the benifit of a doubt that they meant Cotributory or Apparent cause, although that would still be an indicator of a lack of understanding of cause analysis terminology or definitions.
Thanks,
James
Hi Mark
Failure to test is not a Root Cause.
? Where are the people that must have planned and coustiously calculated the quality of the human resources, control equipment, Norms and Safety rules to do the Job?
Did they benchmarked how this work has been successfully done in other oil well sea towers?
For me the Root Cause according to its definitions is HUMAN ERRORS.
My best wishes
Seidel Muriel
Mark,
My view is that “failure to test” would surely meet the definition of a causal factor, not a root cause.
Best Regards to all the TapRoot(R) folks
Dennis Ward
I agree with Dennis and James that “failure to test” indicates a condition and possibly a causal factor, not a root cause.