November 19, 2008 | Mark Paradies

Bad Day on the Drill Rig – Root Cause – Forgot to Hang the Sign!

Here is what a bad day looks like on the drill rig:




Here is the sign that was suppose to prevent the problem … but was not posted:


This accident seems like an excellent candidate for some advanced root cause analysis!

Now for another question: Is one sign a good enough Safeguard to prevent this failure?

Other Safeguards might have included the driller’s knowledge, being careful, or perhaps supervision by the rig manager. These are all Human Action Safeguards. Are they sufficient?

Or should there be an Engineering Safeguard?

Safeguard Analysis is a powerful tool that can help you judge weaknesses in your systems to protect life, property, and the environment (even product quality). If you would like to learn more about applying it at your site, I would suggest attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. See:

For more info.

(And thanks to Bryce Donaldson, a TapRooT® Instructor, for sending these pictures along.)

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