Monday Accident & Lessons Learned: A Published Use of TapRooT® Following an Equipment Failure
This root cause report was prepared for Fermilab Research Alliance (FRA) on September 14, 2007 following the “Large Hadron Collider Magnet System Failure”.
1) On November 25, 2006 a heat exchanger internal to one of the Fermilab supplied magnets collapsed in a pressure test
2) On March 27, 2007 structural supports internal to one of the Fermilab supplied magnets failed in a pressure test.
Here is the link to the Incident PDF: http://www.fnal.gov/directorate/OQBP/index/oqbp_misc/Final_LHC_Root_Cause_Analysis_Report_Rev2_19Sep07.pdf
Here at System improvements, Inc. and in our TapRooT® Root Cause Analysis Courses that we teach, we encourage our process be used for multiple business processes. In this Root Cause Report, the areas below were investigated using our root cause process as one of the investigation tools:
• Project Management
• Agreements
• Specifications
• Design
• Procurement & Construction
• Acceptance & Testing
• Delivery
• Commissioning & Startup
Read the report and see what they determined and also how they integrated TapRooT® into the actual report. Let me know what you think.
