March 20, 2006 | Mark Paradies

Monday Accident & Lessons Learned – Root Cause of Sego Mine Disaster – Lightning???

CNN reported that the owners of the SEGO mine said that the explosion was “caused” by a massive lightning strike that ignited methane gas in a sealed off portion of the mine.

In TapRooT(R) System that cause would be a “Natural Disaster/Sabotage”.

But good investigator would ask …

“Is it OK to run a mine that can be blown up by a lightning strike?”

It seems that something is missing here.

What safeguards should have been in place to make the mine safe?

And even after the explosion that was “caused” by lightning, why couldn’t the miners escape or stay alive? Should the miners have had access to emergency breathing equipment to be able to escape/survive?

I see the mine owner’s statement about “cause” is really a statement about the “initiating event” and not a complete listing of the causes of the 12 miner’s deaths.

I will be looking forward to the MSHA investigation results and I hope they will publish their complete SnapCharT(R) of the sequence of events so that we can see all the failed safeguards and have ideas about additional safeguards that could prevent this type of tragic event.

Because with our understanding of safety, accidents should truly be rare. And when we have fatalities that are a result of insufficient or improperly maintained safeguards, the deaths aren’t really “accidental” – they are caused.

So what can you learn from this accident? Investigations are about more than the initiating event. You need to see the entire SnapCharT(R) (sequence of events) to define all the causal factors and find all the root causes.

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