Monday Accident & Lessons Learned: Sayano-Shushenskaya Hydro Accident

We reported on the Sayano-Shushenskaya Hydro Accident previously at:

http://www.taproot.com/content/2009/08/17/incident-at-russian-hydroelectric-plant-kills-8/

http://www.taproot.com/content/2009/09/01/very-interesting-powerpoint-about-russian-dampower-plant-disaster/

The accident resulted in 74 deaths and losses in the billions of dollars.

A TapRooT® User sent me some new information that I found interesting.

First, here is a pdf with lots of pictures and some analysis:

AccidentRussiaHydroPlant.pdf

Here are a few of the pictures…

Second is a DOE web page with lessons learned. See:

http://oesummary.wordpress.com/2010/02/04/russian-hydroelectric-plant-accident-lessons-to-be-learned/#more-510

This looks like they should have been applying Equifactor® before the accident to handle the equipment reliability problems they were having.

Also, see the lessons learned at the end of the “AccidentRussianHydroPlant.pdf” that is linked to above. Do you think they were based on a through root cause analysis?

Wouldn’t it have been nice to see a real TapRooT® Investigation of this accident…

Imagine a good, complete summer SnapCharT®. And root causes identified for each Causal Factor by using the Root Cause Tree®. And corrective actions developed using the Corrective Action Helper® Module and SMARTER.

How much knowledge is lost because we don’t effectively investigate problems?