June 26, 2009 | Mark Paradies

TVA Publishes Root Cause Analysis of Ash Spill

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I’ll post the links here so that people can review the report.

The Executive Summary:


The presentation slides:


The independent review letter:


The complete report site:


I reviewed the slide show and the Executive Summary and I couldn’t find anything that I would call “root causes.”

I did see a good failure scenario that would make a good SnapCharT® and then could be used to identify Causal Factors (which are similar to the “Failure Conditions” in the presentation pdf). Their failure conditions were:

  • Increased Loads Due to Higher Fill
  • Hydraulically Placed Loose Wet Ash
  • Fill Geometry & Setbacks
  • Unusually Weak Slimes Foundation

But they didn’t analyze these factors to find the root causes behind them and they certainly didn’t look for Generic Causes.

They won’t be reopening this site so this accident won’t be repeated here. But I didn’t come away with lessons that TVA’s Management should be learning to improve their performance.

Am I missing something? Review the materials and see what you think.

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