Anatomy of a Disaster – root cause analysis

On March 23, 2005, BP’s Texas City refinery had a major accident that killed 15 persons and injured 180. The U.S. Chemical Safety Board did an investigation and looked into the root causes of this accident.

Here is an excerpt from the Board’s video:


Note that the problems identified by the Board were not news to BP management. Internal audits and studies by BP had highlighted many of the same problems months before the accident.

This is a great lesson on what to do AFTER you have completed an internal audit. If management had paid attention to their own findings and acted on them, could this fatal accident have been avoided?

We discuss all these audit related issues at our 2-day seminars.


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