Investigating Investigation Methodologies

Exported Comments
Handout For IRIA2003 Presentation

Ludwig Benner Jr
Williamsburg VA 9/18/03


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INVESTIGATION CATALYST COMMENT FILE

Comment export example

 

As presently saved from Investigation Catalyst (RTF text file format)

 

- Why didn't solvent clean out ash in extruder? Timing of fire/solvent shutoff? [Comment Type: question]

- Why did workers have to position themselves in harms way to remove the head? [Comment Type: question]

- Why did Maintenance Tech remove bolts in sequence he did, and would another sequence have changed the outcome? [Comment Type: question]

- Need to confirm that hot oil continued flowing to heat inlet line to PCT after shutdown before and after head blew off - did that contribute to heading of contents? [Comment Type: note]

- Why didnšt HAZOP recommendation successfully control hazard? (Methodological problem) [Comment Type: question]

- Why wasn't unsuccessful recommendation remedied when experience showed it was unsuccessful? (system problem) [Comment Type: question]

- What was the impact trauma that killed 2 workers - tank cover or plastic from inside tank?

- [Comment Type: question]

- Why did Operators position selves with Maintenance Technician at head of PCT (if they did) [Comment Type: note]

- What ignited fire in extruder? Why did it spread [Comment Type: question]

- Who told whom what and why? [Comment Type: question]

- What was data and rationale for this decision? Who made it? [Comment Type: question]

- Find out what procedure is to learn from incidents [Comment Type: note]

- Find out why air could get into the extruder, providing oxygen for fire?? [Comment Type: question]



Example of how it would be used

Above file is converted to text file in Word, and columns are added by user at useršs discretion

 

Task

Assign to

On

Due

Comment
type

Why didn't solvent clean out ash in extruder? Timing of fire/solvent shutoff?

 

 

 

Question

Why did workers have to position themselves in harms way to remove the head?

 

 

 

question

Why did Maintenance Tech remove bolts in sequence he did, and would another sequence have changed the outcome?

 

 

 

question

Need to confirm that hot oil continued flowing to heat inlet line to PCT after shutdown before and after head blew off - did that contribute to heading of contents?

 

 

 

note

Why didnšt HAZOP recommendation successfully control hazard? (Methodological problem)

 

 

 

question

Why wasn't unsuccessful recommendation remedied when experience showed it was unsuccessful? (system problem)

 

 

 

question

What was the impact trauma that killed 2 workers - tank cover or plastic from inside tank?

 

 

 

 

Why did Operators position selves with Maintenance Technician at head of PCT (if they did)

 

 

 

note

What ignited fire in extruder? Why did it spread

 

 

 

question

Who told whom what and why?

 

 

 

question

What was data and rationale for this decision? Who made it?

 

 

 

question

Find out what procedure is to learn from incidents

 

 

 

note

Find out why air could get into the extruder, providing oxygen for fire??

 

 

 

question

 

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