unit 6
Instructions
Fishbone Diagram Project
Read the U.S. Chemical Safety Board investigation report of the 2007 propane explosion at the Little General Store in Ghent, WV. The final report can be read/downloaded at the following link: https://www.csb.gov/assets/1/20/csbfinalreportlittlegeneral.pdf?13741
Additional information on the incident, including a video summary, can be found at the following link: http://www.csb.gov/little-general-store-propane-explosion/
NOTE: This is the same investigation report used to complete the assignments in Units IV and V.
Complete the assignment as detailed below.
Part I: From the information in the report and from the information you developed for the assignments in Unit IV (events and causal factors [ECF] chart) and Unit V (barrier analysis), create a fishbone diagram that illustrates the relationship between the causal factors and the accident. In your diagram, the backbone of the fish should represent the accident, and the big bones should represent the people, procedures, environment, equipment, and policies.
Part II: On a separate page, discuss what new information about the accident is revealed in the chart, and describe how that information might be used to identify potential corrective actions. This part of the assignment should be a minimum of one page in length.
Upload Parts I and II as a single document. For Part II of the assignment, you should use academic sources to support your thoughts. Any outside sources used, including the sources mentioned in the assignment, must be cited using APA format and must be included on a references page.
