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In Unit VI, you had the opportunity to review selected parts of the U.S. Chemica
In Unit VI, you had the opportunity to review selected parts of the U.S. Chemical Safety Board (CSB) investigation Final Report of 09/24/2009 regarding the Imperial Sugar Company Dust Explosion and Fire in Port Wentworth, GA.
The Unit VII Project is comprised of three parts as follows:
Project: Part 1: Create a Barrier Analysis
In this analysis, you need to consider barriers that failed, were not used, or did not exist. A barrier analysis form and summary chart are illustrated in Figure 9.7, Investigation Barrier Analysis Example Scenario, and Figure 9.8, Investigation Barrier Analysis Summary of Example Scenario, of the e-textbook. Please remember that a barrier analysis demonstrates that when an incident occurred, there may be barriers that could have prevented the incident but may not have been used.
From the information in the report, create a three-column barrier analysis worksheet. Use the sample form in Figure 9.7, Investigation Barrier Analysis Example Scenario of the course e-textbook as a template, and follow the instructions below:
• In the first column, list the barriers. Group the barriers by category (failed, not used, did not exist).
• In the second column, describe the purpose of each barrier.
• In the third column, evaluate the performance of the barrier.
Project: Part 2: Create a Fishbone Diagram
Recall that the elements of a fishbone diagram include a head, backbone, ribs, and small bones:
• Head: The head of the fish represents the problem statement. Identify your problem statement for this scenario.
• Ribs: These are the main contributing factors. You may end up with multiple branches from the main ribs as you treat each contributing factor as its mini-rib and keep asking why each factor is occurring. For this project, the contributing factors could fit into the following categories:
• Person
• Procedures
• Environment
• Equipment
• Conditions
• Small bones: In many cases, smaller bones are included on the rib bone to represent a deeper root cause analysis or weakness.
Refer to Unit VI and Figure 11.2, Apollo Fishbone, 5 Why Approaches for Investigation, and Table 11.1, 5 Why Approaches for an illustration and discussion of a Fishbone Diagram.
You may create your fishbone diagram in any program you choose. You can search online for fishbone diagram templates or tutorials in programs, such as PowerPoint, Word, and Excel. Alternatively, you can use a different program and submit the final product image as a PDF or graphics file. Be sure to review the acceptable file formats in the assignment submission area of Blackboard.
Do not submit a hand-drawn diagram.
In your diagram, the backbone of the fish should represent the incident, and the big bones should represent the people, procedures, environment, equipment, and policies.
Project: Part 3: Discussion
On a separate page, write a response that includes the following:
• Discuss what new information about the incident that is revealed in the fishbone diagram.
• Describe how that information might be used to identify potential corrective measures.
• Explain the benefits of barrier analysis.
• Discuss the various aspects of cause-and-effect analysis based on your barrier analysis.
This part of the project should be a minimum of two pages in length.
Formatting
Complete all parts of the project as a single document. Your completed project (all three parts) should be a minimum of four pages in length.
For Part 3 of the project, you should use two academic sources other than the CSB resource to support your conclusions. One source must be from the CSU Online Library. Any outside sources used, including the sources mentioned in the project, must be cited using APA format.
You are encouraged to offer your opinion and experience. Although your opinion or belief may be based on experience and not necessarily a truth claim, you should incorporate resources that support your opinions. You must use at least two peer-reviewed or academically reliable sources to support Part 3 of your project. All sources used must have citations and references formatted in proper APA Style.
Potential Resource for this Assignment
Although not required, you may find the below resource helpful as you complete your project:
Occupational Safety and Health Administration. (2002). Job hazard analysis. U. S. Department of Labor. https://www.osha.gov/sites/default/files/publications/osha3071.pdf
Textbook: Accident Investigation Techniques: Best Practices for Examining Workplace Incidents
Peter Sturm, Jeffrey S. Oakley
Project part 1: refer to chapter 9 pg. 48.
Project part 2: refer to chapter 11.
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