Things just don’t fail they are caused. All causes can be determined and evaluated through investigating the 3 p’s of evidence trails that Exist.
phyiscal ( parts) evidence
Try and avoid bias.,
as you investigate identify stakeholders involved.
Only an non blame evidence based approach shall lead us to the truth of all failures.
Gather all the evidence.
Present the evidence to the stakeholders.
Let them conclude what went wrong at a stakeholder meeting.
Where there is only one rule. One can’t blame anyone but yourself.
Then further try and understand the latencies why people did what they did.
eg choose the cheapest bidder
used up old stock that had been sitting in a yard for xyears
used outdated or wrong components
did not carry our maintenance checks
People were not trained
operating guideline requirements were not clearly stated
engineering design was inappropriate etc etc
only though discovering change and changing people will you resolve such failures.,
As Paul has stated get trained in how to properly investigate and learn from things that go wrong as an individual and as a organisation. without assigning blame.
Take an evidence based approach.
Personally I have estimated that I have experienced 4800 well related ( non injury accident) failures in drilling operations that in the main were never investigated and/or truly resolved. We stop at the symptoms and teareky get to all the root causes. There are generally several per each accident event. Where are all these reports and learnings?
We wonder why things dint improve?
Where I was not trained by any employer in a 40 year career in how to truly investigative drilling failures. That for me was always viewed as a core and essential safety leadership skill?
Sadly many organisations do not yet view majority of such accidental events as safety. Despite all evident FACTs that these are the exact same accident precursors to personal injury.
So why are these drilling events not investigated or viewed as safety by ones self, management and executive as safety?
If we want to truly know and understand where the problems lie. Just look in the mirror each morning as start there.
We can either continue to accept all accident failures and react by pointing the finger somewhere else or all start to do better to prevent them.