On April the 20th 2010 the Deep Water Horizon encountered a blowout. The Blow Out Preventer should have prevented the following disaster but only partly worked. In this Event Map based on the US CSB animation we explain the chain of events. Bart Smit wrote a blog article about visualisation of the facts related to this accident (see here).
An early-morning emergency alert mistakenly warning of an incoming ballistic missile attack was dispatched to cellphones across Hawaii on Saturday January, 13th 2018, setting off widespread panic in a state that was already on edge because of escalating tensions between the United States and North Korea.
Complex problems in your technical systems might appear less complex, if your facilitators were able to keep it simple. These 7 habits stand in the way of keeping it simple!
Failure Mode, Effect and Criticality Analysis is a convenient method to gather knowledge and experience about the behavior of your technical systems. FMECA sessions can be very motivating for your fellow workers because you share insights, learn new things. A skilled FMECA facilitator can make the difference. Key is a simple set of 4 principles.
Wouldn’t it be great if we all got warnings before a major incident occurs so that we can prevent them from happening? Sounds like science fiction perhaps, but it is not. We just need to start looking differently and use different tools. Below is the story of how we discovered what to do differently.