From the fishbone diagram above, it can be noted that people, processes, guidelines, environment, and the equipment all played a key role in the gas explosion. However, the main cause of the accident was a defect in the gas valve opening. New investigations have shown that the accident could have been avoided if there were adequate personnel training. The staff that was left in charge of the gas area had no enough technical knowledge on how to act under different situations within such a dangerous the workplace.
Another cause of the accident that was discovered by the United States Chemical Safety and Hazard Investigation Board was poor or absence of emergency guidelines in the company. The investigation reveals that it almost took half an hour from the time the gas started to leak and the time the explosion occurred. This means that if there were proper emergency mechanism laid in place, the hazard would have been mitigated before it becomes a tragedy.
The other new findings in the investigation include poor evacuation policies. The research has shown that the respondents never issue evacuation order to permit evacuation to take place even after discovering there were at least four people held in the building. Other staff members were confused and never gave the correct directions to the evacuators to follow while inside the building. The final cause of the accident was the distance between the gas tank and the building. Propane is a flammable gas and any explosion would spread fire to the nearest buildings. As such, the move to install the gas tank closer to buildings should not have been welcomed.
The information identified above can help prevent any other similar risk from happening. For instance, the information on lack of training should be used by the management to schedule lessons for all the staff members on emergency management techniques. This is important as it allows the staff to identify any risk in advance, report it to the risk management team and the appropriate action taken. Also, the management of the company should consider the problem caused by the closer proximity of the propane tank to the buildings. As such, the company should construct propane gas tanks far from the buildings. The pipes that transport the gas from the tanks should be thoroughly investigated for any defects in the pipes which may cause an accident. This will prevent any advance risks on the loss of people's lives and damage of property as a result of the explosion of the tanks. All other precaution concerning the storage of flammable substances should be followed to the latter.
Moreover, the management of the company should consider poor evacuation procedure as a policy issue that led the accident to worsen. The company should lay down better evacuation procedures. This includes signage, wind windows, and many doors for safety in case an accident occurs again. Lastly, the company should endeavor to commit itself to ensuring that the scheduled maintenance dates for all the equipment's are followed and the maintenance and inspections are done by well-qualified technicians.
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