Change Analysis Exercise: The Anchor and My Tugboat
DESCRIPTION:
(Refer to video). The tugboat seen in the video is used to maneuver the ships in tight places in the harbor. As you can see, the anchor on the ship being moored
fell on the deck of the tugboat, damaging it and throwing its captain overboard.
EXERCISE:
Using the Change Analysis worksheet on page 2, 1) develop a list of interview questions and 2) determine the possible contributing factors that could have led to
this unfortunate incident
INTERVIEW QUESTIONS:
Change Factor Difference/Change Effect Questions to Answer
What
(Conditions, occurrence, activity, equipment)
When
(Occurred, identified, plant status, schedule)
Where
(Physical location, environmental conditions)
How
(Work practice, omission, extraneous action, out of
sequence procedure)
Who
(Personnel involved, training, qualification,
supervision)EXERCISE