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Subject Matter Expertise Critical to Robust Incident Investigation
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Subject Matter Expertise Critical to Robust Incident Investigation

  • Publish Date: Posted over 1 year ago

Transforming Maintenance Practices through Investigation and Corrective Action: Achieving Success at Multiple Locations

​The Challenge

A carbon dioxide fire suppression system protecting a remote telecommunication facility requires regular inspection, maintenance, and testing. Given the remote location, its limited access, and the infrequent need for interfacing with the specialized equipment, experienced and qualified technicians were challenging to locate, employ and retain. The intersection of inexperience and inadequate system documentation contributed to an inadvertent system discharge and the preventable loss of two technicians.

Our Approach

An external team of subject matter experts comprised of a safety specialist, mishap investigator, fire protection engineer, and military officer assembled and rapidly assembled and deployed to the location of the incident. The team reviewed documentation, conducted multiple investigations of the incident site, and conducted dozens of interviews to discern root causes and contributing factors of the incident and make recommendations for corrective actions that reflected significant process improvements.

The Result

The local facility maintenance team immediately identified other locations where the documentation and expertise of maintenance technicians could be enhanced. Additionally, dozens of occurrences were identified globally, and corrective action plans were implemented to update support documents and technician competence to reduce the risk of recurrence. The team’s third-party objectivity significantly contributed to the valuable candor of the dialogue and recommendations from the investigation and served as a model approach to conducting complex and high-profile investigations.

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