A major utility in the Middle East suffered a catastrophic transformer failure. The resulting substation fire took over six hours to bring under control and resulted in the temporary loss of power to small and large businesses and to many hundreds of local households, as well as causing major traffic disruption to the densely populated local community. The incident highlighted practical difficulties to the local emergency services in tackling the fire.
Soon after the incident, the utility set up a task force to manage the ongoing incident and initiated a thorough investigation to determine a root cause for the failure. Despite the seriousness of the investigation the utility wanted to learn lessons from it and to ‘look within’. The utility asked where it had failed and what needed to be improved?