... indicators have been affect-
ed
by
radiography being carried out on welds up to
70
m away.
74
What Went Wrong?
2.12
CONTROL
OF
MODIFICATIONS
How can we prevent modifications from producing ...
fall.
86
What
Went
Wrong?
between them. Oxygen was also fed to the reactors, but the oxygen
lines are not shown. At the time of the incident only two reactors,
Nos.
1
and...
... (Fig-
ure
1-11,
[16,
171.
8
What
Went
Wrong?
Blowdown
Blowdown
Relief
Valve
RIGHT
Relief
Valve
Open End
-Blank
@
Figure
1 -4.
The
right
and
wrong
ways
to
isolate
a
vent ... 1-6 shows
a thin slip-plate that has been subjected to a gauge pressure of
47 0
psi
(32
bar).
4
What
Went Wrong?
There was another similarity to the first incident.
In
this ca...
...
completed”
[39].
36
What Went Wrong?
Figure
1-13.
This steel box was quite incapable
of
containing a leak
of
steam at
a gauge pressure
of
300
psi
(20
bar).
60
What Went Wrong?
2.6
PROCESS ... fly very far [38]. (See Sections 13.5 and 17.1 for
the hazards of quick-opening lids.)
44
What Went Wrong?
According to the report, the maintenance worker should have...
... 1 04
What
Went
Wrong?
4. 3
LABELING
OF
CHEMICALS
4. 3.1
Poor
or
Missing
Labels
One incident is described in Section ...
of
Zaragoza in December
1990,
Translation
No.
91-1 140 1 ( 849 8e/813e), International Atomic Energy Agency. 1991.
1 14
What Went Wrong?
dioxide to remove the air, and the refrigerated butane ...
14
to
23
amps, was high enough to melt part...
... material.
144
132
What Went Wrong?
was built more than
40
years earlier, and the combination of a full tank
and a low temperature triggered the collapse. For most of the
40
years,
the ... the dike wall was damaged by the
142
What Went Wrong?
this reason, many companies prefer not to use them. If they are
partly choked, burning liquid or particles of hot carbon may be...
... taking.
1 64
What Went Wrong?
13. British Occupational Hygiene Society,
Fugitive Emissions
of
Vapo~~rs
froin
Process Equipment,
Report in
Science Reviews,
Northwood,
UK, 19 84.
14. C. R. ... November 19 84, was one
of
the
worst incidents that has ever occurred in the oil and chemical industries,
exceeded only by Bhopal. According to official figures, 542 people were
ki...
... Workshop,
Atomic Energy Authori-
ty, Hanvell,
UK,
19 84.
13. D. Clarke.
The Chemical Engineer;
No.
44 9, June 1988,
p.
44 .
14.
B.
E.
Mellin,
Loss
Prererzriorz Bulletin,
No.
100, ...
of 23
m; 14 tons of gasoline were
spilled. Three hours later a further length collapsed. The pipe sup-
ports were replaced by the type shown in Figure 9-5 (b).
2 04
What Went Wrong?...
...
7.
Petroleum Review,
Apr. 1976. p. 241 .
2 54
What Went Wrong?
tank should be deemed to be
a
confined space, and the entry proce-
dure should apply.
4.
All managers and supervisors should ...
UK.
199
1.
No.
1,
Jan. 1990.
p.
39.
of
Energy, Washington,
D.C.,
Dec. 19 94. p.
6.
246
What Went Wrong?
Thin films of oil in pipework can explode without a previous f...