...
Take-Off
Valve
Figure
1 -2.
The take-off branch was dismantled with the Demco valve
(Illustrarion courtesy
of
the
US.
Department
of
hbor.)
open.
32
What Went Wrong?
1.4.7
A
Permit ... working on. He checked
that the line was safe to use, and he asked the shift maintenance
22
What
Went
Wrong?
1.3.6
Trapped Pressure
Even though equipment is isolated by slip-pla...
...
[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 ... the level in a vessel (see Sections 2. 6 i, 22 .2 d and e).
Modifications
53
C
Figure
2- 2a.
Original reactor
bypass.
Reactor
C
C
Figure
2- 2b.
Modified reactor
bypass...
...
m away.
74
What Went Wrong?
2. 12
CONTROL
OF
MODIFICATIONS
How can we prevent modifications from producing unforeseen and
undesirable side effects? References
1
and
2
propose a three-pronged ...
pressure
transmitter alarming in control room
Figure
2- 11.
A
modification chain-rupture discs below relief valves.
92
What Went Wrong?
of order and asked an instrume...
... Sticky
warning labels were fixed to them.
No
maintenance work was carried out
1 12
What Went Wrong?
Figure
5 -2.
A
tank may be overpressured
if
the
vent
or
ovefflow
is
more than
8 ... high level. The operators believed these two readings
1 02
What
Went Wrong?
A pressure gauge of this sort with a scale reading up to 1 ,20 0 psi
was installed directly in the plant...
... the dike wall was damaged by the
1 42
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
expelled ... some other sources of leaks and the isolation and
control of the leaking material.
144
1 32
What Went Wrong?
was built more than
40
years earlier, and the combination of a full...
... the fire soon died out (Figure 7-6).
166
What
Went Wrong?
perature. Incidents involving these materials are described in Sections
2. 5, 5 .2. 2 d,
5.6 .2,
and
8.1.5.
8.1
MAJOR
LEAKS
8.1 ...
100, Aug. 1991, p.
1.
20 .
L.
Britton,
Plant/Operatiorzs Progress,
Vol. 9,
No.
2, Apr. 1990, p.
21 .
Loss
Prevention Bulletin,
No. 131, Oct. 1996, p. 13.
22 .
Occupational Hea...
... 9-5 (b).
20 4
What Went Wrong?
17.
Occzipational Safety Observer;
Vol. 2,
No.
9,
U.S.
Dept. of Energy,
18.
A.
B. Smith,
Loss
Prevention Bulletin,
No. 1 02, Dec. 1991, p. 29 .
19. ...
minutes was not long enough for all the steam to condense.
196
What Went Wrong?
exactly what was said and what was meant. Knowing what we
know now, there can be no other cours...
... lnvestigatiorzs,
Report
No.
OSHA/RP- 82/ 0 02,
U.S.
Dept.
of
Labor, Washington D.C Apr. 19 82, p. 32.
5. Reference
4,
p.
22 .
6. Reference
4,
pp.
65-7
1.
22 2
What Went Wrong?
(a)
A
foreman tested ...
co-workers failed to check that the space was clear before locking
the door
[25 ].
23 0
What Went Wrong?
Figure
11-1.
If
part
of
a
vessel cannot be see...