- Heating Equipment
The primary lesson learned was that the active hydrogen facility and existing operating procedure, at the time of the accident, were sound. While this now has been determined, the previous form(s) of this system, associated documentation, and accident history did not provide sufficient basis to assume continued safe operation. The review of furnace operation subsequent to this accident now provides a basis to evaluate the safe operation of furnace #4 as well as other similar facilities.
The failure to apply the appropriate procedure suggests the need for either additional administrative controls and/or periodic refresher training.