Disclaimer: The Lessons Learned Database includes the incidents that were voluntarily submitted. The database is not a comprehensive source for all incidents that have occurred.
The possible outcomes from new maintenance scenarios can be predicted by using an accurate simulation. The proposed filter change-out maintenance was studied to identify conditions to which the catalyst might be exposed and a mock-up of the…
Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…
An investigative communication notes that "mechanical integrity programs at refineries repeatedly emphasize inspection strategies rather then the use of inherently safer design to control the damage mechanisms that ultimately cause major process…
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