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.
As demonstrated by the fire discussed above, lack of adequate maintenance, system monitoring and oversight of maintenance of these facilities can contribute to the ignition of a fire that is difficult to extinguish and poses an extreme danger to…
1. Management must ensure that operating decisions are not based primarily on cost and production. Performance goals and operating risks must be effectively communicated to all employees. Facility management must set safe, achievable operating…
After the aforementioned incident, a rigid cage was designed to protect the reactor from external conditions, and to protect the contents of the hood and any experimenter from the reactor, in the event of a pressure burst from the reactor cell.…
Personnel should be properly supervised, and supervisors should be aware of the activities of their personnel. Personnel must be motivated to adhere to established policies and procedures. All personnel associated with potentially hazardous work…
Several recommendations were outlined by the investigating committee to govern future operations of the hydrogen compressor in the synthetic liquid fuels laboratory:
Mounting hardware incorporated polymeric braces not suitable for long-term exposure to sunlight and temperature extremes. With time, the polymeric materials had disintegrated, allowing the mounting brackets to become loose. In addition, the…
Based on the results of the company investigation and analysis of an amateur video, the company determined that the incident could have been caused by the failure of one of the following plant components:
· pipes leading to the reactor…
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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