Here is an opportunity to see misfortunes resulting from flaws in judgment on minor decisions. Observe these chemical plant case histories that involve relatively minor errors in design, operation, or maintenance. These incidents occurred within ordinary equipment found in most plants and refineries. Each minor error resulted in an unforgettable incident for the involved designers, operators, and maintenance crews, as well as their supervisors. You may have experienced similar memorable moments.
Note the fundamentals covered. Each can be shared in a technical review meeting or within control rooms. As our knowledgeable supervisors and veteran operators continue to move to other areas or retire, we are working with less people. We must share our past experiences with our leaner crews to avoid repeated incidents. Short, focused narratives with high-impact, vivid illustrations can help us “Picture This!” It behooves us to share our costly information within our organizations and within technical meetings to help make us a better industry.