Archives of Personal Papers ex libris Ludwig Benner,
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Investigating Investigation Methodologies
Handout 2 For IRIA2003 Presentation
Ludwig Benner Jr
Williamsburg VA 9/18/03
Examples of questions raised by MES
- Why didn't solvent
clean out ash in extruder?
- Timing of fire/solvent
- Was hot oil
involved with PCT pressure rise?
- Why did workers
have to position themselves in harms way to remove the head?
- Why did Maintenance
Tech remove bolts in sequence he did, and would another sequence have
changed the outcome?
- Need to confirm
that hot oil continued flowing to heat inlet line to PCT after shutdown
- before and after
head blew off - did that contribute to heading of contents?
- Why didn't HAZOP
recommendation successfully control hazard? (Methodological problem)
- Why wasn't
unsuccessful recommendation remedied when experience showed it was
unsuccessful? (system problem)
- Why did Operators
position selves with Maintenance Technician at head of PCT (if they did)
- What exactly
created internal pressure -what were roles of hot oil, overfilling, and
decomposition of stored material in PCT
- What ignited fire
in extruder? Why did it spread
- Who told whom what
and why about pre-run?
- What was data and
rationale for this decision? Who made it?
- Find out what
procedure is to learn from incidents system breakdown or people problem?
- Find out why air
could get into the extruder, providing oxygen for fire??
- What was the impact
trauma that killed 2 workers - tank cover or plastic from inside tank?