System Improvement Should Be the Objective of Investigations

by Ira J. Rimson and Ludwig Benner, Jr.
 


    “In the 1990 HAZOP, the team identified failure of the extruder drive as a condition that could create a “no flow” situation, in which case it was recommended that the polymer flow be stopped. The polymer catch tank and the reactor knockout pot were the only possible destinations to which the flow could be diverted. However, the HAZOP team did not consider this situation as a possible cause of excess polymer accumulation and level in either vessel.

This statement, in contrast, is unambiguous and explicit, yet once again omits any rationale for why the HAZOP team did not consider the scenario that precipitated the mishap.

    “The 1990 HAZOP study did not completely evaluate the extruder. The team noted that insufficient design information was available … and recommended a follow-up HAZOP of the extruder once the engineering drawings were finalized. This analysis was never conducted.

"If we don't know why the system broke, we can't define the problem and fix it."


Here is an example of a multiple “did not.” Although the first states explicitly that the study’s evaluation was limited and why, the second is a vague, passive-voice statement that lacks any assignment of accountability that might provide insights into what happened.

    “In a 1993 incident, the polymer catch tank was overfilled when the extruder malfunctioned. Polymer was carried into the vent line and solidified, and the line had to be cut. Nevertheless, the 1999 HAZOP still failed to identify the means by which an excess level could occur in the vessel.

The authors inserted the literary surrogate “failed to” in place of “did not,” a common misdirection that, in addition, interjects the opinion of the report’s author(s) that a perpetrator strayed from the expected standard(s) of conduct. (“Nevertheless” is a clue that a value judgment is about to follow.)

    “Overfilling contributed to the March 13, 2001, incident because it was partly responsible for plugging the vent and relief piping – which confined the mass of plastic to the polymer catch tank. If the HAZOP studies had identified credible scenarios involving vessel overfilling and overpressurization due to extruder malfunctions, [then] additional safeguards could have been recommended to reduce the probability or severity of the hazards. If overfilling had been effectively controlled, [then] the sequence of events that led to the March 13 incident would have been less likely – even without knowledge of the decomposition hazard.”

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