A Furnace Tube Failure Case History Is Revisited

A Furnace Tube Failure Case History Is Revisited 

Let s apply the concept of shared responsibility to an incident found earlier in Chapter 6, A Furnace Temperature Safeguard Is Altered the incident is supported by four 

It would be easy to say that this incident was just a result of human error. But, Trevor Kletz says, there is little we can do to prevent people from making mistakes, especially those due to a moment s forgetfulness. We have to design the procedures, the equipment, and controls in the workplace differently. 

If we search for culprits to blame using the finger-pointing method Ian Nimmo just described, the investigation process is very simple. As Nimmo indicated, we identify specific individuals (in this case the chemical process operator) as accountable for the incident. It would be easy to say the operator failed to follow established procedures. Disciplinary actions could result to teach people that this is unacceptable behavior. [3J Using just the first-layer approach would be a waste of effort. Such injustice could create an atmosphere encouraging sincere individuals to be less likely to report all the facts. It is probable that we would not find out all the underlying contributors and hence be unable to effectively prevent a repeat of an incident with a 5.5 million (U.S., 1979) price tag. 

Jack Phil ley began his article, Investigate Incidents with Multiple Root Causes, [8] as follows  

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A furnace tube failure case history is revisited... 

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