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.
In the future, refining, petrochemical, and chemical industries need to review material verification programs to ensure that the maintenance procedures include sufficient controls and positive material identification (PMI) testing to prevent…
This occurrence underscores the importance of completing a hazard analysis for each different process. Non-safety-related systems or equipment may be used for purposes other than their primary purpose so long as potential hazards are identified…
An important lesson to be derived from this incident is the need to carefully engineer and test all repairs and modifications to high-pressure process equipment.
Hazards should be eliminated to the extent possible rather than depending on workers to follow an operations manual.
Potassium carbonate draw-off operations should be improved, and the operations manual should be revised. The manual…
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