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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.
Do not interconnect hydrogen drain trap lines with other drain lines
Thoroughly inspect equipment installation to manufacturer’s installation instructions
Warn against unauthorized field modifications
Consult the…
Management should ensure that a complete and thorough review of the previous work activities identified in the work package is performed at the pre-job briefing for the planned work. Work activities should be discontinued if any confusion exists…
Work pre-planning is essential whenever maintenance or work activities may have an adverse impact on everyday operations. When there are changes to the operational status of any critical system, especially a safety critical system, those changes…
The lessons learned in this situation center around basic conduct of operations principles. Policies and procedures related to operations performance, safety performance, and management oversight were in place. They were not employed…
Standard procedure must be followed in all cases. Assumptions are made at great risk. Risk also increases with complacency.
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