Archives of Personal Papers ex libris Ludwig Benner, Jr.
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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 shutoff/fire out?
  • 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?