Case Study: One Checklist Item Can Make a Difference.

摘要

This is a case study of a consultation to prepare a large wastewater reclamation facility's Risk Management Plan for submission to US Environmental Protection Agency. During the Process Hazards Analysis (PHA), a simple checklist item was further explored. During the ensuring discussion, it was determined that a potential release of flammable material might occur. A recommendation was created to address the scenario. Very soon after the PHA was concluded and before management analyzed and addressed the recommendation, the identified scenario occurred. Operator intervention may have prevented a potential release of 80,000 pounds of Chlorine and 54,000 pounds of Sulfur Dioxide. This paper describes the events and lessons learned. Lessons focus on inherent safety, use of checklists for conducting PHAs, culture change and competency of PHA teams.