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author

Jedediah Redman
Dan Benac
Dorothy Shaffer

published on

March 2017

The catastrophic or major incident is immediately investigated, but what about the near misses or precursors to major incidents? Are they investigated? Major failures often do not occur as one iso-lated issue or event; there are often less severe precursors to a major event. This paper presents a best practice and arguments for reviewing apparently minor ammonia plant failures in order to avoid ma-jor events as demonstrated through the judicious analysis of small equipment failures. Multiple small equipment case histories and the lessons learned from these failure investigations are presented to encourage investigation of what may initially appear as insignificant failures, for their value in pre-vention of major incidents.

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jedediah redman

dan benac, PE, CFEI, ASM Fellow

dorothy shaffer