Investor Presentaiton
Scientific Method Example - Seal Leak
Potential cause
Poor installation
by one fitter
Poor installation
by all fitters
Overpressure
Generic seal
problem
Component
problem
BAKERRISK
Verification
Review of maintenance
history where similar work
carried out
Review of maintenance
procedures with all fitters
concerned
Review of DCS data
Background gas level
measurements
Review spares stock against
manufacturer's specification
·
Finding
Leaks have occurred where
other fitters have installed seal
Hypothesis
FALSE
No evidence that the work was
being done differently to that in FALSE
the manual
No evidence of overpressure
Slight rise in average toxic gas
levels for past 18 months (not
acted upon)
Spares supplier changed 2 years
previously. Same spec but slight
difference in compressibility of
O-ring seal
Hazards 29 | CCPS Incident Investigation Book 3rd Edition | 23 May 2019 | 16:25-16:50
FALSE
CONFIRMED
CONFIRMED
24
24View entire presentation