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Deadly Exposure by Cara Putman - FictionDB
Learn More - opens in a new window or tab. Report item - opens in a new window or tab. Seller assumes all responsibility for this listing. Item specifics Condition: Like New : An item that looks as if it was just taken out of shrink wrap. No visible wear, and all facets of the item are flawless and intact. See all condition definitions - opens in a new window or tab. DuPont did not provide a back-up method to ensure timely change-out and the maintenance software was not documented or reviewed in accordance with Management of Change MOC processes.
On the morning of the incident, maintenance personnel replaced the phosgene hose on the phosgene tank not involved with the incident because of a suspected flow restriction. As the hose and valve assembly was decontaminated in a water bath, the adhesive ID tag fell off and revealed a corroded section of the stainless steel braid and collapsed PTFE liner.
Chapter Analysis of Deadly Exposure
When the worker saw this, he told coworkers that they were lucky in catching the hose before it ruptured. Supervisors were not informed of the issue and it was not captured as a near-miss event. The worker planned to tell the supervisory staff on Monday, when they would return to work after the weekend, and expected a full investigation. This notification would have fallen outside of the DuPont Belle policy for reporting incidents within a hour period.
Though supervisors were not typically onsite on weekends, management and safety and health experts were at the facility that morning of Saturday, Jan. The CSB outlined recommendations for Belle that involve improving the existing maintenance management program by supplementing the computerized system with sufficient redundancies and conducting MOC reviews for all changes to preventative maintenance orders for all Process Safety Management-critical equipment in the computerized maintenance management system.
Additionally, revisions were suggested for the near-miss reporting system and investigation policy so that it is operational at all times.
The CSB also recommended that the Belle plant revise their emergency response protocol to require that a responsible and accountable employee be available at all times to provide timely and accurate information to emergency dispatchers. They also recommended that DuPont prohibit the use of hoses with permeable cores and materials susceptible to chlorides corrosion for phosgene transfer.
Acceptable corrective action can be found on the CSB website for the incident. From Apollo to the Space Shuttle, and now to the next generation of aircraft and spacecraft hardware, many hydraulic pressurized systems have been and continue to be utilized at NASA centers and facilities. Large quantities of ammonia were used at centers to support and onboard to sustain shuttle operations.
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Many leaks occurred during shuttle processing, which resulted in immediate exposure risks to the surrounding area in addition to larger risks associated with ammonia clouds moving into areas of operation. Although the airborne clouds were lower in toxicity, they still presented a major risk for large populations of workers. Even more potentially hazardous was the use of highly toxic hydrazine as a hypergolic fuel for shuttle maneuvering system thrusters.
Multiple thrusters on each shuttle required multiple feed lines throughout the vehicle, support structures, and around processing facilities and the launch pad that all required maintenance. Local maintenance and operating guidance per system manufacturers and certifiers is coordinated by the pressure system manager at each NASA center.
Timely reporting of equipment degradation or damage, or any hazardous condition, to the person with the authority to mitigate the hazard source or eliminate human exposure risk saves lives and enables mission success. Occupational Safety and Health Administration. October 2, Final Investigation Report. Chemical Safety and Hazard Investigation Board. September Smith, Sandy.
belgacar.com/components/enlever/comment-enlever-la-localisation-sur-iphone-6.php July 13, Accessed August 7, This is an internal NASA safety awareness training document based on information available in the public domain. The findings, proximate causes and contributing factors identified in this case study do not necessarily represent those of the agency.
Sections of this case study were derived from multiple sources listed under References. Any misrepresentation or improper use of source material is unintentional. Resources Informational and educational awareness materials. Featured Resource. Professional Development Products and services to assist employees with continual learning.
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