CSB Accident Investigation Report Formosa_IL_Report-Chinese

2023-11-24View Original

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Reply #22023-11-24

This post was last edited by sinoeng on 2023-11-24 at 12:44. The 3 most important lessons: 1. Human reliability – incorrect operation of valves； 2. Process medium — Ignoring PHA/HAZOP ； 3. Admin procedure – lacks redundancy measures. Fully in accordance with the “4-24 Causation Model” (website link: https://bbs.hcbbs.com/thread-4470769-1-1.html)

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CSB Accident Investigation Report Formosa_IL_Report-Chinese

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