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Incident from unauthorized process change

Incident reported in which an operator applied his own initiative and omitted 3000 kg of water from the batch.

The workforce should be encouraged to suggest process changes, but it is vital that any suggested changes are discussed and analyzed before being implemented on the plant.  It may not always be obvious to all operators why a particular ingredient is added to a process, it may be there just as a moderator / inhibitor to prevent a known danger from occurring.

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