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Non Evaluated Plant Mods cause incident

Original Basis of safety

The original basis of safety had postulated that there could be a double charge of caustic to a batch, this had been experimentally checked and found to be safe.

The Incident

Later on the plant was modified, there was no cross checking with the hazards group, and a charge of 40 times the correct one was made in error.  This led to the ejection of the batch contents.  Fortunately no-one was hurt.

The Lessons

When a hazard has been identified and made safe, it is essential that later plant amendments be re-evaluated to ensure that the basis of safety is still valid

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