(185c) Considerations for Transient Operation - Fire Incident

This is the story of a root cause analysis (RCA) for a fire in a chemical operation during a transient operation. Findings from this investigation illustrate the hazards and key preventative measures that can be utilized to prevent this type of incident. It also illustrates how abnormal or transient operations should be considered in process design and procedure development. Results from the root cause analysis and the lessons learned will be explained. Several aspects will be discussed including a number of latent factors, multiple design and procedural issues, identification of potential scenarios in safety reviews, and design of controls and alarms.