TABLE OF CONTENTS Chemical plant managers aspire to hire individuals who can think for themselves, analyze a complex problem, and solve it quickly. However, it is risky business if these companies fail to properly educate all of their team members on the danger of unauthorized changes. It is dangerous for companies to allow well-meaning employees to introduce quick alterations into their carefully engineered plant without some sort of formal review. One-minute modifications included in this chapter can also include: simple errors introduced by lack of procedures, incomplete understanding of the procedures, insufficient training, or failure to consult specifications. The quick fixes in the following examples led to nightmares.
The purpose of this chapter is to raise awareness. Details to consider for a Management of Change Program suitable to satisfy OSHA's Process Safety Management regulation will follow in Chapter 11.
Several decades ago, an instrument mechanic working for a large chemical complex was assigned to repair an analyzer within a nitric acid plant. He had experience in other parts of the complex, but did not regularly work in the acid plant. As part of the job, the mechanic changed the fluid in a cylindrical glass tube called a "bubbler." This bubbler scrubbed certain entrained foreign materials and also served as a crude flow meter as the nitrous acid and nitric acid gases flowed through this conditioning fluid and into the analyzer.
The instrument mechanic replaced the fluid in the bubbler with glycerin. Unfortunately, the glycerin reacted...
