Chain of Events. Cause and Effect. We analyse what went right and what went wrong as we discover that many outcomes can be predicted, planned for and even prevented.
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Chain of Events. Cause and Effect. We analyse what went right and what went wrong as we discover that many outcomes can be predicted, planned for and even prevented.
On the 20th of September, 2022 at the BP Husky Toledo refinery in Ohio, a level transmitter change out from a month prior triggered a chain of events that would cost two operators their lives. We look at how poor Management of Change, high alarm rates and a resistance to stopping the job, let a plant upset turn into a disaster.
Causality
Chain of Events. Cause and Effect. We analyse what went right and what went wrong as we discover that many outcomes can be predicted, planned for and even prevented.
