What Happened:
Two contractors re-injected the wrong clamp. The flange bolts failed, and the two contractors involved in the work died in the steam released. In the legal case, the judge focused on the possibility of human error. The company should have anticipated the possibility of this human error and concluded that the site did not sufficiently protect the workers from that.
Humans do make errors – Anticipate Human Error
CLICK HERE for the European Process Safety Centre (EPSC) Learning Sheet