Consider Human Error and Domino Effects (EPSC Learning Sheet July 2025)

At an Ethylene unit in the Czech Republic (2015), when swapping over cooling water supply lines during a flowmeter calibration, the operator made a simple mistake. While intending to open valve #3 on the spare supply line, he closed the identical valve #2 instead, shutting off all cooling water to the Light Ends columns. A...

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