NDK Crystal Vessel Rupture, Illinois, 2009

[mechcolor]

How important this is for us to implement the findings of an incident investigation?
Despite strong recommendations from an outside consultant and its insurer, NDK management did not implement them.
An important to learn from incident involving a pressure vessel rupture due to a combination of stress corrosion cracking and temper embrittlement.
Uncertified pressure vessels were used which were allowed to be but with annual inspection which could not be proven.

[opo21]

And the masterclass video: https://www.youtube.com/watch?v=uo7H_ILs1qc

[ivani1]

Clear message.

And the masterclass video: https://www.youtube.com/watch?v=uo7H_ILs1qc

[neo]

A lot recommendation which were provided before the incident occurred means timely action is so very important when we talk about the pressure containment barrier.
Internal inspection was the recommendation and we see that due to overly developed production targets, inspection teams are required to agree on relying on the external inspections and delay the internal inspections. I understand such incidents should be shared on a lot regular basis with engineering & management staff during Safety meetings to learn and apply what is so critical to operate & maintain safely.

[jeem]

What should be the protocol of checking in the recommendations being followed, and implemented rightly?
And that has to be target date driven with some sort of internal or external checks.

[ivani1]

One (but not too many) system is the solution to have such recommendations tracked, updated, closed with evidence.

What should be the protocol of checking in the recommendations being followed, and implemented rightly?
And that has to be target date driven with some sort of internal or external checks.

[jeem]

The challenge is that there are a lot many sources through which critical recommendations are generated. Start with Inspection /integrity itself working to identify issues with the assets. Yes, they issue their recommendations but not every recommendation is applied in time. Delays may not cause direct impacts but we have seen increased damages due to outstanding recommendations. Moving forward, audit recommendations which are generated by internal teams then from external parties. How many times they are conducted in time or extended with a proper risk assessment? Then studies, root cause analysis, how to make sure whatever is done here is implemented and not missed out. Then definition of an action being actually critical to operate & maintain. That filter is required to be applied separately for every finding /recommendation. A lot comes to the mind when we talk about all this.