Investigation results, lessons learned and follow up actions from a near miss incident involving loss of reactor cooling will be presented. Lessons learned include several things that should keep us up at night: (1) what risks could be lurking in my older processes that were not designed with the latest standards? (2) what risk am I taking during maintenance operations including shutdowns and startups? (3) where in my process is there potential for human error? and (4) what scenarios might I not have anticipated in my PHA?
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