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Case Study: Heat Exchanger Rupture Incident access the Chemical Safety Board's (CSB) Case Study on the 2008 Goodyear Heat Exchanger Rupture incident.
1. Using the information in the CSB Case Study, identify probable direct causes, contributing causes, and root causes of the incident. Explain the reasoning you used to reach these causes. You may make assumptions concerning any missing investigative information as long as you clearly state your assumptions. Discuss how and where your proposed causal factors fit into the causation model on page 356 of the course textbook. For the root causes only, provide recommended corrective actions.
2. Create an Events and Causal Factors chart that follows the timeline of the incident. Be sure to include all causal factors you identified in your discussion, as well as any other conditions and events that are relevant to understanding the accident sequence.
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