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COMMUNICATION AND

INFORMATION
- Contrary to the standard
operating procedure
-Information delay had
caused great expansion
damage

MANAGEMENT ENGINEERIN
G INTEGRITY
- did not refer to the other
accidents that had - Control
occurred before this system (no
accident The sensor)
-No person was incharge
to monitor the site for a Social
certain period Technical
-safety operations were
badly coordinated Framewo
rk

SITE AND
PLANT
SYSTEM FACILITY
CLIMATE
-Design codes-
-Technical plant: nature of
understanding hazardous
failure release, (Safety
issue)

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