6 of 41 closures failed the evidence test: three on canceled work orders, two on documents that do not say it, one on a withdrawn change.
A PHA revalidation session reaches node 12, fuel to the burners
The hydrogen plant's study is due again, and session four of twelve reaches the reformer furnace. Under node 12 sit three records the old study never met.
demoSample data throughout: the refinery, its people and its figures.
- 0108:02
200 records since the last study, pinned under 41 old nodes
Hazard study facilitatorAt 08:02 the five systems were read again and nothing new came back. The wall lays out the old study's nodes by plant section, with 96 changes, 17 incidents, 58 updated documents and 29 recommendations pinned where their tags and drawings put them. Across the top: node 12 next, one question, 133 days before the limit.
- 0208:55
A fuel change whose hazard review found no new hazard
Hazard study facilitatorThe first slip is the change that moved trim fuel from pipeline natural gas to the refinery fuel gas header, closed 12 weeks after the old study. Its hazard review reads: same burners, same header pressure, no new hazard. The marked passage shows what it left out: the burner data sheet was missing from its list of updated documents.
- 0308:58
Flames on row 3 tubes, and the arch alarm stayed silent
Hazard study facilitatorThe near miss came the next spring. Rich fuel gas reached the trim tips and flames touched row 3 tubes for 11 minutes, with the hottest tube at 1,742°F against a 1,715°F survey limit. The lab sample put the gas 23% over burner design. Row 3 air registers had been locked at 60% five months before, and the arch alarm did not sound.
- 0409:01
An arch trip closed on a work order nobody ever worked
Hazard study facilitatorThird comes a recommendation raised after an earlier overfiring upset: add an independent high arch temperature trip. In the tracker it shows closed, with a work order as its evidence. The closure test says that order was canceled, no trip was ever built, and the last study took the closure as done. By hand, work orders get opened one at a time, so most closures go untested.
- 0509:04
No old row covers rich trim fuel, so the agent asks one question
Hazard study facilitatorNode 12 shows six of its 14 old rows. Two carry red flags: one leans on the arch alarm that did not sound, the other on flame scanners fitted only to the end burners. The question card shows how the agent got there: rows read, three records pinned, no covering row, one question for the facilitator, and no scenario.
- 0609:07
The team ranks the new row 4×3, then tries to credit the arch trip
Study teamWith the facilitator, a process engineer and the board operator checked in, the team picks Other than, writes the cause and consequence in its own words, and ranks the row severity 4, likelihood 3. When someone lists the arch trip as a safeguard, the form refuses it: never built, citing the recommendation. Typing the bare tag, or calling it the independent arch trip, gets the same refusal.
- 0709:10
A red row leaves the room with an action and an interim measure
Hazard study facilitatorSaved with a safeguard people do perform, the row lands in the red, so the form asks for an action, an owner, a written date and an interim measure. The team names a fuel gas quality analyzer with a high alarm, and a row 3 burner round each shift until then. The work needs an outage, so the date moves to the next planned one.
- 0809:19
The drawing the checker opens shows an alarm and no trip
Process safety managerThe facilitator proposed reopening the trip's closure the day before. Countersign stays locked until the process safety manager has opened all three pieces of evidence in person: the tracker entry, the canceled work order and the current drawing. On the drawing revision the passage is marked. The arch carries the alarm only, and the trip's tag appears nowhere on the sheet.
- 0909:22
Reopened by two people, and the trip blocked from credit in any row
Process safety managerWith all three records open, the countersign goes on. The closure now reads reopened, proposed by the facilitator and signed by the manager. It moves back to still open with an action for its owner, and the trip cannot be credited in any row until the work is done and the closure passes again. On the report, four of the six failed closures still wait for a ruling.