Abstract
Abstract Is a utility part of the plant safety systems? Is up‐to‐date documentation of the utility system needed? Two operating units were evacuated during a small release of a toxic compound. The release occurred during a refrigeration system outage caused by low level in the cooling tower. Among the causes of the low cooling tower level was out of date documentation for the cooling tower makeup water supply.This paper presents a multiple cause, system oriented incident investigation of the release. Additional causes and recommendations for improvement are included in the paper.
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