Case Study: Heat Exchanger Rupture Incident
YOU MUST USE ATTACHMENT FOR THIS QUESTION!!!
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.
The chart can be created using MS-Word, PowerPoint, or Excel, or it can be hand drawn and scanned.
Completed case study must be a minimum of three pages and maximum of five pages, not including the title page, reference page, and chart. Use APA formatting for all of your assignment, as well as for all references and in-text citations.