Why is it important to account for all personnel when an accident occurs?

Read the Case Study titled “Heat Exchanger Rupture and Ammonia Release in Houston, Texas”
(No. 2008-06-I-TX). The Case Study can be found at the U.S. Chemical Safety Board website: http://www.csb.gov/. Click
on the “Investigations” tab, and then click on “Completed Investigations.” Search for “Goodyear Heat Exchanger Rupture.”
Open the Case Study under the “Documents” heading.

Once you finish reading the Case Study, answer the following questions based upon your readings on Pressure Hazards,
Electrical Hazards, and Welding.

1. Summarize the sequence of events that led up to the disaster. What preventative measures would you have
taken to make sure the pressure did not build up to the subsequent explosion?

2. Critique the accident investigation as it was performed by the government official. What other facts or steps would
you need in order to make a proper assessment of the accident?

3. Why is it important to account for all personnel when an accident occurs? What steps could Goodyear
management have made to ensure all employees were accounted for?

4. Conclude with your own thoughts on the Case Study. Did you agree or disagree with any methods the
investigators used? Why are pressure and electrical hazards so dangerous?

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