And the root cause of opening the wrong valve is?
Operator should have been moire careful! And should have self checked. And should have used STAR (Stop-Think-Act-Review).
And the Corrective action is:
Tell them to be more careful next time!
Category: Human Performance, Pictures
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Ouch! That looks like tough job.
Comment by Linear Actuator — February 10, 2009 @ 10:54 pm