Chapter 2. Modifications

I consider it right that every talented man should be at liberty to make improvements, but that the supposed improvements should be duly considered by proper judges.—George Stephenson, 1841

Many accidents have occurred because changes were made in plants or processes and these changes had unforeseen side effects. This chapter describes a number of such incidents. How to prevent similar changes in the future is discussed. Some of the incidents are taken from references 1 and 2, where others are described as well.

2.1. Startup Modifications

Startup is a time when many modifications may have to be made. It is always a time of intense pressure. It is therefore not surprising that some modifications introduced during startup ...

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