-_; Re: GROUP 7: Ethylene release and fire at Kuraray America in Pasadena, Texas: From the Human Error Perspective: by DARRYL B N l-OSEPHJUK -Wednesday. is October 2023. 8:47 PM A very good evening, Sir HakimJaurey, and fellow colleagues. Thank you for the inrdepth sharing ofyour previous post,Jaurey. Also, great to know that we are from the same learning center. l would like to add a point to item 2 ofthe above post ofyours about "Communication Breakdown". Referring back to Kuraray Plant's incident, Eval Reactor 2 with different deSIgn pressure is one ofthe human error perspectives that we can discuss. While watching the video again and again, I wondered and analyzed, what makes the Eval Reactor 2 have a different pressure capacity from the other reactors when their size is identical. It could be the case that certain human errors occurred during the engineering and deSIgn stage that resulted in the lower design pressure of 74OPSI. The evidence of ineffective or lack of training is presumed when the new board operator who came in shortly after 10 am. on May 19", 2018 did not recall that this reactor has a maximum design pressure of MOPSI. With these uncertainties, he still initiated the next step of the start-up which was also considered a human error. A few things are suggested to minimize the impact ofthese variances including a clear label of design pressure on the reactor. A clear label on the reactor is a 'form of noniverbal communication that may alert the plant operator about these differences. Other than that, the conduct of refresher training for the board operator is also required to ensure that they are aware of the plant that they are currently handling