High Temperature Sulfidation

Ф52” just upstream of bend ruptured

Low Silicon CS

8”

Tesoro Refinery, 2 Apr 2010, six fatalities

Thinning & Over pressurization

CLSCC

Normal event Quick fixing based on symptoms & no RCA

Fast repair , Quick production back & staff get recognition

Attending the next problem and then next & next

Develop- reactive staff - reactive role models

Prone to Catastrophes

Solar Potential

Thank YOU