Got this at work today... pretty interesting and shows you how systems can break down due to a serious of minor mishaps.

The attached link is to a video clip. It was produced by the CSB investigation team, explaining the sequence of events leading up to one of the BP Texas City refinery explosions in 2005.

It contains a number of conclusions but highlighting root causes as being a combination of equipment malfunctions, poor design and operator procedural issues combining to catstrophic effect.


http://powerlink.powerstream.net/002...Animations.asx