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CTA Report, Draft 1, ISP Review - US Chemical Safety and Hazard ...

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Subtree B<br />

Fire in 405 oven<br />

Oven has<br />

openings to allow<br />

process material<br />

to pass through it<br />

405 oven doors<br />

open<br />

Combustible<br />

material in 405<br />

oven caught on<br />

fire<br />

Normal<br />

Fire in oven 405<br />

not detected<br />

405 oven<br />

operating too hot<br />

<strong>Safety</strong><br />

consequence of<br />

operation with<br />

oven doors open<br />

not evaluated<br />

Crew involved in<br />

cleaning<br />

elsewhere<br />

No fire detection/<br />

suppression<br />

system in oven<br />

Corrective<br />

actions for<br />

previous oven<br />

fires LTA<br />

Heat produced by<br />

405 oven caused<br />

ignition of<br />

material<br />

Buildup of<br />

combustible<br />

material in 405<br />

oven<br />

405 oven<br />

temperature<br />

control was<br />

malfunctioning<br />

Nonroutine<br />

operations<br />

management LTA<br />

Normal<br />

Oven safety<br />

guidelines such<br />

as NFPA 86 not<br />

followed<br />

Identification of<br />

underlying<br />

causes LTA<br />

405 oven on<br />

Oven cleaning<br />

frequency LTA<br />

Oven<br />

temperature<br />

control problem<br />

not repaired<br />

<strong>CTA</strong> incident<br />

investigation<br />

program LTA<br />

Normal<br />

Maintenance<br />

program LTA<br />

126

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