Use the T2 incident of Problem 13-5 to list the most important elements of an
Incident Investigation; i.e. a) the underlying and root causes of the incident,
and b) the first and other recommendation layers.
Program and encourage participation.
As emphasized in this chapter, many incidents and grave consequences are
due to the failure to use codes, standards, and other Recognized and
Generally Accepted Good Engineering Practices (RAGAGEP). Read the West
Pharmaceutical Services Dust Explosion and Fire (2003) Incident (CSB report)
and a) describe the incident, b) list the major recommendations, and c) site
the RAGAGEP that is used most frequently.