Case Study: DuPont La Port Leak
A catastrophic failure in following procedure led to a toxic chemical release, demonstrating how a single missed step can have fatal consequences.
Then: The Analog Failure
1. Start Procedure: Operator begins draining a pressure vessel using a paper checklist.
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2. Missed Step: Operator fails to verify a critical valve is closed. The paper checklist doesn't enforce this check.
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3. Continue Process: Believing the system is safe, the operator proceeds.
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4. Catastrophe: Toxic Methyl Mercaptan leaks through the open valve, resulting in 4 fatalities.
Now: The ReVisionz Digital Solution
1. Start Procedure: Operator begins task on a tablet with a guided digital procedure.
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2. Enforced Check: The ReVisionz platform requires digital verification that the valve is closed (e.g., via sensor data or manual confirmation). The next step is locked until this is complete.
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3. Safe Continuation: With the valve confirmed closed, the system allows the operator to proceed safely.
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4. Safe Outcome: The task is completed without incident. A full digital audit trail is created.
Case Study: BP Texas City Explosion
A breakdown in communication during a shift handover resulted in a distillation tower being overfilled, leading to one of the worst refinery accidents in U.S. history.
Then: The Analog Failure
1. End of Shift: Outgoing team notes high liquid levels in a distillation tower.
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2. Verbal Handover: Critical information about the high levels is not clearly communicated or documented for the incoming team.
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3. Start of New Shift: Incoming team, lacking full context, begins the next process step.
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4. Catastrophe: The tower overfills, releasing a vapor cloud that ignites, killing 15 people.
Now: The ReVisionz Digital Solution
1. End of Shift: The ReVisionz system automatically flags the high liquid level on a shared digital dashboard.
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2. Digital Handover: A structured digital form requires the incoming team to acknowledge the critical alarm before taking control. The data is persistent and unmissable.
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3. Start of New Shift: Incoming team has full, accurate context and addresses the high level first.
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4. Safe Outcome: The situation is managed correctly. Operations continue safely. with a guided digital procedure.
Case Study: Piper Alpha Disaster
The deadliest offshore oil disaster in history was triggered by an incomplete permit-to-work system, where a pump was started while its safety valve was removed for maintenance.
Then: The Analog Failure
1. Maintenance: A pump's safety valve is removed. A paper permit-to-work is created.
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2. Incomplete Handover: The paper permit is not properly filed or communicated during shift change. It gets lost in the shuffle.
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3. New Shift Begins: Unaware of the maintenance, the new crew needs to start the pump. There is no clear visual warning.
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4. Catastrophe: The pump is started, gas leaks from the missing valve, ignites, and causes a series of explosions, killing 167 men.
Now: The ReVisionz Digital Solution
1. Maintenance: A digital permit-to-work is created. The pump is digitally locked-out in the control system.
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2. Persistent State: The ReVisionz Control of Work platform ensures the pump's "Under Maintenance" status is visible to all personnel on a live digital dashboard and persists across shifts.
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3. New Shift Begins: The control system physically prevents the pump from being started. An alarm would sound if an override is attempted.
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4. Safe Outcome: The error is prevented. Maintenance is completed, the permit is digitally closed, and the pump is safely returned to service.
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