Causes of failure in corrective maintenance-a case study

The main objective of the project was to investigate causes of failure in corrective maintenance through applying Swiss Cheese Model. This is illustrated by a case study of an accident at Tosco Avon refinery in 1999. The main causes were identified as negligence of management, wrong decisions made and that no proper procedures were followed during the maintenance work. A general risk assessment procedure for corrective maintenance has been developed. It includes checklist questions for taking the decision to stop operation or not as well as propositions of risk assessment tools and recommendations on reporting procedures during the maintenance work. It was concluded that the accident could probably have been prevented if proper maintenance procedures had been followed.