On the 20th of September, 2022 at the BP Husky Toledo refinery in Ohio, a level transmitter change out from a month prior triggered a chain of events that would cost two operators their lives. We look at how poor Management of Change, high alarm rates and a resistance to stopping the job, let a plant upset turn into a disaster.
With John Chidgey.

Formal Report:

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Episode Gold Producers:

'r', Steven Bridle and Kellen Frodelius-Fujimoto.
Episode Silver Producers:

Mitch Biegler, Shane O'Neill, Jared Roman, Katharina Will, Chad Juehring and Ian Gallagher.