For Kim Woods Only
Unit VII Case Study: Heat Exchanger Rupture Incident
Review the attached Chemical Safety Board’s (CSB) Case Study on the 2008 Goodyear Heat
Exchanger Rupture incident.
1. Using the information in the CSB Case Study, identify probable direct causes, contributing causes, and root causes of the incident. Explain the reasoning you used
to reach these causes. You may make assumptions concerning any missing
investigative information as long as you clearly state your assumptions. Discuss how
and where your proposed causal factors fit into the causation model (attached). For
the root causes only, provide recommended corrective actions.
2. Create an Events and Causal Factors chart that follows the timeline of the incident. Be sure to include all causal factors you identified in your discussion, as
well as any other conditions and events that are relevant to understanding the
accident sequence.
The chart can be created using MS-Word, PowerPoint, or Excel, or it can be hand
drawn and scanned.
The completed case study must be a minimum of three pages and maximum of five
pages, not including the title page, reference page, and chart. Use APA formatting for all of
your assignment, as well as for all references and in-text citations.