Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in...

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Transcript of Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in...

Page 1: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 2: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 3: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 4: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 5: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 6: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 7: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 8: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 9: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 10: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 11: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 12: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 13: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 14: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 15: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 16: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 17: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 18: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 19: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 20: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 21: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 22: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 23: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 24: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 25: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 26: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 27: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 28: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 29: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 30: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 31: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 32: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 33: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
Page 34: Site 9920 Accident Investigation Board Report, January 2014...Day-to-day management engagement in Team 5434-2 was not sufficient to assure safety. The Site 9920 FSOP (FSOP-EFS-OOI)
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