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 Case Study: Heat Exchanger Rupture Incident
 access the 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 on page 356 of the course textbook. 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.
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.

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