∗
A small project design was changed on site.
∗
Site change used a decommissioned module.
∗
The modification was tested and worked.
∗
ESD functionality was not tested as not part of the small
project modifications.
∗
The decommissioned module had a connection to ESD rail,
which was not identified on drawings or during wiring
changes.
∗
Result was that the change prevented the ESD system
from functioning.
Project 2: Findings