Alarm floods and plant incidents

Alarm floods and plant incidents

Human error in aviation

An incident involving a passenger jet flying over Europe was due to human error. The pilots of the jet while crossing countries failed to establish contact with the next Air Traffic Controller as they were entering the wrong radio frequency. Both the pilots missed the error. The result was that air force jets were scrambled to escort the passenger jet, as per emergency protocol. Finally the pilots managed to contact the ATC in emergency frequency and the situation was controlled.
Think about it....highly trained pilots making a mistake....


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Human error likely caused the deadly explosion

http://www.manufacturing.net/news/2016/10/basf-says-deadly-explosion-german-plant-likely-caused-error
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Human factors aviation incident

http://www.hindustantimes.com/india-news/ht-exclusive-when-jet-airways-flight-with-150-people-made-a-blind-landing/story-J4G7r26AZbUQC7WzQStbiJ.html

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Interesting article on incentives and motivation

 http://insight.kellogg.northwestern.edu/article/finding-the-right-performance-incentives-to-motivate-employees

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Interesting human factors incident

Interesting incident about a plane descending 4000 feet as a camera carried by the pilot got wedged between the seat and yoke in this link

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Ineffective Inspection, Maintenance Practices, Oversight Led to Washington Metrorail Fatal Accident

Ineffective Inspection, Maintenance Practices, Oversight Led to Washington Metrorail Fatal Accident


Reasons common to CPI accidents! The human is the connection.....


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Incorrect rotation of positive displacement pump

 Incorrect rotation of positive displacement pump

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Interesting presentation on human factors by NTSB

 http://www.ntsb.gov/news/speeches/RSumwalt/Documents/Sumwalt_140112.pdf

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Human error by a Pilot

On 08.08.2014, an Indian commercial passenger jet was involved in loss of altitude incident during cruise over Turkish Airspace. The incident occurred after the aircraft had flown for 04 hours 43 minutes from Mumbai. The aircraft was flying on westerly track which was between 230 and 300 degrees and was flying on auto pilot at a height of 32000 feet. The Pilot in command was undergoing controlled rest as per statutory requirements and the controls were with the First Officer.

The First Officer, while updating the direction heading 292 degree, instead turned the altitude knob to 292 FL (29000 feet) and pressed thereby causing the aircraft to descend as the auto pilot obeyed the order to descend to 29000 feet. The Turkish Air Traffic Controller noticed the aircraft descent and called through radio about the unauthorized descent. Subsequently, the First Officer pressed ALT HOLD and climbed back to FL320 (32000 feet). The First Officer then woke up the Captain who was undergoing controlled rest and informed him of the incident. (Source: DGCA incident report).

In our industry, there have been numerous incidents where wrong setpoints or outputs have been entered by the DCS operator, leading to plant upsets. Do you consider this in HAZOP's?

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Of Mimic panels and Video walls - back to the past??

 I just returned from a large modern refinery. When I visited the control room, with large video walls, my thoughts went back to 1979 when I was operating an ammonia plant with pneumatic controllers and no DCS. The wall above the controllers had a mimic panel that depicted the complete process flow diagrammatically. This depiction covered the whole control room wall between the controllers and the ceiling, so it was large and easy to see.  The motors and pumps had running lamp indications in the panel. For 300 control loops, we had about 200 hard wired alarms located between the controllers in sets of 20.

See a concocted image of a mimic panel located above pneumatic controllers similar to the one I had used below:

The modern control room I visited looked similar to the one below, with large video walls:

I was recollecting the progress in instrumentation - from pneumatic control systems to electronic to DCS without video walls and now DCS with video walls. - back to the past!!!!
Technology can and will always be an enabler only and as long as human beings exist, human errors will continue...take for instance the modern day DCS. We have so many alarms that inundate the operator during plant upsets, that vendors now sell alarm suppression software! Why do we need that many alarms in the first place???

One important philosophy in Process Safety - KEEP IT SIMPLE AND DON'T FORGET THE PAST!!

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Safe in India - a new initiative

I came across the website www.safeinindia.org run by three IIM graduates. SafeInIndia is an initiative to address the issue of crush injuries in the Automotive Sector and work on win-win sustainable solutions.
Glad to see such initiatives springing up. Their report on the automobile sector is available for download from their website which can be accessed here www.safeinindia.org.
 
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Lack of Consideration for Human Factors Led to In-Flight Breakup of SpaceShipTwo

Lack of Consideration for Human Factors Led to In-Flight Breakup of SpaceShipTwo

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Hicks on biz: Human error is inevitable | Columnists | Opinion | Edmonton Sun

Hicks on biz: Human error is inevitable | Columnists | Opinion | Edmonton Sun

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Pipelne that spilled oil was badly thinned

There are excellent lessons to be learnt fom this incident. It reinforces what I have always been saying : Smart technology needs Smart people! It cannot function alone...

http://news.yahoo.com/pipeline-spilled-oil-california-coast-badly-corroded-073802050.html?soc_src=copy


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Similar flight numbers spark scare - Times of India

 http://timesofindia.indiatimes.com/india/Similar-flight-numbers-spark-scare/articleshow/45053195.cms

See the human factors in the above article.

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Lessons from an air crash

The NTSB's investigation of an air crash at San Francisco airport during landing last year mentions that

"The board’s acting chairman, Chris Hart, warned that the accident underscores a problem that has long troubled aviation regulators around the globe — that increasingly complicated automated aircraft controls designed to improve safety are also creating new opportunities for error. 

The Asiana flight crew ‘‘over-relied on automated systems that they did not fully understand,’’ Hart said. 

‘‘In their efforts to compensate for the unreliability of human performance, the designers of automated control systems have unwittingly created opportunities for new error types that can be even more serious than those they were seeking to avoid,’’ he said. "

Read the article in this link. 

I am a firm believer of keeping it simple. Just because that vendors try to sell you a piece of "latest" technology, do not buy it unless you are convinced it will be useful for you. If the argument is that we need more automation systems as competency is going down, I would answer by saying, keep your systems simple so that your training programs become more effective!


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Process safety - where are we heading??

I was reading an article on process safety and a new terminology called "peak risk". In the last decade a number of new terminologies and technologies have mushroomed. But I think we have lost our way somewhere. Ultimately, accidents happen due to decisions taken by Management that have an effect on process safety and causes a catastrophic accident. Over a period of years, chemical manufacturing companies have fewer and fewer technical personnel on the board. As long as we do not address this issue, new terminologies and new technologies will only make someone's purse fatter but will not prevent a catastrophic accident!

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"This is your pilot sleeping"

A recent incident in a British airline where both the pilot and copilot dosed off because of lack of adequate sleep in the previous nights highlights the importance of fatigue management in the chemical industry, too. While the chance of a control room operator in a common control room in a chemical unit to fall asleep unnoticed is less, fatigue often impairs judgement and reaction. For plants using process simulators for training, it is worth to take the trainee through a series of night shift training sessions so that he himself feels the difference.
Read about the incident in this link.

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Duty time limitations for flight maintenance engineers

The DGCA ( Director General of Civil Aviation) has drafted duty time limitation for flight maintenance engineers to avoid human error. Much of what is mentioned in the draft holds good for chemical industries also. Read the draft advisory article in this link

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