“Oops, sorry!” and other safety system war stories

• Paul Gruhn

Keywords: Accident, Online changes, Management of change, Documentation, Control, Safety, Software, Hardware, Communication, IEC 61131-3, Redundancy, Management

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Abstract:

Would you rather learn from the mistakes of others, or make them all yourself? While we learn better making our own mistakes, the risks to everyone involved can be very high. It’s important that we learn from the mistakes of others. Unfortunately, not everyone likes to reveal or admit to such problems. However, people need to know what happened at places like Flixborough, Chernobyl, Bhopal, and Texas City so we don’t repeat the same mistakes (and kill thousands more in the process). Not all mistakes have such high visibility or impact. The following collection of stories is meant to be both educational as well as entertaining. They involve problems at many different plant sites using many different control and safety systems. Problems include undocumented software features, programming errors, human errors, hardware failures, inadequate training, poor documentation, poor planning, poor management of change and more. Company names do not appear and the names of individuals have been changed. There are many different lessons to be learned. © 2009 Inside Publishing. All Rights Reserved.

Volume: 2010   Issue: 1

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