Accidents: Don’t Simply Blame the Operator

Incident may have stemmed from equipment issues or poor management

accidents dont blame operators mn

This Month’s Puzzler Our refinery suffered an incident that nearly led to a fire. It occurred after the board operator started the isobutanes pump on an alkylation unit surge tank (see Figure 1). The pressure safety valve popped, the flow switch in the vent tripped and so did the unit interlock on the high-high level switch. This happened while a field operator was busy walking down one of the alkylation towers looking for leaks. That operator remembers the light on the pump station being off and assumed the low-level switch stopped the pump. I work in a different part of the refinery and have been assigned to investigate the incident. I found the hand-operated…

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    Full Story
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