Computer Control and Human Error by Trevor Kletz

By Trevor Kletz

Content material:
Preface

, Pages iii-iv
Forethought

, Page vii
Introduction

, Pages 1-2
1 - a few incidents that experience happened, normally in computer-controlled method plants

, Pages 3-44
2 - threat and operability (hazop) stories utilized to computer-controlled strategy plants

, Pages 45-80
3 - the explanations why computer-controlled structures fail

, Pages 81-113
Afterthoughts

, Pages 114-116
Index

, Pages 117-120

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Additional resources for Computer Control and Human Error

Sample text

Study 6 reviews changes made during commissioning of the plant. An earlier study (Hazard Study 0) is now being introduced. It is carried out at the start of a project, before the engineering design department is involved, and asks if the right product is being made by the most suitable route and in the most suitable location. Two related hazard identification techniques — FMEA (Failure Modes and Effects Analysis)13 and FMECA (Failure Modes Effects and Criticality Analysis) — will also be referred to later in this chapter.

Fitting alarms illustrates the maxim that if we deal with each problem as it arises, the end result may be the opposite of that intended. If an operator wishes to know when a measurement changes, but the change does not require immediate action by the operator, the computer can be programmed to display a message instead of sounding an alarm. When a power failure occurred on one plant the computer printed a long list of alarms. The operator did not know what had caused the upset and did nothing.

They should be discharged to a flare stack, scrubbing system or catchpot45. 6. 1 An operator wanted to reduce the temperature on a catalytic cracker from 982°F to 980°F. Unfortunately he pressed the keys in the wrong order (908) and immediately pressed the 'Enter' key. The computer responded with impressive speed, slamming slide valves shut and causing a flow reversal along the riser. Fortunately there were no injuries and only a small fire, at a leaking joint. 9 During the Hazop of computer-controlled plants we should consider the results of errors in entering data.

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