Plant Went 89 Days with Safety System Impaired: What About Your Plant?

By Mark Sen Gupta

Technology Trends

An article from the Union of Concerned Scientists recently caught my attention. A nuclear facility in Nebraska had been operating 89 days with crucial hand-operated valves locked in the wrong position, despite detailed written procedures. The article goes on to describe how the valves were visually checked and signed-off THREE different times during the 89-day period.


This story highlights one of the biggest threats to safe operations known: humans. Every decision and action that requires a human in the mix is a decision or action at risk. This is why nearly 50 percent of incidents are linked to human error. ARC advocates that anything that can be automated, should be automated. As this story highlights, reliance on written procedures for manual verification failed three different times. Is it the fault of the procedures? Maybe, but that wasn’t the findings of the investigation. It could also be the reliance on procedures instead of technology to avoid costs.

In this particular case, instrumentation that verified the valve positions would have alerted Operations to the error. Although there are a lot of articles discussing the rise of cheap sensors, industrial-hardened sensors will always carry the extra cost burden of the packaging, installation, engineering, and administration. While costly, it’s a lot less so than an incident.

Other costs were not considered in the past that could help companies justify the added expense of technological solutions. These include insurance savings as insurance underwriters begin to scrutinize risk more closely, the cost of negative publicity (consider the costs surrounding the Keystone pipeline and the impact of pipeline leaks, plus the negative impacts on the company brand such as brought on by the Exxon Valdez accident), avoided litigation and associated productivity losses, faster startups, employee morale and retention, etc.

Automation is a wondrous thing. Using automation properly helps everyone. End users should review their standard operating procedures for tasks that could be automated on a regular basis and look for ways of removing reliance on humans. Safety is a prickly subject because everyone says publicly they’re doing awesome and take it seriously; however, the truth is revealed in action. Private conversations reveal a truth that usually not in line with the public face. A better understand at all levels in the organization of the benefits and risks, will help alleviate the disparity.

The Abnormal Situation Management Consortium maintains a running list of safety-related incidents which illustrate how often safety incidents occur and may help provide ideas for justifying projects in your own facilities.

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