June 2, 2004—The UK’s Health and Safety Executive (HSE) has recently updated its popular guide aimed at facilities managers with responsibility for safety-related control systems in any industry.
“Out of Control: Why control systems go wrong and how to prevent failure” (2nd Edition) features a description and analysis of 12 incidents. In these, control system failures caused fatal crushing, amputation, physical trapping, microwave injury, gas releases, an acid spillage, the listing of a drilling rig, and the malfunctioning of a radiation shield.
The guide shows how the incidents could have been prevented by the application of straightforward precautions. A summary of a further 22 incidents lists primary and secondary causes. Together, these results reveal the relative importance of each activity in a typical development lifecycle.
For the 34 incidents analyzed, 44% had inadequate specification as their primary cause. The other results were 20% changes after commissioning, 15% design and implementation, 15% operation and maintenance, and 6% installation and commissioning. This means approximately three-fifths of all control system failures are built-in before operation commences.
Copies of “Out of Control: Why control systems go wrong and how to prevent failure (2nd edition),” (HSE ref: HSG 238) are available from HSE Books.
