Ogle Russell A, Morrison Delmar Trey, Carpenter Andrew R
Exponent, Inc., 185 Hansen Court, Suite 100, Wood Dale, IL 60134, United States.
J Hazard Mater. 2008 Nov 15;159(1):135-41. doi: 10.1016/j.jhazmat.2008.01.065. Epub 2008 Jan 31.
One of the objectives of process automation is to improve the safety of plant operations. Manual operation, it is often argued, provides too many opportunities for operator error. By this argument, process automation should decrease the risk of accidents caused by operator error. However, some accident theorists have argued that while automation may eliminate some types of operator error, it may create new varieties of error. In this paper we present six case studies of explosions involving operator error in an automated process facility. Taken together, these accidents resulted in six fatalities, 30 injuries and hundreds of millions of dollars in property damage. The case studies are divided into two categories: low and high automation complexity (three case studies each). The nature of the operator error was dependent on the level of automation complexity. For each case study, we also consider the contribution of the existing engineering controls such as safety instrumented systems (SIS) or safety critical devices (SCD) and explore why they were insufficient to prevent, or mitigate, the severity of the explosion.
过程自动化的目标之一是提高工厂运营的安全性。人们常说，手动操作给操作员犯错提供了太多机会。据此观点，过程自动化应降低由操作员失误导致的事故风险。然而，一些事故理论家认为，虽然自动化可能消除某些类型的操作员失误，但它可能会产生新的失误种类。在本文中，我们展示了六个涉及自动化过程设施中操作员失误导致爆炸的案例研究。这些事故总共造成六人死亡、30人受伤以及数亿美元的财产损失。案例研究分为两类：低自动化复杂度和高自动化复杂度（各三个案例研究）。操作员失误的性质取决于自动化复杂度水平。对于每个案例研究，我们还考虑了现有工程控制措施（如安全仪表系统（SIS）或安全关键设备（SCD））的作用，并探究它们为何不足以预防或减轻爆炸的严重程度。
