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SCADA and Alarm Management - DCE FEL ČVUT v Praze

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• Bunsfield Oil Storage ‐ 2005<br />

Incident Use Cases<br />

– In December 2005, a number of explosions occurred. A large<br />

fire engulfed a high proportion of the site. Over 40 people<br />

were injured; fortunately there were no fatalities.<br />

• <strong>Alarm</strong> management issues<br />

– <strong>Alarm</strong>s are not tested regularly<br />

Source<br />

Failure<br />

Types<br />

Stylistic or Cultural Indicators<br />

Commitment<br />

Competence<br />

Cognizance<br />

data collected & analyzed<br />

Diagnostic <strong>and</strong><br />

remedial measures<br />

<strong>Management</strong><br />

Functional<br />

Failure<br />

Types<br />

General Failure Types<br />

Accidents<br />

Incidents<br />

Near-Misses<br />

1-10 hit list<br />

Proactive Design<br />

SI Projects<br />

Best Practices<br />

Areas of incidents prevention<br />

Interface<br />

between the<br />

organization<br />

& the individual<br />

Safety Information System<br />

Condition<br />

Tokens<br />

Precursors<br />

Poor workplace design<br />

High workload<br />

Unsociable hours<br />

Inadequate<br />

training<br />

Poor perception<br />

of hazards<br />

<strong>Alarm</strong>s<br />

Human Factors<br />

Control room<br />

design<br />

Workplace<br />

Organization Individual<br />

Unsafe Acts<br />

Errors &<br />

Violations<br />

Near miss Auditing<br />

Training<br />

Workspace<br />

Motivation<br />

Attitude<br />

Group Factors<br />

Working Practice<br />

13.12.2012<br />

7

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