Alarm Rationalisation

Safety Moment - Ignoring the Alarm

When an Alarm is received, many operators are too ready to
assume the alarm is out of order. They thus ignore it or send
for the instrument mechanic. By the time the mechanic
confirms that the alarm is correct. It is too late.

An Incident:
After making some modifications to a pump, the pump was
restarted to transfer process liquid. When the transfer was
complete, the operator pressed the STOP button on the
control panel and saw that the Pump Running light went out.
He also closed a remotely operated valve in the pump delivery
line.
Several hours later, the high-temperature alarm on the pump
sounded. Because the operator had stopped the pump and
seen the Pump Running light go out, he assumed the alarm
was faulty and called an instrument mechanic. Soon afterward
an explosion occurred in the pump.

Version 1.0 June 2006

bp proprietary & confidential fieldofthefuture TM
 Alarm Rationalisation
Safety Moment - Ignoring the warning
Cause of the Incident:
When the pump was modified, an error was introduced into
the circuit. As a result, pressing the STOP button did not stop
the pump but merely switched off the Pump Running light.
The pump continued running against a closed delivery valve,
overheated and the material in it decomposed explosively.

Lessons Learnt:
•Always test after modifications,
•Training should emphasize the importance of responding to
alarms,
•They might be correct! If operators ignore alarms, it may be
because experience has taught them that alarms are
unreliable,
•Alarms should be adequately maintained.

Version 1.0 June 2006

bp proprietary & confidential fieldofthefuture TM