A Case Study Illustrating the System-Induced Error Approach

A CASE STUDY ILLUSTRATING THE SYSTEM-INDUCED ERROR APPROACH 

In a batch reaction plant, an exothermic reaction was cooled by water circulating in a jacket. The circulating pump failed and the reactor went out of control causing a violent explosion. A low flow alarm was present but was inoperable. A critical pump bearing had not been lubricated during maintenance, and the collapse of the bearing had led to the pump failure. 

The incident report stated that the cause of the accident was human error. Although maintenance procedures were available, they had not been used. The 

Introduction The Role of Human Error in Chemical Process Safety 

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