One simple switch left off
Major problems and catastrophes have resulted
On numerous occasions!
By Nick Markowitz Jr.
Fire Investigator/Researcher
A worker at a large Biomedical/Chemical manufacturer leaves a vital switch to a manufacturing process in the off position over a weekend and it results in $20,000.000.00 Loss of product in this automated plant.
A service tech leaves a switch in program mode instead of normal mode and Allegheny Counties 911 center goes down for several hours after a rouge number comes into the system and ties it up resulting in at least one death of an infant. Sprinkler Control Valves are turned off by Building Maintenance Men and a trouble signal is ignored and 3 firefighters loose there lives when a fire breaks out which would have been controlled by the sprinklers.
All of the above are true events which are among many tragic events that play out in this country on an almost daily basis, because a switch is turned off and forgotten about.
Not just any switch but very critical ones.
It is very easy for this to happen when people forget they have done it because they get busy with another project or service call to run to etc. and there is no follow up.
While many safety programs have been put in place to catch these mistakes they still happen. Some systems now have very visible flashing and blinking lights reminder buzzers etc. They warn a critical device has been shut off or bypassed to prevent a problem and often times they are ignored or simply disabled or the safety light or buzzer it self malfunctions .
Even more disturbing is the number of critical switches that have no warning they have been disabled. Sometimes just an out of service tag is placed on the switch some times not even this simple device is used.
OSHA has developed the Lock out Tag Out program to help prevent Accidents to personnel from electrical shock, hi pressures, temps etc.
But many standards do not address switch shut off issues where immediate Life Safety issues are not present and only become apparent when a device has failed to operate because it was inadvertently shut off .In the case of the 911 center it was several months before they had a problem because a simple switch was turned off and not restored.
Recently I replaced an older Foam Releasing Fire Panel at a Petroleum Transmix Facility
Which protected the Propane and Gasoline Loading Rack area .And was surprised to find the older panel had no supervision of the main electric coil which releases the foam. The one critical circuit the panel was designed around and personnel on site had no idea if this coil was working or not. They knew if the power was off battery low wiring to pull stations and rate of compensation detectors and if valves were turned off or working etc. but no idea the foam would or would not release. After many accident investigations of fire system failures etc UL and NFPA have now recognized this one area that was over looked and now the coils are fully supervised. But it also depends on the installer properly wiring it as well. Modern Fire Systems now have all kind of safety features built in to detect when a panel or one of its functions is not operating properly, which in the long run will help prevent problems but again many times it is strictly up to the persons installing the systems, inspecting the systems and operating the systems to make sure proper procedures are carried out. This is why on Nuclear Submarines when a command is given it is repeated down the line several times to make sure all involved in the command make sure it is carried out. It may seem over kill but this is what the Navy found out was critical in making sure Nuclear Subs operate safely and why our Atomic Sub Fleet has such a good safety record. Because they try to keep the human factor in check.
I work in many High Risk Industrial Facility’s where it is critical to note positions of valves and switches where trained plant personnel conduct regular hourly inspection tours. But some plants leave it up to a Minimum wage Security Guard to take readings etc. which could very well be jeopardizing the people in the plant and surrounding community. I know this all too well because when I worked as a guard while attending Refrigeration &Heating trade school I worked at a plant in Carnegie area which made cooking oil called Mallot Industries where they wanted us to push a switch to turn on a massive oil fired boiler system if it went off line. One very cold night it did.
I refused to throw the switch and called the Plant Engineer because I saw an irregularity with the system I was cursed and screamed at for waking him up and by my guard supervisor from CPP Security for making them come to the plant at 3:00 am .But after they arrived and saw the problem they quickly apologized .I was even given a small token of thank you as well
Thank God that night I was working and not another guard as things could have been catastrophic as fuel oil had built up in the boilers because they did not fire on properly
And there would have been an large flash over an possible explosion when the fire button was activated.
Needless to say after that incident Guards were to no longer hit the button and call plant personnel instead. Makes you wonder just what the hell these plant owners were thinking in the first place. Eventually the boilers where replaced and old boiler house torn down.
In a couple of cases when I was working as a guard at places and I pointed out a problem the plant owners had me moved to another site seems I had uncovered a scheme to damage a factory and collect the insurance money and foiled there plans.
Eventually these unsafe places went bankrupt. It is unfortunate how many bad business owners there are in the world who do not care about there employees one only has to look at the mining industry in West Virginia this year.
Because safety rules were ignored or violated to keep production operating.
Knowing all the problems that go on with critical switches and signals you would think by now many of these issues would be addressed but unfortunately it is not until the investigation is conducted that a problem is discovered.
This is why you always see codes being updated but all too often existing problems are never corrected or addressed and Codes still are often inadequate and take several revisions till all issues are covered.
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