Fable
Factory safety inspections and specialized equipment inspections
A chemical plant has two sets of safety inspections each year. The first is a comprehensive safety inspection covering fire access routes, hazardous chemical storage, explosion-proof electrical equipment, and emergency plans, across more than twenty workshops plant-wide. The second is a special inspection of automated equipment, covering only the sensor accuracy, control logic redundancy, and failover mechanisms of the central control system. The two inspections differ in report format, inspector qualifications, and rectification procedures.
One year the factory launched a cost-cutting and efficiency drive, merging the two inspections into one annual major inspection. The safety team figured that since they were entering the workshop anyway, they might as well check everything in one trip. The automation equipment section was embedded into the comprehensive checklist as a small subsection, and the original four-hour specialized inspection was compressed into forty minutes. The inspector went down the automation equipment subsection of the comprehensive checklist, ticked a few items as operating normally, and left.
Three months later, a slight drift occurred in the reactor temperature control system—the sensor reading was five degrees lower than the actual temperature, and the control system triggered no alarm because the deviation did not exceed the safety threshold set in the comprehensive checklist. Twelve hours later the temperature deviation widened to fifteen degrees, and the system finally alarmed, but corrosion had already appeared on the inner wall of the reactor. Production was halted for three weeks for repairs.
The accident investigation found that the automated special inspection originally had its own independent threshold standards: a temperature-control deviation of more than three degrees had to be marked yellow, and more than five degrees had to be marked red and trigger the maintenance process. These standards were overridden when merged into the general inspection—the general inspection checklist covered fire safety and hazardous chemicals, and its thresholds were too coarse for precision control systems.
The factory restored the double-inspection system, but made one improvement: a cross-reference table was added to the first page of both inspection reports. The comprehensive inspection report stated which specialized inspection items were not covered this time, and the specialized inspection report stated the impact of this item's risk on the factory-wide comprehensive score. The two reports were not merged, but each could see the other's existence and scope of conclusions.
At the year-end safety committee summary, the factory director hung the whole-factory map and the workshop cross-section side by side on the wall. From then on, he no longer stuffed the cross-section into the whole-factory map, nor used the whole-factory map as a substitute for opening up the equipment and taking a look. The two maps had different scales, and if either replaced the other, information would be lost.