The document describes several workplace accidents caused by human error and how they could have been prevented. It discusses how small mistakes or lapses in judgement can lead to serious accidents, especially in hazardous industrial environments like power plants. The document then introduces the XPSOES Safety System, which uses mobile devices and real-time equipment status checks to stop work if unsafe conditions are detected, in order to prevent accidents caused by workers unknowingly interacting with live equipment.
2. Human Error
A Gas Turbine generator is about to sycnhronize. But something is wrong.
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3. Human Error
A Gas Turbine generator is about to sycnhronize. But something is wrong.
Q9 Disconnector is OPEN. It must be closed manually.
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4. Human Error
A Gas Turbine generator is about to sycnhronize. But something is wrong.
An operator is asked to close Q9 Disconnector.
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5. Human Error
A Gas Turbine generator is about to sycnhronize. But something is wrong.
An operator is asked to close Q9 Disconnector.
Instead of Q9 Disconnector, the operator closes Q81 Earth Switch by mistake !
The result is direct terminal short circuit on generator with catastrophic damage.
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7. Human Error
Electrical Maintenance Team is
working on Station Service TR
Transformer Off-Load tap changer
will be adjusted.
They –probably- think that it is safe
to work on a off-load tap changer
while transformer is off-load.
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8. Human Error
Electrical Maintenance Team is
working on Station Service TR
Transformer Off-Load tap changer
will be adjusted.
They –probably- think that it is safe
to work on a off-load tap changer
while transformer is off-load.
Then, the transformer explodes.
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9. Human Error
Electrical Maintenance Team is
working on Station Service TR
Transformer Off-Load tap changer
will be adjusted.
They –probably- think that it is safe
to work on a off-load tap changer
while transformer is off-load.
Then, the transformer explodes.
Three people were killed in this accident.
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10. Human Error
Rectificer-B is isolated for a
routine maintenance work.
After completing the work, the
permit was cancelled.
Isolation Breaker-B is open and
Bus-B is supplied from Rectifier-
A via the coupler.
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11. Human Error
Rectificer-B is isolated for a
routine maintenance work.
After completing the work, the
permit was cancelled.
Operator opens Breaker-A,
instead of closing Breaker-B.
Isolation Breaker-B is open and
Bus-B is supplied from Rectifier-
A via the coupler.
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12. Human Error
Rectificer-B is isolated for a
routine maintenance work.
After completing the work, the
permit was cancelled.
Operator opens Breaker-A,
instead of closing Breaker-B.
Isolation Breaker-B is open and
Bus-B is supplied from Rectifier-
A via the coupler.
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Loss of 125 VDC, Substantial damage to
the turbine, +$100M property damage and
repair time >12 months
13. Three Questions
• Is it the right equipment?
• Is it isolated from the system properly?
• Is it the right operation?
A wrong answer to these questions can
cause serious accidents in workplace.
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15. Human Factor in Accidents
Two types of unitentional human failures (unsafe acts):
Errors (slips/lapses) Mistakes
These are unintended
actions. Errors can occur
during a familiar task.
Errors of judgement or
decision making. Intended
actions are wrong.
It is impossible to eliminate human errors
completely by training or punishment.
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16. XPSOES Safety System
Scan the
Equipment tag
Query Response
Evaluate safe
working
conditions using
real time status
If the predefined
safe working
conditions do
not exist, STOP
message is
displayed on the
mobile device
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19. XPSOES Implementation
Any Mobile device will
work
Mobile devices without
camera can also be
used with NFC (not
effected by low/no
light, dust, ice, fog)
Industrial Rugged
Mobile devices IP68
certified & for ATEX
Zone 1, 2 are available
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Our Systems are
independent from
Hardware. We don’t
give you dedicated
handheld devices
which will get obsolete
within 1-2 years
20. XPSOES in Action
A Gas Turbine generator is about to sycnhronize. But something is wrong.
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21. XPSOES in Action
Electrical Maintenance Team is
working on Station Service TR
Transformer Off-Load tap changer
will be adjusted.
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22. XPSOES in Action
Rectificer-B is isolated for a
routine maintenance work.
After completing the work,
the permit was cancelled.
Isolation Breaker-B is open
and Bus-B is supplied from
Rectifier-A via the coupler.
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