9/16/2017 Migration gone bad | Control Engineering

Migration gone bad

Starting up a process unit is tricky, but with inadequate training on a complex system, the result can be disastrous, which was
proven to be the case with a runaway chemical reaction in a recent incident.
Peter Welander
07/14/2016

One extensively documented process safety incident is particularly germane to this larger
discussion because it involves a control system migration with new distributed control
systems (DCSs) and human-machine interfaces (HMIs) but with inadequate operator training. The
incident happened at the Bayer CropScience plant in Institute, W. Va., on August 28, 2008, when a
runaway chemical reaction in its methomyl pesticide production unit caused a 4,500-gal pressure
vessel partially filled with flammable solvents to explode. There were two fatalities and much
damage to the plant from the explosion and fire that burned for more than four hours. This incident
has been thoroughly studied by the CSB (Chemical Safety Board), and its report released in
January 2011 provides the information for this discussion. The entire report makes for fascinating
reading which is also unsettling in many respects. Its summary called out five causes for the
explosion, three of which touch on the control system migration project the plant had just executed
with the second hitting the nail on the head:

"2. Operations personnel were inadequately trained to operate the methomyl unit with the new DCS."

Here are some key facts from the report:

The pesticide produced at this plant is used seasonally in agricultural applications, so the company only produced it at
one time each year. The idle time on the unit was used for maintenance and in this case, for the control system upgrade.
Two related production units were located side-by-side in the facility, Larvin and methomyl, and shared a control room
although the two operated separately.
The Larvin unit had undergone a similar DCS migration the year before. That changeover had worked well and everyone
at the plant was satisfied with the implementation.
The integrator that installed the Larvin system created a comprehensive training program for the operators, including time
on a process simulator. Before the unit restarted, documentation was complete, and the operators were confident and
well prepared to move to the new system.

Such was not the case when the methomyl unit was getting ready to restart. Quoting again from the CSB report:

"Management concluded that comprehensive formal training and practice using

the new DCS on the methomyl process w[ere] unnecessary. They incorrectly
assumed the methomyl and oxime board operators had become proficient from
the many operating hours using the DCS on the Larvin unit. Methomyl and oxime
board operators had minimal training on a few specific processes, but general
training took place during the operators' shift as time allowed and was self-
directed and self-paced. Informal, on-the-job training intended to develop the
necessary skills to run the system can lead to inappropriate or incorrect practices
that became the norm in the absence of proper training tools and instruction
(CCPS, 1994). The CSB concluded the training was inadequate."

"Prior to the methomyl startup, management provided operators time on the

console during the DCS upgrade to practice using the new system. However,
management did not require any methomyl operator to use this time to learn and
practice operating the methomyl unit, and operators could decide for themselves
how much time they needed to become familiar with the new DCS. Management
also assumed that operators directly involved in designing the mimic displays and other customizable features would have had
adequate exposure to the new system."

The report makes the point that the upgrade project followed normal procedures. The operators were involved in analyzing the
old HMI graphics and participated in design of the new ones, but contrary to their assumptions, it was not enough to infuse the
level of competence necessary. Starting up a process unit is tricky under the best of circumstances, but with inadequate
training on a complex system, the result can be disastrous.

Peter Welander is a contributing content specialist for Control Engineering. Edited by Chris Vavra, production editor, Control
Engineering, CFE Media, cvavra@cfemedia.com.

ONLINE extra

See related stories on high-performance HMIs and more information on DCS migrations linked below.

Related News:
DCS migrations: Opportunity for improvement, or operational disaster - 14.07.2016 04:05
Implementing high-performance HMIs - 14.07.2016 04:03

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