An operator at a critical facility entered the electrical distribution room. He started to isolate a part of the system for a routine maintenance in accordance with an approved procedure. When he actually turned the switch to isolate the system, a major portion of the facilities power was lost with a large portion of the supported customers. It was determined afterward that the operator actually entered the wrong distribution room, shutting down power to the wrong part of the facility.

At a nuclear power plant, an operator following an approved procedure to perform maintenance on some instrumentation caused the reactor to scram, shutting down the plant. The operator mistakenly hooked up a test signal to the wrong instrumentation causing a power spike to be seen by the protective circuitry, causing the shutdown.

Each of these incidents was caused by confusing labeling — the first by two identical electrical distribution rooms next to each other with very small labeling, the second by labeling that made it difficult to tell which system it belonged to. I have seen companies spend enormous time and effort on the design, procedures, and training; but when it came to labeling, almost no thought or effort was made in this area to eliminate risk. Labeling and system identification should be addressed during the design and construction, but unfortunately so many of our facilities were built without labeling being a priority. Lucky that labeling issues can be easily addressed post construction.

The major things that can be done involve relatively little resources for big payoffs in risk mitigation. Some things that can be done are:

• Color coding:  Painting piping systems different colors to identify which system they belong to, painting floors and doors in support rooms to differentiate them as to what part of the plant they support,  color coding labeling for different systems or trains.
• Coding:  Identify support systems with a uniquely prominent coding, such as, all “A” side systems start with a capital “A.” If you have three trains in a plant, maybe the sequence starts with a star for one, a box for another and a triangle for the third.
• Schematics:  I have seen schematics placed on electrical distribution panels to identify logical connections and painting on floors of manufacturing process trains and sequencing.

These are just a few of the ways labeling can reduce the chances of mistakes and mitigate the risk within facilities. Next time you are in your facility, look around at the labeling and marking. Are there ways to eliminate possible confusion? Would simply making the labeling larger help?

We are in the business of mitigating risk…this is an area that we could make very reasonable strides toward that goal with relatively little investment.

As always, comments are welcome!!

Terry