Janitor Responds to Nuisance Alarm by Killing Power to Critical Freezer
Decades of Scientific Research Lost, causes $1M in damages
As reported by the Times Union, a janitor working in a chemistry-biology research lab at Rensselaer Polytechnic Institute in Troy, NY, mistakenly shut off power to a super-cold freezer-destroying decades of scientific research.
The situation: Research samples were stored in the freezer at minus -112 degrees Fahrenheit. To prevent the samples from being damaged by temperature exceedances, the freezer had alarms set to go off at minus-108.4 degrees Fahrenheit and minus-115.6 degrees Fahrenheit.
Incident Timeline
- September 14, 2020 — The freezer alarm went off when the temperature rose to -108.4 degrees. The lab’s faculty and students responded to the alarm determining the samples were OK but there was an issue with the freezer.
- Emergency repairs were scheduled for September 21, 2020. In the interim, the alarm was left active causing a beeping sound.
- September 17, 2020 — A custodian working in the area heard the alarm sound and attempted to silence the “annoying alarms” from the electrical panel. The custodian thought he was turning on the electrical breakers when he actually turned them off. He took this action despite a sign posted on the freezer door about the alarm and the freezer awaiting repair.
- September 18, 2020 — The research staff discovered that the temperature in the freezer had risen to minus -25.6 deg F causing the research samples to be damaged or destroyed.
The Cost of the Incident
- “A majority of specimens were compromised, destroyed and rendered unsalvageable demolishing more than 20 years of research”, according to a lawsuit file by RPI.
- It is estimated that it would take $1 million to recreate the research.
How to Learn from an Incident
Learning from incidents is made easier by considering the following:
- It’s not about blame — Clear your mind of the motivation to “determine what the person did wrong”. When it comes to learning from human error, focusing on blame is never productive. Instead thinking “why did it make sense for the person (custodian or operator / dispatcher) to act the way they did?” yields more enlightening and actionable conclusions.
- Beware of hindsight bias — This form of cognitive bias makes us view past events as being more preventable than they actually were. If you are thinking “We would have never done that, allowed that to happen, or made that decision”, then you are in the midst of hindsight bias.
“Each time History Repeats Itself, the price goes up” — Ronald Wright
Lessons Applicable to Facilities Management
Although the incorrect action was taken by a custodian, the incident is relevant to facility operations. An incorrect response to a nuisance alarm could have been taken by an operator, dispatcher, or maintenance technician.
- Address high risk scenarios with multiple protection barriers — For high-risk, critical assets and spaces it may be wise to implement multiple protective barriers. In this case the warning note on the freezer (single barrier) was insufficient.
- Encountering a physical impediment (lock-out device) in the electrical panel might have caused the custodian to consider his actions further before switching off the breaker.
- A facility risk assessment might suggest an alarm be generated in the event of power loss.
- Focus attention on high-risk scenarios — Provide an operator dashboard that shows the status of critical assets and spaces. It should show how high-risk scenarios are changing with time and indicate whether they are on the path to resolution or impact (consequence).
- Design for (anticipate) human error — The investigation conducted by RPI’s safety staff determined the custodian made an error in reading the electrical box. It also concluded he did not “believe he had done anything wrong but was just trying to help”.
- Suppress nuisance alarms — Alarms are meant to indicate a problem that requires timely corrective action. An alarm is a nuisance when it is active but does NOT indicate a problem or require an action. Nuisance alarms distract and desensitize operators increasing the chances of making an error (incorrect response).
- Some automation systems include functionality for nuisance alarms to be suppressed (hidden from the view of the operator) temporarily (alarm shelving) or indefinitely (out-of-service). Suppressing the alarm would have muted the alarm sound.
Call to Action
If this incident has given you something else “to keep you up at night”, consider taking action to mitigate the risk you have identified.
At Virtual Facility we can help. Our platform helps you focus on high-risk assets and spaces enabling you to always be responding to the most critical alarms. It also includes powerful analytics to identify nuisance alarms so that they can be fixed and/or suppressed from the operator.
Email us: makebetterwork@vfacility.ai
