April 25, 2016 | Mark Paradies

Monday Accident & Lessons Learned: Human Error + Equipment Failure = 911 System Outage

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The following sequence is from the Clarence Bee

First, an air conditioning unit for a power supply room failed.

No big deal … There’s an automatic backup and a system to notify the engineer.

Oops … It failed too.

Well, at least there is a local temperature alarm. The local maintenance guy will do the right thing … Right?

Sorry. In the “heat” of the moment, he pushed the “kill” button.

Unfortunately, this was for fire emergencies and it cut off all the power to the 911 system. And nobody knew how to reset it. 

Finally, the tech rep from Reliance Electric arrived and the system was restored – 3.5 hours after the kill switch was pushed.

What can you learn from this incident?

  • Do your people know what to do when things go wrong? 
  • Do you do drills? 
  • Are things clearly labeled? 
  • Are there response procedures? 
  • How long has it been since people were trained?
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Root Cause Analysis
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