Abnormal Situations – The solution is not a product. It is a system.
Solving Abnormal Situations
Abnormal situations remain one of the largest unmanaged risks in process industries. For decades, plants have absorbed shutdowns, equipment damage, safety incidents, and lost production as a cost of doing business. The Abnormal Situation Management (ASM) Consortium was formed to change that.
Abnormal situations are not rare events — they are systemic operational failures that cost the process industries billions each year.
To address this, the Abnormal Situation Management (ASM) Consortium was formed in 1992, led by Honeywell and funded jointly by industry leaders and the National Institute of Standards and Technology (NIST). The mission was clear: combine best practices and advanced technology to reduce abnormal events, improve operator performance, and lower risk.
Industry research revealed:
- Major refinery incidents average $80 million
- Some plants experience hundreds of shutdowns annually
- Equipment damage claims exceed $2.2 billion per year
- Preventable abnormal situations cost U.S. industry over $10 billion annually
Most sites lacked even the metrics to quantify their full exposure.
Stage 1: Fix the System Before Adding Technology
ASM audits identified recurring weaknesses:
- Alarm overload and poor alarm design
- Disconnected DCS, alarm, and safety systems
- HMIs built for steady-state, not disturbances
- Weak root cause discipline
- Inconsistent safety culture and leadership commitment
- Inadequate abnormal-scenario training
Traditional audits focused on compliance. ASM focused on organizational consistency and culture, referencing safety maturity research by James Reason.
The key finding across sites:
The number one problem is management leadership and ownership of systems.
Many issues could be corrected without new technology — simply by strengthening management systems and accountability.
Design for Normal vs. Design for Resilience
Most plants are engineered to optimize production during normal conditions. During upsets, that same design creates alarm floods, diagnostic confusion, and delayed response.
Best-in-class sites deliberately designed for abnormal conditions — embedding diagnostic views, dynamic displays, and strategies that support manual intervention when control systems struggle.
That shift — from optimization to resilience — is foundational.
Stage 2: Collaborative Decision Support (AEGIS)
Stage 2 introduced AEGIS (Abnormal Event Guidance Information System), integrating:
- State Estimators
- Fault diagnostics
- Sensor validation
- Multivariate analysis
- Simulation-based root cause tools
Operators must interpret 2,000–5,000 data points under stress. State Estimators help detect subtle degradations — drifting transmitters, flooding, valve failures, feed contamination — before they escalate.
The system is not an add-on dashboard. It integrates into operator workflow and human-machine interface design.
Human Factors Matter
The consortium also addressed:
- 12-hour shift fatigue
- Vigilance loss
- Cognitive overload
- Lessons from aerospace and military operations
Technology supports people — it does not replace them.
Leadership Determines Success
Across all findings, one theme remained consistent:
Technology cannot compensate for weak management systems.
Reducing abnormal situations requires:
- Clear executive ownership
- Root cause discipline
- Meaningful metrics
- Cultural consistency
- Continuous improvement
Abnormal situations are system failures — not operator failures.
The ASM Consortium demonstrated that with disciplined management, human-centered design, and integrated decision support, plants can significantly reduce risk and operational losses.
“The solution is not a product. It is a system”. (Ian Nimmo)
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