A fire incident at the ExxonMobil Refinery Rotterdam was investigated by the Dutch Safety Board. The Board concluded an alarm management problem and operators not following procedures. ErgoS HF Engineering investigated the public reports and concludes that there is a lot more to learn looking at current practices in alarm management, process overview graphics, and human behavior. The public reports do not mention HF/Ergonomics. We are convinced that the fire could have been prevented by good HF Engineering. Read our full report here.