ࡱ> JLGHIu@ sbjbj h4jR7vvvv4fffh΋D24ŤŤŤ[]]]]]]$.R@Ťvv*^^^v[^[^^zh~hk Zfت'4<X,, kvvvv,kŤ^tUŤŤŤ $=HBB H Human Factors Methods for Improving Performance In the Process Industries Draft 2 Center for Chemical Process Safety American Institute of Chemical Engineers New York, NY Preface For over 40 years, the American Institute of Chemical Engineers (AIChE) has been involved with process safety and loss prevention in the chemical, petrochemical, hydrocarbon processing and related industries. AIChE publications are information resources for chemical engineers and other professionals to better understand the causes of process incidents and offer ways to prevent them. The Center for Chemical Process Safety (CCPS), a directorate of AIChE, was established in 1985 to develop and disseminate information for use in promoting the safe operation of chemical facilities and processes with the objective of preventing chemical process incidents. CCPS activities are supported by the funding and technical expertise of over 80 corporations. Several government agencies and nonprofit and academic institutions also participate in CCPS endeavors. With the support and direction of its advisory and management boards, CCPS established a multifaceted program to address the need for process safety technology and management systems to reduce potential exposures to the public, the environment, personnel and facilities from chemical process incidents. Over the past several years, CCPS has extended its publication program to include a Concept Series of books. These books are focused on more specific topics than the longer, more comprehensive Guidelines series and are intended to complement them. With the issuance of this title CCPS has published over 80 books. In 1989, CCPS published the landmark Guidelines for the Technical Management of Chemical Process Safety. This was followed in 1992 by Plant Guidelines for Technical Management of Process Safety which presented information on how to effectively implement, at a plant level, the various components of process safety management systems. An addendum to this publication was produced, Human Factors in Process Safety Management, which provided guidance on how human factors considerations could be applied to key elements of process safety management systems. In 1994, CCPS published the Guidelines Book, Guidelines for Preventing Human Error in Process Safety. This book provides the underlying principles and theories of the science of human factors, as well as their application to process safety and to the technical management of process safety systems. This publication, Practical Application of Human Factors in the Process Industries, is the result of the desire of the CCPS sponsoring companies to provide guidance at the plant level on specific, effective, practical techniques and tools that can be applied to improve process safety. The book provides brief overviews of how a human factors program can be established and implemented, but the heart of the book is a series of two page stand alone summaries of particular topics relating to human factors that a plant engineer can access and apply without reading the entire book. Each two page summary contains a short introduction to the topic, a description of the tools available, an example with graphics and flowcharts as needed, and references for further reading. It is hoped that this book will take the specialist subject of human factors and put it into practical terms that any engineer can apply to ultimately improve process safety performance. Acknowledgements To be completed Abbreviations and Acronyms To be completed. Table of Contents To be completed. Part I: Introduction 1 Introduction 1.1 Human Error We often hear the term human error implicated as a cause of major accidents. However, this does not always refer to a single incorrect action by an operator or controller, as Reasons (1990) Swiss Ccheese model below shows:shows in Figure 1-1. Figure 1.1 shows that (Crowl: I think we need a few sentences explaining this figure. Should Danger actually be Hazard? I suggest adding the word Incident or Accident to the left hand side of the figure. Is the date on Reason 1990 or 1997, as shown on the figure?) Humans have an influence over every layer of defencse within a system. The actions of the last person at the sharp endincident end in Figure 1-1 may prove to be critical in an accident sequence but the same person has usually acted only as a gatekeeper in a more systematic process, preventing the previous deficiencies of others from taking effect previously (e.g. poor design, poor decisions, lack of resources). Therefore, it is useful to understand where the holes / deficiencies lie and where simple human fallibility can prove critical to safe operations. Types of Human Error Reasons (1990) outlined several types of human failure: slips, lapses, mistakes and violations. Slips are associated with faulty action execution, where actions do not proceed as planned. This is often called finger trouble since the person knows exactly what they intend to do but it goes awry somewhere along the way. Lapses are associated with failures of memory. Again, the intention is correct but actions getare omitted or parts of the action sequence getare repeated. These errors tend to occur during the performance of fairly automatic or routine tasks in familiar surroundings, and attention is captured by something other than the task in hand. Examples include misreading a display, forgetting to press a switch, or accidentally batching the wrong amount to a batch counter. Mistakes occur when the execution is perfect but the plan itself failed to meet its objective, either because it was inappropriate for the situation, or the situation was novel and therefore no plan was available. An example could be misdiagnosing the interaction between various process variables and then carrying out incorrect actions. Violations are situations where operators deliberately carry out actions that are contrary to organiszational rules and procedures. This is not the same as sabotage. V - violations do not intend to cause harm. The operator might not follow the procedure might not be followed because, for example, they procedures are might be out-of-date or impracticable. It is also possible that Tthe procedure might appear to have little worth to the operators or the supervisors condone doing things in a different way. Theis above classifications for human error isare useful since it allows us to predict the variations in human action within a task and to identify where the holes in the final slice of the Swiss Ccheese lie. 1.2 Human Factors Human Ffactors is a common term given forto the widely-recognized discipline of addressing interactions in the work environment between people, and a facility, its management systems, and other people. Christensen, et al. (1988) defines human factors and ergonomics as: that branch of science and technology that includes what is known and theorized about human behavioral and biological characteristics that can be validly applied to the specification, design, evaluation, operation, and maintenance of products and systems to enhance safe effective, and satisfying use by individuals, groups, and organizations The UK Health and Safety Executive (HSG48, 200X) defines human factors as: environmental, organizational and job factors, and human and individual characteristics which influence behavior at work in a way which can effect health and safety. There are many sub-themes underneath this umbrella to human factors including term such as human-computer interaction, work environment, cognitive ergonomics and engineering psychology. However, they all have the same goal - to fit the task and environment to the person rather than forcing the person to significantly adapt in order to perform the work. 1.3 Purpose of This Book Consideration of the human factor is a key aspect of process safety management. Yet many organizations are struggling with how to get to grips with the subject in order to make a real impact on process safety. The main purpose of this guidance documentConcept Series book is to assist organizations in their efforts to address human factors issues. Specifically, this documentbook provides: A model and working definition of human factors; Illustrations of the benefits of human factors initiatives through the use of short case studies; Links between human factors and the business life cycle; Descriptions of key human factors topics together with practical techniques that can be applied in the workplace at the level of both the corporation and the facility; and References for additional resources to add to your knowledge base of human factors. This book provides the basic understanding of human factors and guidance on how human factors are applied. It will be useful to process and plant design engineers, plant operations and maintenance personnel, plant managers, and all other interested parties. with a basic understanding of the important elements of human factors and guidance for their practical applications. In the next section, a model for human factors is presented as an organizing construct for the remainder of the book. The structure of this book is as follows. Part I provides an introduction to human factors. The bookPart II provides anbrief overviews ofn how a human factors program can be established and implemented, but tThe heart of the book is contained in Part III. Part III is a series of two page short, stand alone summaries ofon particular human factors topics relating to human factors that a plant engineer can access and apply without reading the entire book. Each two page summary contains a short introduction to the topic, a description of typical issues and examples, approaches used to handle the topic, a description of the tools available, an example with graphics and flowcharts as needed, and references. for further reading. Additional resources, including journal, book and internet resources, is provided for further information. The techniques described within this document will be those that book have been consistently applied and are tried and tested within the process industry. The majority will be applicable Most of the techniques can be applied with following little training although will obviously require some practice in application in order to gain the best results. Along side the technique description or reference this document will give some guidance on the level of expertise necessary to apply the technique in order to allow the reader to make an informed decision of the best approach to take. 1.4 References Christiansen ..(1988) (Need complete citation). HSG 84 (200X) (Need complete citation) Reason, J. (1990). Human Error. (Cambridge: Cambridge University Press).  SHAPE \* MERGEFORMAT  Figure 1-1: Reasons (1997) Swiss cheese model for the cause of accidents related to human error. (Crowl: Need to confirm date of reference. Should Danger be Hazard? I think we should also label the star burst on the left as an Accident. The reference to Reason (1997) can be removed from the figure since it is noted in the caption. Organisation is spelled Organization in the U.S. 2 Why is Human Factors Needed? Human Ffactors plays an important role in process safety by utilizing scientific knowledge and fundamental principles from many disciplines to reduce incidents. Its proper application can also result in improved operating effectiveness and reliability. By considering these human factors and their interactionWith the application of human factors, it is possible to reduce the likelihood of human error, increase productivity and quality and reduce the risk of work-related musculoskeletal disorders. If human factors principles are integrated throughout the lifecycle of an asset;- from the design stage, through commissioning, operation and maintenance and looking ahead to decommissioning;- then the people within the system can be optimiszed rather than simply fire-fighting the problems that arise whilst operating complex systems. Too often, the lessons learned from human factors happen after an incident occurs. Some well-established examples are provided later in this chapterChapter 3. Our shared goal of improving process safety can be met by applying the analytics of human factors before an incident occurs. Therefore iIt is surprising that the value of assessing human factors has not yet been comprehensively accepted throughout the industry. There may be a number of reasons for this but sSome potential reasons perceptions for this may be; Human factors is ill defined; Human factors is difficult to apply and therefore is only the domain of specialists; Human factors is expensive and adds little tangible benefits Each of these issues is discussed below. Human Factors is Ill Defined Theis verbal definitions provided by Christiansen, et al.(1988) and the U.K. Health and Safety Executive (HSG48, @00X) above is furtherare enhanced by the use of the model illustrated in the figure belowshown in Figure 2-1. This model uses the concept of three overlapping domains: namely, the individual, the organiszation and the job. and can be usefully applied to the area of process safety. The job domain, includes 1) the design of tasks taking account of ergonomic principles referring related to human capabilities and limitations, 2) the physical design of the workplace and 3) the working environment and the mental requirements to carry out the tasks. The individual domain, refers to the persons attributes, skills, perceptions etc. Some attributes, such as personality, cannot be changesd whilst other like while other skills can. The organization domain refers to organizational practices, and procedures and culture and can have the greatest impact on group and individual safety performance. Yet - these influences are often overlooked. The use of theis model allows the identification of key elements within each domain and therefore gives a point of reference for an assessment. However the model also illustrates that the domains are overlapping and therefore for any human factors assessment some consideration of the interface with the other domains must be considered. Human Factors is Difficult to Apply Like many other disciplines there is a wide range of problems that can be addressed which vary in both scope and technical difficulty. Some of these problems may be addressed through the use of relatively simple techniques, which, following some training and practice, can be readily applied by non specialists, for example, . An example of this is procedural task analysis. Other problems will require the use of highly technical approaches and highly skilled specialists., for example, An example of this would be workload analysis of a pilot or astronaut. Human Factors is too Expensive Section XX of this document contains some brief descriptions of case studies where the application of human factors has been considered to have been of high value. Again like other disciplines the secret is to ensure the use of the right techniques at the right time and to gain buy in to the process and the results. Alternatively of course the cost of not considering human factors could also be highlighted. Chapter 3 contains a number of case histories related to human factors. Many of these incidents resulted in human injury, death, damage to the environment, loss of capital equipment and inventory and damage to the industrys license to operate. Clearly the cost of an accident far exceeds the proper application of human factors in the first place.  Figure 2-1: Human factors in industrial health and safety (HSG48) 3 Examples of Past Incidents (Crowl: We need a few paragraphs on this table. The paragraphs should first explain the table, including the headings across the top. Then it should present to the reader the significant conclusions drawn from the case histories, referring to individual case histories, if necessary. Should we remove the company name from the incident, and just provide the location and date? Table 3-1: Summary of significant incidents with human factors issues. Human Factors IssuesPast IncidentsConsequenceCommunicationsTrainingEquipmentMaintenanceDecisionsProceduresHuman Machine InterfaceOcean Ranger Platform collapse84 fatalitiesOcean Ranger's radio operator did not call for help on normal distress frequencies. Instead, he used a frequency used exclusively by oil companies.Only 40 of the 200 crew who worked the rig had been trained in the use of lifeboatsUseless safety gear - no survival suits available. Lifeboats not designed for waves that high. One unusable anyway.Control room operators had little training and no proceduresFlixborough - 28 fatalities 86 injuredDrawing of change done on shoproom floor onlyThe operators were not trained in HAZIDNot supervised by qualified engineerTo bypass one reactor vessel with a temporary modification to allow the plant to continue to operateNo time limit set for the temporary changeSevesoNo fatalities directly attributed. Multiple illnessesIcmesa did not communicate what chemicals had been releasedBursting disc blew on a reactor vessel set point too high. Reactor vessels inadequateSecondary receiver recommended by manufacturer to collect any vented material not fittedFailure to follow operating procedures order of steps reversed I thought the batch was not finished per procedure and left that way for the weekend because people wanted to get home)Three Mile Island - LOCANoneTraining for operators not adequate no feedback to studentsTurbine trip. Subsequently, PORV sticks open.Two block valves left in closed position after maintenance 2 days before Operators reduced coolant water flow into reactor attempting to prevent flooding caused meltdownOperators misled by control panel poor design. Over 100 alarms not prioritised. Warning light showing valves closed obscured by maintenance tag Human Factors IssuesPast IncidentsConsequenceCommunicationsTrainingEquipmentMaintenanceDecisionsProceduresHuman Machine InterfacePhillips Petroleum flammable vapour release and explosion23 fatalities 132 injuredPrior concerns that alarm was not audible in certain areas of the plant. Emergency control room damaged by blast so comms disruptedPart of plug lodged in pipework during clearing work. Specialist contractor employed but no site personnel in attendance throughout. Air hoses to valve cross-connected so opened when should have closed.Only single isolation provided for this operationIsolation and double block procedure not followed on site. Procedure required air hoses to be disconnected prior to maintenance not done. PTW system not enforced.Shell in TexasSeveral minor injuriesLessons learned from previous incidents not shared / actioned. Poor radio comms prevented on-site supervisor relaying commands to CCR operatorsOnce gas leak had occurred, correct shutdown & emergency response prevented escalation.Poor maintenance regimeTo start up PGC unit despite high vibration readingsShaft blowouts not covered. No contingency if high vibration occurred. Lack of clear indications in the control room Human Factors IssuesPast IncidentsConsequenceCommunicationsTrainingEquipmentMaintenanceDecisionsProceduresHuman Machine InterfaceTexaco Milford Haven26 injuriesAlarm flooding one every 2 to 3 secs. Senior personnel joined operators in CCR too many cooks not enough co-ordinationPoor training relating to abnormal operationsFlare drum pump-out system modified three years earlier HAZID identified problem but no further analysis performedPoor maintenance regime many faults were being lived with until planned shutdownTo keep unit running when it should have been shut downShutdown of neighbouring units according to procedure - successfulControl valve indicated open when it was in fact shut. Too much text, not enough use of colour on screens. No overview of whole process 4 Human Factors in the Life Cycle of a Chemical Plant The typical life cycle of a chemical plant includes three broad categories: Process Design and Project Execution Plant Operation Plant Maintenance It is most cost effective to address potential human factors issues in the initial design and construction of a chemical processing plant. or during a major project. The tired well-used phrase Do it right the first time would seem is applicable here. Any human factor issues that are discovered at a later date, perhaps revealing themselves as a process safety incident, will consume precious resources to address. Human factors issues addressed later in the life cycle will cost considerably more time, effort and cost to handle. The cost will be particularly high if the issue is identified as a result if an accident. (Crowl: Can we come up with a simpler and perhaps more obvious example to replace this?) If , for example, an over zealous project engineer activates all of the various DCS alarms that are available in the hardware system just because he can, then at some later date many of those alarms that are unnecessary and lead to operator overload will have to be reevaluated and potentially deactivated. It would also makes sense to continuously evaluate human factors throughout the operation and maintenance of a chemical processing facility to proactively remove those human factor concerns in a proactive manner. Proactively, hHuman factors can be addressed proactively during the conduct of any of the myriad of safety reviews performed during plant operation, such as PHAs, MOC Safety Reviews, Job Safety Analyses, etc. Reactively, human factors issues can be addressed using investigations findings after a process safety incidents. Surely, the proactive approach is the most prudentbest approach. Chapter 2 Part III of this book discusses Hhuman Fhactors Topics using a topical layoutorganization. Another reasonable way to present organize this information to the reader would be throughis to grouping these Human Factors Ttopics using a plant life cycle layoutapproach. If this e second arrangement plant life cycle methodwas is employed, there would necessarily be a certain amount of redundancy will occur within theis book. It was decided instead to provide the reader one listing of each Human Factor Topic, and then relate how these topics would be categorized under plant life cycle. This is done below: However, to assist the reader in understanding the life cycle approach, this organization is provided in Tables 4-1 through 4-3. Table 4-1:Human factors topics related to process design and project execution. (Crowl: The section and titles must be updated to correspond with the revised outline) SectionHuman Factors Topic2.1Human Error2.2HF Issues in Project Planning, Design an Execution 2.3How to Incorporate Human Factors into Hazard Analysis and Risk Assessment 2.4Human / Computer Interface 2.5Process Control Systems 2.6Competence Management 2.7Procedures 2.8Physical Activity Factors 2.13Maintenance 2.14Labeling2.15Management of Change 2.16Emergency Preparedness & Response 2.21Equipment Design 2.22Facilities and Workstation Design  Table 4-2: Human factors issues related to plant operations (Crowl: The section and titles must be updated to correspond with the revised outline) SectionHuman Factors Topic2.1Human Error2.3How to Incorporate Human Factors into Hazard Analysis and Risk Assessment 2.5Process Control Systems 2.6Competence Management 2.7Procedures 2.8Physical Activity Factors 2.9Fitness for Duty 2.10Environmental Factors2.11Operator Workload 2.12Shift work Issues2.14Maintenance2.15Management of Change2.16Emergency Preparedness & response2.17Incident Investigation2.18 Communication2.19Safety Culture2.20Behavior Based Safety2.22Facilities & Workstation Design2.23Human Factors in Management and Organizations Table 4-3: Human factors issues related to plant maintenance. (Crowl: The section and titles must be updated to correspond with the revised outline) SectionHuman Factors Topic2.1Human Error2.7Procedures2.8Physical Activity Factors2.9Fitness for Duty2.13Maintenance2.14Labeling2.18Communication 5 Linkage to Other CCPS Publications To be completed. 6 How to Use this Book (Crowl: This needs to be updated at a later date when everything is more settled). The book is written withPart I contains a description of the purpose of the book and a model for understanding human factors in this Chapter This is followed by approaches for implementing human factors in the corporate and facility setting (Part II) and then by key topics for human factors (Chapter 2Part III),. , and rReferences of important terms and resources for more information are provided in the appendices (Appendices). Section B. of this Chapter presents this books working model for human factors and Section E. displays a graphic linking human factors to the life cycle of a chemical plant. In Chapter 3Part II, human factors applications are covered at the corporate level and strategies for implementing human factors in a plant or engineering department are addressed. The emphasis is on identifying the needed elements and strategy for developing a human factors program. The first section of the Chapter deals with corporate level applications of human factors stressing the need for management commitment, accountability and clear measures of success. The second section brings into focus a human factors implementation strategy for plant or engineering department, including approaches for securing resources, establishing processes and feedback loops. Chapter 2 Part IIIintroduces key topics on human factors identified and vetted by the CCPS subcommittee. A broad range of human factors topics are covered in a concise and systematic format. Each of the 23 topics is covered in a two-page short brief with a focus on relevant human factors principles, available tools and industry applications. Where appropriate, graphics are used to reinforce concepts and references are provided for further information. Topics with potential regulatory implications (e.g., hazard analysis and OSHA PSM) are noted as such. Readers may go directly to their topics of interest as each major section in Chapter 2 is written to serve as a stand-alone description of the topic. The practical approaches to human factors presented in this Chapter will make it possible for plant personnel to directly apply human factors topics of interest to improve process safety performance. In the appendices, the book contains a glossary of human factors terms, references for further information, a bibliography and a subject index. 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