Human Factors Handbook for Process Plant Operations E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 485

Veröffentlichungsjahr: 2022

Beschreibung

Human Factors Handbook for Process Plant Operations Provides clear and simple instructions for integrating Human Factors principles and practices in the design of processes and work tasks Human Factors, the science of interaction between humans and other elements of a system, draws from disciplines such as psychology, ergonomics, anthropometrics, and physiology to understand how and why people behave and perform as they do--and how best to support them in performing tasks. The goals of the Human Factors approach are to improve human reliability, minimize the risk from human error, and optimize the working environment, human wellbeing, and overall system performance. Human Factors Handbook for Process Plant Operations guides supervisors, managers, and engineers on incorporating Human Factors principles and practices into plant maintenance and operations. With thorough and accessible coverage of all Human Factors topics of relevance to process industries, this easy-to-use handbook uses real-world anecdotes and case studies to demonstrate effective training and learning, task planning, communications, emergency response, risk and error management, and more. Throughout the text, the authors offer valuable insights into why people make mistakes while providing advice on how to help workers perform their process operational tasks successfully. * Explains all essential Human Factors concepts and knowledge with clear descriptions and illustrative examples * Offers actionable advice and models of good practice that can be applied to design, process operations, start-ups and shut-downs, and maintenance * Addresses job aids, equipment design, competence, task support, non-technical skills, working with contractors, and managing change * Discusses how lack of Human Factors considerations during the engineering design phase can adversely affect safety and performance * Describes how to use indicators to both recognize and learn from human error and performance issues Written by highly experienced operating and maintenance personnel, Human Factors Handbook for Process Plant Operations is an indispensable resource for everyone involved with defining, planning, training, and managing process operations, maintenance, and emergency response in the food, pharmaceutical, chemical, petroleum, and refining industries. The missions of both the CCPS and EI include developing and disseminating knowledge, skills and good practices to protect people, the environment, and property by bringing the best knowledge and practices to industry, academia, governments and the public around the world through collective wisdom, tools, training and expertise. The CCPS, an industrial technology alliance of the American Institute of Chemical Engineers (AIChE), has been at the forefront of documenting and sharing important process safety risk assessment methodologies for more than 35 years and has published over 100 books in its process safety guidelines and process safety concept book series. The EI's Technical Work Program addresses the depth and breadth of the energy sector from fuels and fuels distribution to health and safety, sustainability and the environment. The EI program provides cost-effective, value-adding knowledge on key current and future international issues affecting those in the energy sector.

Leseprobe

Table of Contents

Cover

Title Page

Copyright

Dedication

List of Figures

List of Tables

Glossary

Acronyms

Acknowledgements

Foreword

Part 1: Concepts, principles, and foundational knowledge

1 Introduction

1.1 What is “Human Factors”?

1.2 Purpose of this handbook

1.3 Why Human Factors?

1.4 The structure of this handbook

2 Human performance and error

2.1 Learning objectives of this Chapter

2.2 An example of successful human performance

2.3 An example of unsuccessful human performance

2.4 Key learning points from this Chapter

3 Options for supporting human performance

3.1 Learning objective of this Chapter

3.2 Types of human performance

3.3 Types of human performance, errors and mistakes

3.4 Selecting options for supporting human performance

3.5 Key learning points from this Chapter

4 Supporting human capabilities

4.1 Learning objectives of this Chapter

4.2 Attention

4.3 Vigilance

4.4 Memory

4.5 Cognitive capacity

4.6 Cognitive heuristics/biases

4.7 Key learning points from this Chapter

Part 2: Procedures and job aids

5 Human performance and job aids

5.1 Learning objectives of this Chapter

5.2 An example of a major accident

5.3 The role of job aids in supporting human performance

5.4 Approach to developing effective job aids

5.5 Key learning points from this Chapter

6 Selecting a type of job aid

6.1 Learning objectives of this Chapter

6.2 Stage 1: Determining the need for a job aid

6.3 Stage 2: Selecting the type of job aid

6.4 Electronic job aids

6.5 Key learning points from this Chapter

7 Developing content of a job aid

7.1 Learning objectives of this Chapter

7.2 Outputs from task analysis

7.3 Outputs from Hazard Identification and Risk Analysis

7.4 User involvement

7.5 Validation of job aids

7.6 Keeping job aids up to date

7.7 Key learning points from this Chapter

8 Format and design of job aids

8.1 Learning objectives of this Chapter

8.2 Structure and layout

8.3 Navigation

8.4 Instructional Language

8.5 Pictorial information

8.6 Icons

8.7 Key learning points from this Chapter

Part 3: Equipment

9 Human Factors in equipment design

9.1 Learning objectives of this Chapter

9.2 Definitions

9.3 Major accident example

9.4 Error traps

9.5 How might poor equipment Human Factors cause error?

9.6 Example of poor equipment Human Factors

9.7 Supporting human performance by good equipment design

9.8 Mitigating poor design

9.9 Key learning points from this Chapter

Part 4: Operational competence

10 Human performance and operational competency

10.1 Learning objectives of this Chapter

10.2 What is competency?

10.3 Competency Management

10.4 An example of effective Process Safety Competency Management

10.5 An example of gaps in operational competency

10.6 Competency influencing factors

10.7 Key learning points from this Chapter

11 Determining operational competency requirements

11.1 Learning objectives of this Chapter

11.2 Identify and define safety critical competency: overview

11.3 Step 1: Identify safety critical tasks

11.4 Step 2: Identify required competency

11.5 Step 3: Define performance standards

11.6 Key learning points from this Chapter

12 Identifying learning requirements

12.1 Learning objectives of this Chapter

12.2 Competency gap analysis

12.3 Training Needs Analysis

12.4 Key learning points from this Chapter

13 Operational competency development

13.1 Learning objectives of this Chapter

13.2 Good practice in learning

13.3 Key learning points from this Chapter

14 Operational competency assessment

14.1 Learning objectives of this Chapter

14.2 Reasons for competency assessment

14.3 How to conduct assessment of competency

14.4 Reassessment

14.5 Managing competency gaps

14.6 Competency and learning records

14.7 Key learning points from this Chapter

Part 5: Task support

15 Fatigue and staffing levels

15.1 Learning objectives of this Chapter

15.2 A fatigue‐related accident

15.3 Managing fatigue risk

15.4 Key learning points from this Chapter

16 Task planning and error assessment

16.1 Learning objectives of this Chapter

16.2 Incident example

16.3 Human Factors and task planning

16.4 Error assessment within task planning

16.5 Key learning points from this Chapter

17 Error management in task planning, preparation and control

17.1 Learning objectives of this Chapter

17.2 Overview

17.3 Preventing optimism bias in task planning: scheduling

17.4 Assigning safety critical tasks

17.5 Distractionsand interruptions

17.6 Long and low demand tasks

17.7 The Human Factors of control of work packages

17.8 Team briefings

17.9 Human Factors of system isolation

17.10 Human Factors of managing interlocks and automatic trips

17.11 Key learning points from this Chapter

18 Capturing, challenging and correcting operational error

18.1 Learning objectives of this Chapter

18.2 Failing to spot, challenge, and recover from errors

18.3 Why do we fail to capture, challenge, and correct errors?

18.4 Coaching people to recognize risk of making errors

18.5 Error Management Training

18.6 Enabling challenge of task performance

18.7 Key learning points from this Chapter

19 Communicating information and instructions

19.1 Learning objectives of this Chapter

19.2 Incident example

19.3 Causes of poor communication

19.4 Human Factors of communications

19.5 Avoiding communication overload

19.6 Human Factors in shift handover

19.7 Key learning points from this Chapter

Part 6: Non-technical skills

20 Situation awareness and agile thinking

20.1 Learning objectives of this Chapter

20.2 What are situation awareness and agile thinking?

20.3 Accidents from poor situation awareness and rigid thinking

20.4 Causes of poor situation awareness and rigid thinking

20.5 Key learning points from this Chapter

21 Fostering situation awareness and agile thinking

21.1 Learning objectives of this Chapter

21.2 Training in situation awareness skills

21.3 Practical situation awareness tools and tactics

21.4 Recognizing loss of situation awareness

21.5 Fostering agile decision‐making

21.6 Key learning points from this Chapter

22 Human Factors in emergencies

22.1 Learning objectives of this Chapter

22.2 An example accident

22.3 Supporting human performance in emergencies

22.4 Non‐technical skills for emergency response

22.5 Key learning points from this Chapter

Part 7: Working with contractors and managing change

23 Working with contractors

23.1 Learning objectives of this Chapter

23.2 An accident involving contractors

23.3 Human Factors tactics for supporting contractors

23.4 Key learning points from this Chapter

24 Human Factors of operational level change

24.1 Learning objectives of this Chapter

24.2 What do we mean by operational level change?

24.3 Operational level change and major accidents

24.4 Recognizing operational level changes that impact human performance

24.5 Managing Human Factors of changes

24.6 Key learning points from this Chapter

Part 8: Recognizing and learning from performance

25 Indicators of human performance

25.1 Learning objectives of this Chapter

25.2 What are performance indicators?

25.3 Identifying human performance indicators

25.4 Examples of human performance indicators

25.5 Sharing and acting on human performance indicators

25.6 Key learning points from this Chapter

26 Learning from error and human performance

26.1 Learning objectives of this Chapter

26.2 The importance of understanding error

26.3 Examples of poor learning

26.4 Learning in high performing teams

26.5 Human Factors of investigating process

26.6 Selecting preventive Human Factors actions

26.7 Learning

26.8 Key learning points from this Chapter

References

A  Human error concepts

A.1 Human Error categorization and terminology

A.2 Compliance concepts

A.3 Five Principles of Human Performance

A.4 Twelve Principles of Error Management

B  Major accident case studies

B.1. Texas City Refinery explosion, 2005

B.2. Bayer Crop Science plant explosion in West Virginia, U.S.

B.3. Longford gas plant explosion, Australia, 1998

B.4. Milford Haven refinery explosion, Wales, 1994

B.5. DuPont Yerkes chemical plant explosion, 2010

B.6. Macondo well blowout, 2010

C  Human Factors Competency Matrix

D  Competency performance standards

E  Learning methods and performance

F  Situation awareness and behavioral markers

G  Human Factors change checklist

Index

Wiley End User License Agreement

List of Tables

Chapter 3

Table 3-1 SRK types of human performance

Table 3-2 Case study example of a knowledge‐based mistake

Table 3-3 Example of a rule‐based mistake

Table 3-4 Example of skill‐based human error in a major accident

Chapter 6

Table 6-1: Guidelines for rating task complexity

Table 6-2: Guidelines for rating task frequency

Table 6-3: Time available to complete a task

Table 6-4: Definition of types of operational job aids

Table 6-5: Pros and cons of electronic job aids

Chapter 7

Table 7-1: Example task analysis as a table

Chapter 8

Table 8-1 Typical structure of procedures

Table 8-2 Checklist for layout of job aids

Table 8-3 Checklist for instructional language

Table 8-4 When to use different presentation options

Chapter 9

Table 9-1 Examples of poor design for hard‐wired interfaces – physical pane...

Chapter 10

Table 10-1 Key features of effective process safety Competency Management

Chapter 11

Table 11-1 An example industry standard

Table 11-2 Generic example of a competency standards matrix

Table 11-3 Petrochemical example of a competency standards matrix

Chapter 12

Table 12-1 Competency Gap Analysis and Training Needs Analysis template

Chapter 13

Table 13-1 Learning methods for developing individuals

Table 13-2 Team learning methods

Chapter 14

Table 14-1 Suitability of and differences between competency assessments

Chapter 15

Table 15-1 Principles of shift design

Chapter 16

Table 16-1 Example of locks removed on wrong blinds

Table 16-2 Task planning tactics for potential high‐risk situations

Table 16-3 Task planning tactics for different task errors

Chapter 17

Table 17-1 Scheduling

Table 17-2 Barrier ownership to prevent commissioning loss of containment

Table 17-3 Example tactics for enabling attention

Table 17-4 An isolation incident: relying on experience

Table 17-5 Human Factors of isolation

Table 17-6 Example of defeating an interlocked valve

Table 17-7 Human Factors good practice for interlocks and trips

Chapter 18

Table 18-1: Draining pumps leads to product release

(adapted from

[71]

)

Table 18-2: Error management training and coaching

(adapted from

[75]

)

Table 18-3: High‐risk observable behaviors

Table 18-4: Error detection techniques

Table 18-5: Examples of error recovery techniques

Table 18-6: Types of task verification

Chapter 19

Table 19-1: Verbal and communication techniques

Table 19-2: Shift handover contributed to a massive explosion

Table 19-3: Shift handover risk factors

Table 19-4: Elements of effective handover

Chapter 20

Table 20-1: Cognitive biases

Chapter 21

Table 21-1: Situation awareness – Assessment record

Table 21-2: Human performance tools – examples

Table 21-3: Clues for recognizing impaired Situation Awareness

Table 21-4: Group‐think – behaviors (symptoms)

Table 21-5: Confirmation bias – observable behavior

Chapter 22

Table 22-1: Non‐technical skills and error prevention

Table 22-2: Stress indicators in emergency situations

Table 22-3: Shared situation awareness requirements

Table 22-4: Emergency decision‐making aids

Table 22-5: Leadership in emergency situations

Table 22-6: Delegating and communicating in emergency situations

Chapter 24

Table 24-1 Tips on recognizing change

Chapter 25

Table 25-1 Leading and lagging indicators

Table 25-2 Specifying a human performance indicator

Chapter 26

Table 26-1 High performing teams and self‐learning from error

Table 26-2 Investigation biases and mitigating strategies

Table 26-3 Human Factors investigation tools

Table 26-4 Effective learning tips

APPENDICES A

Table A-1 ‘Hearts and Minds’ definitions for non‐compliance

APPENDICES C

Table C-1 Human Factors Competency Matrix

APPENDICES D

Table D-1 Competency standards template – Skill‐based task

Table D-2 Competency standards template – Procedure/Rule‐based task

Table D-3 Competency standards template – Knowledge‐based task

APPENDICES E

Table E-1 Application of learning methods to type of performance

APPENDICES F

Table F-1 Situation awareness – behavioral markers for oil and gas industry...

APPENDICES G

Table G-1 Human Factors Change Checklist

List of Illustrations

Chapter 1

Figure 1-1 Human Factors science, concepts and principles

Figure 1-2 Overview of the handbook, by chapter

Chapter 2

Figure 2-1 “Miracle on the Hudson”

Figure 2-2 Performance Influencing Factors

Chapter 3

Figure 3-1 The Skill‐Rule‐Knowledge Performance Model

Figure 3-2 Human performance modes, errors and mistakes

Figure 3-3 Strategies for knowledge and rule‐based human performance

Figure 3-4 Supporting skill‐based performance

Chapter 4

Figure 4–1: Typical vigilance decrement

Chapter 5

Figure 5-1: Overview of Human Factors aspects of developing a job aid

Chapter 6

Figure 6-1: Selecting a type of job aid for operational use

Figure 6-2: Using HIRA risk matrix results to assess task safety criticality...

Figure 6-3: Example of a formal safety critical task assessment

Figure 6-4: Task safety criticality rating

Figure 6-5: Mapping of type of job aid to type of task performance

Chapter 7

Figure 7-1: Example of a graphical task description

Figure 7-2: Example of HIRA results

Figure 7-3: Task walk‐through process

Chapter 8

Figure 8-1 Good practice SOP example

Figure 8-2 An example grab card

Figure 8-3 An example decision flow chart for unresponsive casualties

Figure 8-4 An example of icon and color coding

Figure 8-5 Examples poor and good practice of instructional language

Figure 8-6 An annotated diagram

Figure 8-7 An example of icon and color coding

Chapter 9

Figure 9-1 The Buncefield fuel storage facility before and after

Figure 9-2 A Human Factors solution to selecting the right control

Figure 9-3 A common error trap

Figure 9-4 Control and instrumentation panel

Figure 9-5 User‐ centered design

Figure 9-6 Examples of good and poor natural mapping for a stove

Figure 9-7 Example of good practice in natural mapping

Figure 9-8 Principles of good alarm design

Chapter 10

Figure 10-1 Competency Management

Chapter 11

Figure 11-1 SCTA and Level of Training

Chapter 13

Figure 13-1 Example of competency development through training

Figure 13-2 The Learning Pyramid

Chapter 14

Figure 14-1 Learning assessments

Chapter 15

Figure 15-1 Example of rapid rise in fatigue scores from a 16‐hour day

Figure 15-2 Working without rest breaks

Figure 15-3 Working nights

Figure 15-4 Typical scope of fatigue risk policy

Figure 15-5 Guidelines on shift design

Figure 15-6 Signs and symptoms of fatigue

Figure 15-7 Signs of under staffing

Figure 15-8 Managing workloads

Figure 15-9 A simple task timeline

Chapter 16

Figure 16-1 Examples of error‐likely situations

Chapter 17

Figure 17-1 Overview of HF task planning, preparation and control

Figure 17-2 Open language for inviting questions and opinions

Figure 17-3 Barrier ownership prevented wrong valve line up

Figure 17-4 Tactics for minimizing distraction and interruptions

Figure 17-5 Schematic of some factors influencing attention span

Figure 17-6 Features of a good Tool Box Talk or task briefing.

Chapter 18

Figure 18-1: Draining pumps

Figure 18-2: Categories of cognitive error

Figure 18-3: Factors contributing to error

Figure 18-4: Error contributing factors

Figure 18-5: Cognitive skills required for error self‐management

Figure 18-6: Factors building psychological safety

Figure 18-7: Challenging skills

Chapter 19

Figure 19-1: Repeating back

Chapter 20

Figure 20-1: Stages of situation awareness

Chapter 21

Figure 21-1: Behavioral Markers for “Actively seeks relevant information”

Figure 21-2: Causes of failed Situation Awareness

Chapter 22

Figure 22-1: Error recognition and management process

Figure 22-2: Human Errors – categories

Figure 22-3: Refinery explosion, Philadelphia Energy Solutions

Figure 22-4: Stress management – training strategies

Figure 22-5: Decision‐making in emergency situations.

Chapter 24

Figure 24-1 Types of change and impact

Figure 24-2 Sample Management of Change process

Chapter 25

Figure 25-1 Design of human performance indicators

Figure 25-2 Gathering and reviewing feedback

Figure 25-3 Stress in the workplace and performance

Figure 25-4 Signs of mindfulness

Figure 25-5 Lessons learned – knowledge sharing

Chapter 26

Figure 26-1 Steps of effective learning – learning process

Figure 26-2 The consequences of blame culture

Figure 26-3 “New” Just Culture Process

Figure 26-4 Error – causal factors and conditions

Figure 26-5 Matching improvements to type of error

Figure 26-6 Goals of Restorative Just Culture

APPENDICES A

Figure A-1 Energy Institute human performance principles

Figure A-2 What are the causes of incidents?

APPENDICES B

Figure B-1 Texas City Refinery Explosion

Figure B-2 Bayer Crop Science plant damage

Figure B-3 Longford Esso Gas Plant explosion

Figure B-4 The explosion and fires at Milford Haven.

Figure B-5 Interaction of the key valves and vessels

Figure B-6 The polyvinyl fluoride process

Figure B-7 Deepwater Horizon Oil Spill – Macondo blowout

Guide

Cover

Table of Contents

Title Page

Copyright

Dedication

List of Figures

List of Tables

Glossary

Acronyms

Acknowledgements

Foreword

Begin Reading

References

A Human error concepts

B Major accident case studies

C Human Factors Competency Matrix

D Competency performance standards

E Learning methods and performance

F Situation awareness and behavioral markers

G Human Factors change checklist

Index

Wiley End User License Agreement

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HUMAN FACTORS HANDBOOK FOR PROCESS PLANT OPERATIONS

Improving Process Safety and System Performance

CENTER FOR CHEMICAL PROCESS SAFETYAMERICAN INSTITUTE OF CHEMICAL ENGINEERSNew York, NY

This edition first published 2022

© 2022 the American Institute of Chemical Engineers

A Joint Publication of the American Institute of Chemical Engineers and John Wiley & Sons, Inc.

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Library of Congress Cataloging‐in‐Publication Data

Cover Design: WileyCover Image: Pand P Studio/Shutterstock, manine99/ Shutterstock, agsandrew/Shutterstock

This book is one in a series of process safety guidelines and concept books published by the Center for Chemical Process Safety (CCPS). Refer to www.wiley.com/go/ccps for full list of titles in this series.

It is sincerely hoped that the information presented in this document will lead to a better safety record for the entire industry; however, neither the American Institute of Chemical Engineers, its consultants, CCPS Technical Steering Committee and Subcommittee members, their employers, their employers' officers and directors, nor Greenstreet Berman, Ltd., and its employees and subcontractors warrant or represent, expressly or by implication, the correctness or accuracy of the content of the information presented in this document. As between (1) American Institute of Chemical Engineers, its consultants, CCPS Technical Steering Committee and Subcommittee members, their employers, their employers' officers and directors, and Greenstreet Berman, Ltd., and its employees and subcontractors, and (2) the user of this document, the user accepts any legal liability or responsibility whatsoever for the consequence of its use or misuse.

Human Factors Handbook For Process Plant Operations is dedicated toJack L. McCavit

Jack is passionate about process safety, especially in the areas of culture and human factors. His work, both in his career at Celanese, and after his retirement, has concentrated on educating workers and industry leaders on the importance of process safety, the payback of sustaining a great program, and most importantly, the impact of not making process safety a top priority. Jack had first‐hand experience with the latter when he witnessed a butane vapor cloud explosion at the Celanese site in Pampa, Texas, in 1987, resulting in three fatalities and dozens of injuries. Based on his significant and relevant expertise, Jack was selected as the technical manager for the prominent Baker Panel investigation of the BP Texas City Explosion in 2005.

Jack is a CCPS Fellow, an AIChE Fellow, and is rumored to be the fifth most famous Texan in history. He was the committee chair for the CCPS flagship book, Guidelines for Risk Based Process Safety, and a driving force behind CCPS's Vision 20/20.

It is both an honor and a privilege to see Jack in action!

Louisa A. Nara, CCPSC

CCPS Global Technical Director

List of Figures

Figure 1-1 Human Factors science, concepts and principles

Figure 1-2 Overview of the handbook, by chapter

Figure 2-1 “Miracle on the Hudson”

Figure 2-2 Performance Influencing Factors

Figure 3-1 The Skill‐Rule‐Knowledge Performance Model

Figure 3-2 Human performance modes, errors and mistakes

Figure 3-3 Strategies for knowledge and rule‐based human performance

Figure 3-4 Supporting skill‐based performance

Figure 4–1: Typical vigilance decrement

Figure 5-1: Overview of Human Factors aspects of developing a job aid

Figure 6-1: Selecting a type of job aid for operational use

Figure 6-2: Using HIRA risk matrix results to assess task safety criticality

Figure 6-3: Example of a formal safety critical task assessment

Figure 6-4: Task safety criticality rating

Figure 6-5: Mapping of type of job aid to type of task performance

Figure 7-1: Example of a graphical task description

Figure 7-2: Example of HIRA results

Figure 7-3: Task walk‐through process

Figure 8-1 Good practice SOP example

Figure 8-2 An example grab card

Figure 8-3 An example decision flow chart for unresponsive casualties

Figure 8-4 An example of icon and color coding

Figure 8-5 Examples poor and good practice of instructional language

Figure 8-6 An annotated diagram

Figure 8-7 An example of icon and color coding

Figure 9-1 The Buncefield fuel storage facility before and after

Figure 9-2 A Human Factors solution to selecting the right control

Figure 9-3 A common error trap

Figure 9-4 Control and instrumentation panel

Figure 9-5 User‐ centered design

Figure 9-6 Examples of good and poor natural mapping for a stove

Figure 9-7 Example of good practice in natural mapping

Figure 9-8 Principles of good alarm design

Figure 10-1 Competency Management

Figure 11-1 SCTA and Level of Training

Figure 13-1 Example of competency development through training

Figure 13-2 The Learning Pyramid

Figure 14-1 Learning assessments

Figure 15-1 Example of rapid rise in fatigue scores from a 16‐hour day

Figure 15-2 Working without rest breaks

Figure 15-3 Working nights

Figure 15-4 Typical scope of fatigue risk policy

Figure 15-5 Guidelines on shift design

Figure 15-6 Signs and symptoms of fatigue

Figure 15-7 Signs of under staffing

Figure 15-8 Managing workloads

Figure 15-9 A simple task timeline

Figure 16-1 Examples of error‐likely situations

Figure 17-1 Overview of HF task planning, preparation and control

Figure 17-2 Open language for inviting questions and opinions

Figure 17-3 Barrier ownership prevented wrong valve line up

Figure 17-4 Tactics for minimizing distraction and interruptions

Figure 17-5 Schematic of some factors influencing attention span

Figure 17-6 Features of a good Tool Box Talk or task briefing.

Figure 18-1: Draining pumps

Figure 18-2: Categories of cognitive error

Figure 18-3: Factors contributing to error

Figure 18-4: Error contributing factors

Figure 18-5: Cognitive skills required for error self‐management

Figure 18-6: Factors building psychological safety

Figure 18-7: Challenging skills

Figure 19-1: Repeating back

Figure 20-1: Stages of situation awareness

Figure 21-1: Behavioral Markers for “Actively seeks relevant information”

Figure 21-2: Causes of failed Situation Awareness

Figure 22-1: Error recognition and management process

Figure 22-2: Human Errors – categories

Figure 22-3: Refinery explosion, Philadelphia Energy Solutions

Figure 22-4: Stress management – training strategies

Figure 22-5: Decision‐making in emergency situations.

Figure 24-1 Types of change and impact

Figure 24-2 Sample Management of Change process

Figure 25-1 Design of human performance indicators

Figure 25-2 Gathering and reviewing feedback

Figure 25-3 Stress in the workplace and performance

Figure 25-4 Signs of mindfulness

Figure 25-5 Lessons learned – knowledge sharing

Figure 26-1 Steps of effective learning – learning process

Figure 26-2 The consequences of blame culture

Figure 26-3 “New” Just Culture Process

Figure 26-4 Error – causal factors and conditions

Figure 26-5 Matching improvements to type of error

Figure 26-6 Goals of Restorative Just Culture

Figure A-1 Energy Institute human performance principles

Figure A-2 What are the causes of incidents?

Figure B-1 Texas City Refinery Explosion

Figure B-2 Bayer Crop Science plant damage

Figure B-3 Longford Esso Gas Plant explosion

Figure B-4 The explosion and fires at Milford Haven

Figure B-5 Interaction of the key valves and vessels

Figure B-6 The polyvinyl fluoride process

Figure B-7 Deepwater Horizon Oil Spill – Macondo blowout

List of Tables

Table 3‐1: SRK types of human performance

Table 3‐2: Case study example of a knowledge‐based mistake

Table 3‐3: Example of a rule‐based mistake

Table 3‐4: Example of skill‐based human error in a major accident

Table 6‐1: Guidelines for rating task complexity

Table 6‐2: Guidelines for rating task frequency

Table 6‐3: Time available to complete a task

Table 6‐4: Definition of types of operational job aids

Table 6‐5: Pros and cons of electronic job aids

Table 7‐1: Example task analysis as a table

Table 8‐1: Typical structure of procedures

Table 8‐2: Checklist for layout of job aids

Table 8‐3: Checklist for instructional language

Table 8‐4: When to use different presentation options

Table 9‐1: Examples of poor design for hard‐wired interfaces – physical panels

Table 10‐1: Key features of effective process safety Competency Management

Table 11‐1: An example industry standard

Table 11‐2: Generic example of a competency standards matrix

Table 11‐3: Petrochemical example of a competency standards matrix

Table 12‐1: Competency Gap Analysis and Training Needs Analysis template

Table 13‐1: Learning methods for developing individuals

Table 13‐2: Team learning methods

Table 14‐1: Suitability of and differences between competency assessments

Table 15‐1: Principles of shift design

Table 16‐1: Example of locks removed on wrong blinds

Table 16‐2: Task planning tactics for potential high‐risk situations

Table 16‐3: Task planning tactics for different task errors

Table 17‐1: Scheduling

Table 17‐2: Barrier ownership to prevent commissioning loss of containment

Table 17‐3: Example tactics for enabling attention

Table 17‐4: An isolation incident: relying on experience

Table 17‐5: Human Factors of isolation

Table 17‐6: Example of defeating an interlocked valve

Table 17‐7: Human Factors good practice for interlocks and trips

Table 18‐1: Draining pumps leads to product release

Table 18‐2: Error management training and coaching

Table 18‐3: High‐risk observable behaviors

Table 18‐4: Error detection techniques

Table 18‐5: Examples of error recovery techniques

Table 18‐6: Types of task verification

Table 19‐1: Verbal and communication techniques

Table 19‐2: Shift handover contributed to a massive explosion

Table 19‐3: Shift handover risk factors

Table 19‐4: Elements of effective handover

Table 20‐1: Cognitive biases

Table 21‐1: Situation awareness – Assessment record

Table 21‐2: Human performance tools – examples

Table 21‐3: Clues for recognizing impaired Situation Awareness

Table 21‐4: Group‐think – behaviors (symptoms)

Table 21‐5: Confirmation bias – observable behavior

Table 22‐1: Non‐technical skills and error prevention

Table 22‐2

:

Stress indicators in emergency situations

Table 22‐3: Shared situation awareness requirements

Table 22‐4: Emergency decision‐making aids

Table 22‐5: Leadership in emergency situations

Table 22‐6: Delegating and communicating in emergency situations

Table 24‐1: Tips on recognizing change

Table 25‐1: Leading and lagging indicators

Table 25‐2: Specifying a human performance indicator

Table 26‐1: High performing teams and self‐learning from error

Table 26‐2: Investigation biases and mitigating strategies

Table 26‐3: Human Factors investigation tools

Table 26‐4: Effective learning tips

Table A‐1 ‘Hearts and Minds’ definitions for non‐compliance

Table C‐1 Human Factors Competency Matrix

Table D‐1 Competency standards template – Skill‐based task

Table D‐2 Competency standards template – Procedure/Rule‐based task

Table D‐3 Competency standards template – Knowledge‐based task

Table E‐1 Application of learning methods to type of performance

Table F‐1 Situation awareness – behavioral markers for oil and gas industry

Table G‐1 Human Factors Change Checklist

Glossary

Accident:

An event that can cause (or has caused) significant harm to workers, the environment, property, and the surrounding community.

Anthropometrics:

The science of measuring the size and proportions of the human body (called anthropometry), especially as applied to the design of furniture and machines.

Behavioral marker:

Non‐technical behaviors that can be observed and described. They refer to a prescribed set of behaviors and are indicative of specific types of non‐technical skills performance (e.g., effective decision‐making in emergencies) within a work environment.

Cognitive overload

:

A mental state where an individual is unable to process all the information provided by the system.

Cognitive underload:

A mental state when an individual is under‐stimulated due to insufficient workload. This mental state leads to lack of attention.

Competency Assessment:

System which allows measuring and documenting personnel competency. The goal of competency assessment is to identify problems with employee performance, and to correct these issues before they affect performance.

Competency:

Set of skills and knowledge which enables a person to perform tasks efficiently, reliably and safely to a defined standard.

Competency Gap:

Difference between the current competency level and the required competency level of an employee.

Competency Management:

Method of categorizing and tracking the development of individual employee competency, allowing an organization to track progress, and identify future training needs.

Fatigue:

Fatigue is a decline in physical and/or mental performance.

Hold Points:

Point where change cannot happen until there has been verification that the prerequisites have been achieved.

Human Error:

Intended or unintended human action or inaction that produces an unintended result. This includes, but is not limited to, actions by designers, operators, planners/schedulers, maintainers, engineers or managers that may contribute to or result in accidents

[1]

.

Human Factors:

Discipline concerned with designing machines, operations, and work environments so they match human capabilities, limitations, and needs. This includes any technical work (engineering, procedure writing, worker training, worker selection, operations, maintenance, etc.) related to the human interface in human‐machine systems

[1]

.

Human Performance:

Measure of an individual’s ability to execute a task effectively.

Incident:

Event, or series of events, resulting in one or more undesirable consequences, such as harm to people, damage to the environment, or asset/business losses.

Job aid:

Specific information or material intended to help workers execute a task more effectively.

Learning:

Acquisition of knowledge or skills through study, experience, or being taught.

Major accident:

Major accident means an occurrence such as a major emission, fire, or explosion resulting from uncontrolled developments in the course of the operation of any establishment, and leading to serious danger to human health or the environment (whether immediate or delayed) inside or outside the establishment, and involving one or more dangerous substances

[2]

.

Mistake:

A decision or judgement that is misguided.

Non‐technical skills:

The cognitive, social, and personal resource skills that complement technical skills and contribute to safe and efficient task execution

[3]

.

Performance Influencing Factors (PIFs):

Characteristics of the job, the individual and the organization that influence human performance

[4]

.

Performance standards:

Description of how the job is a description of what (actions/tasks) needs to be taken/executed, how the job must be done (behaviors/methods) and outcomes/results that will define satisfactory or acceptable performance.

Psychological safety

:

The outcome of an open workplace culture where people are willing to express an opinion, or admit mistakes or unsafe behaviors, without fear of being embarrassed, rejected, or punished.

Root cause:

Fundamental, underlying, system‐related reason why an incident occurred that identifies a correctable failure(s) in management systems. There is typically more than one root cause for every process safety incident.

Rota:

A period of work taken in rotation with other workers (an abbreviation of rotation).

Rotation:

A period of work taken in rotation with other workers.

Shift working (shifts):

Work which takes place on a schedule outside traditional day work hours. It can involve evening or night shifts, early morning shifts, and rotating shifts.

Training:

“Practical instruction in job and task requirements and methods. Training may be provided in a classroom or at the workplace, and its objectives are to enable workers to meet some minimum initial performance standards (minimum required competency level), maintain their proficiency, or to qualify them for promotion to a more demanding position”

[5]

.

Vigilance

decrement:

Decline in “the ability to sustain attention and remain alert to a particular stimulus over a prolonged period of time”

[6]

.

Acronyms

Acronym

Meaning

ANP

Agência Nacional do Petróleo (Brazil Petroleum Regulator)

BP

British Petroleum

CCPS

Center for Chemical Process Safety

CK

Checklist

CSB

Chemical Safety Board

CRM

Crew Resource Management

DCS

Distributed Control System

DFC

Diagnostic Flow Charts

DIF

Difficulty, Importance and Frequency Analysis

DOE

Department of Energy

DT

Decision Tree or Diagnostic Tree

EEMUA

Engineering Equipment and Materials Users Association

FCCU

Fluidized catalytic cracking unit

GC

Grab Card

GUI

Graphical User Interface

HIRA

Hazard Identification and Risk Analysis

ICAO

International Civil Aviation Organization

IChemE

Institute of Chemical Engineers

IOGP

International Association of Oil and Gas Producers

ISO

International Standards Institute

ISOM

Isomerization

LEL

Lower Explosive Level

LFL

Lower Flammability Level

LOPA

Layers of Protection Analysis

MDMT

Minimum design metal temperature

MEB

Material and Energy Balance

MOC

Management of Change

NATO

North Atlantic Treaty Organization

OIM

Offshore Installation Manager

OSHA

Occupational Safety and Health Agency

PFD

Process Flow Diagram

P&ID

Piping and Instrumentation Diagrams

PSB

Plant Status Boards

PSI

Process Safety Information

PSV

Pressure Safety Valve

PTW

Permit to Work

RBPS

Risk Based Process Safety

SCTA

Safety Critical Task Analysis

SH

Shift Handover

SOP

Standard Operating Procedure

SRK

Skills, Rule and Knowledge

STAR

Stop Think Act and Review

QRA

Quantitative Risk Analysis

WI

Work Instruction

UK

United Kingdom

U.S.

United States

Acknowledgements

The American Institute of Chemical Engineers (AIChE) and the Center for Chemical Process Safety (CCPS) express their gratitude to all the members of the Human Factors Handbook for Plant Operations Project Team and their member companies for their generous efforts and technical contributions. The committee structure for this concept book differs from other CCPS books in that this was a project done in collaboration with the Energy Institute (EI) and the generous efforts and technical contributions of the EI Technical Partner and Technical Company members is also gratefully acknowledged.

The writers from the Human Factors consultancy Greenstreet Berman Ltd are also acknowledged, especially the principal writers Michael Wright and Dr. Ludmila Musalova, with additional inputs from David Pennie, Rebecca Canham and Ninoslava Shah.

Project Team Members

Chris Aiken

Cargill, Chair

Eric Freiburger

Linde, Vice Chair

Stuart King

Energy Institute (EI), Co‐Chair

Charles Cowley

CCPS Staff Consultant, Project Manager

Sandra Adkins

BP

Lee Allford

Energy Institute (EI)

Mayara Carbono

Ex Ecolab

Carlos Carvalho

Petrobras

Erin Collins

Jensen Hughes

Ruskin Damani

Reliance

Gretel D'Amico

Pluspetrol

Joseph Deeb

Exxon Mobil (retired)

Alexandre Glitz

CCPS Emeritus

Cheryl Grounds

CCPS Emeritus

Jeff Hazle

Marathon

Gregg Kiihne

BASF

Ajay Shah

Chevron

Caroline Morais

ANP

Andrew Moulder

Inter Pipeline

Meg Reese

OxyChem

Rob Saunders

Shell

Scott Wallace

Olin (retired)

Gabriela Dutra (ex Braskem), Sahika Korkmaz (ex Chevron) and Josué Eduardo Maia França (Petrobras) also contributed to certain stages of the project.

Before publication, all CCPS and EI books are subjected to a thorough peer review process. CCPS and EI gratefully acknowledge the thoughtful comments and suggestions of the peer reviewers. Their work enhanced the accuracy and clarity of this concept book. The peer reviewers have provided many constructive comments and suggestions. They were not asked to endorse this book and were not shown the final manuscript before its release.

Peer Reviewers

Linda Bellamy

White Queen BV

Michelle Brown

FMC

Denise Chastain‐Knight

Exida

Palani Chidambaram

DSS

Ed Corbett

UK Health and Safety Executive

David Cummings

DuPont

Rhona Flin

Aberdeen University

Jerry Forest

Celanese

Jeff Fox

CCPS Emeritus, ex Dow

Osvaldo Fuente

Dow

SP Garg

GAIL

Zsuzsanna Gynes

The Institution of Chemical Engineers

John Herber

CCPS Emeritus

Alison Knight

3M

Susan Lee

Marathon

Maria Chiara Leva

TU Dublin

Keith Mayer

Kraton Polymers

Rob Miles

Hu‐Tech

Chelsea Miller

Chevron

Raphael Moura

ANP

Cathy Pincus

ExxonMobil

Tim Thompson

Braskem

Elliot Wolf

Chemours

Neal Yeomans

Advansix

The affiliations of writers, project team members and peer reviewers were correct at the time of publication.

Foreword

Humans are resourceful, resilient, innovative, smart creatures. They can also be error‐prone – forgetting to complete a step in a sequence, misunderstanding instructions, making mistakes in task execution. Disentangling these strengths and limitations, determining how and why human performance can be both resilient and fragile is the science of human factors.

The military and aviation sectors were the first to appreciate that the design of equipment and task environments had to take into account the psychological, anatomical and physiological capabilities of the human operators. The influential role of the organizational culture and its component systems on both managers and workers also became apparent. As the hybrid blend of engineers, psychologists, designers and other human factors specialists began to coalesce in the late 1940s, professional human factors and ergonomics societies were formed, helping to systematize an established body of evidence relating to human factors science, with a range of accepted methods for investigation and intervention. But it has taken some time for the value of this approach for the management of workplace operations to be recognized across industrial sectors.

In the early 1990s, I was working on research projects examining psychological aspects of offshore safety in the oil and gas industry. These were influenced by Lord Cullen’s Inquiry reports on the Piper Alpha disaster and included studies of safety climate, managerial behaviors, emergency response decisions, supervisors’ leadership. It was evident that there was very limited knowledge in this sector of the factors influencing human performance. So, my colleague Georgina Slaven and I decided we would edit a book on this subject and submitted a proposal to PennWell Books. They liked our proposal, but not our title, ’Human Factors in the Offshore Oil Industry’ as one of their reviewers, an industry expert, had told them that no‐one would know what this meant. Our book was published in 1996 with a different title that did not use the mysterious term ‘Human Factors’.

More than two decades later, at the time of this book’s publication, awareness and understanding of the factors influencing human performance in the process industries has become more active. This volume, one of a series directed by the Center for Chemical Process Safety, reflects the increased activity in the process industries. It provides an essential handbook for people on the frontline of plant operations, helping them apply good human factors principles and knowledge with practical techniques.

It has been written especially with operations and maintenance supervisors in mind, since such technical specialists have not traditionally been educated on the factors influencing human performance during their basic training, and there is now a vital need to address that pervasive knowledge gap.

Engineers, process safety practitioners and regulators who wish to gain an understanding of Human Factors concepts and methods will find much of immediate practical value.

This book has been written by a combined panel of plant operations professionals with in‐depth knowledge of a wide range of process plants together with very experienced Human Factors experts. It has then been widely peer‐reviewed, resulting in a comprehensive handbook that is easy to follow. Each of the 26 chapters contains essential knowledge, presented in a straightforward, accessible manner and supported by numerous examples to show why the concepts are relevant in processing industries. A notable feature is the analysis of major accidents from this sector that reveal where human factors contributed to failure or recovery during the event.

Practical tools and techniques are provided for each topic area with guidance for application and more experienced practitioners will discover new ideas for their portfolio of Human Factors methods.

This valuable handbook is definitely recommended reading for those striving to improve the safety and efficiency of process plant operations.

Rhona FlinProfessor of Industrial PsychologyAberdeen Business SchoolRobert Gordon University

Part 1:Concepts, principles, and foundational knowledge

1  Introduction

1.1 What is “Human Factors”?

As illustrated in Figure 1-1, like engineering, Human Factors is a combination of science, concepts, and principles. Human Factors draws on several scientific disciplines. These include psychology, ergonomics, anthropometrics, and physiology. The Human Factors approach uses these disciplines to help people understand how and why they behave and perform as they do, and how best to support them to perform tasks. The science adds to the knowledge gained from operational experience.

Figure 1-1 Human Factors science, concepts and principles

Human Factors also provides a set of principles and concepts that can be used to guide day‐to‐day decisions. The decisions focus on how best to support successful human performance. This approach helps people to understand tasks from the perspective of the person doing the work and provides ideas on how to support people to perform better. It advocates an orientation (a way of thinking) towards making improvements that support human performance and the prevention of error. It recognizes people's capabilities and commitment, and it aims to maximize people's roles in safe and productive operations, and to build their ability to cope mentally and emotionally with stressful and demanding tasks, i.e., psychological resilience.

A short video that presents a Human Factors view for successfully addressing human performance, titled Being Human, is available as a resource for “understanding and accepting why, as people, we do what we do, why we do it, and the way we do it.” [7]

Human Factors covers a very wide range of topics including, training, work planning, and fatigue. Many of these topics come under existing management systems, such as the operation of rotating shift schedule systems, and training systems. Human Factors provides knowledge, tools, and insights that can be integrated into an organization's existing systems of work and operational management, safety assessments, incident investigations, and day‐to‐day operational decision‐making. In this book, the terms ‘incident’ and ‘accident’ will be used interchangeably.

1.2 Purpose of this handbook

1.2.1 Purpose and scope

This handbook provides practical advice and examples of good practice that can be applied to design, process operations, start‐ups and shut‐downs, maintenance, and emergency response. It is a comprehensive but simple to understand handbook aimed at people responsible for the process operations.

The handbook:

Provides examples of practical application, principles, and tools. It also provides an understanding of the fundamentals of Human Factors, so the reader can develop their own approach.

Provides an explanation of how people think and behave, why people make mistakes, and how to help people perform process operational tasks successfully. This includes how to support human performance through procedures and job aids, training and learning, effective task planning, high reliability communications, fatigue risk management, development of error management skills, and preparing people to perform emergency response tasks.

Briefly covers the Human Factors of change management and managing contractors. It also offers help on how to learn from errors, and how to use indicators of human performance to improve support to people.

1.2.2 Other guidance

How does this handbook fit with other guidance documents?

Safety culture, leadership, and process safety management are covered in other CCPS publications, as shown by the book front covers. Most chemical process businesses have a set of process safety management systems in place already. The advice in this handbook can be integrated into these process safety management systems.

Human Factors methods, such as error analysis and Human Reliability Assessment, typically applied during a “Hazard Identification and Risk Analysis”, are not covered in this handbook. CCPS books on “Bow Ties in Risk Management” and “Guidelines for Integrating Process Safety into Engineering Projects” are available if further information is needed. This handbook does outline forms of error assessment that can be used by everyone involved in task planning and task management.

This handbook can be read in conjunction with other CCPS guidance on safety culture and process safety management, including:

Essential Practices for Creating, Strengthening, and Sustaining Process Safety Culture

[8]

.

Process Safety Leadership from the Boardroom to the Frontline

[9]

.

Guidelines for Risk Based Process Safety

[5]

[10]

.

Recognizing and Responding to Normalization of Deviance

[11]

.

Human Factors Methods for Improving Performance in the Process Industries

[12]

.

Investigating Process Safety Incidents

[13]

.

Some of the elements within “Guidelines for Risk Based Process Safety” are relevant to this handbook. Therefore, they have been referenced at various points throughout the handbook as additional information where this would be helpful to the reader.

1.2.3 Who should read this handbook?

This handbook is intended for everyone involved with defining, planning, instructing, and managing process operations, maintenance, and emergency response. This includes:

Frontline supervisors.

Designers.

Operations and maintenance managers.

Plant superintendents.

Process engineers.

Project managers.

Construction managers.

Process safety and health and safety personnel with the role of coaching higher‐level managers on Human Factors aspects.

The handbook is intended for people who understand process operations and have some process safety management experience.

1.2.4 A note on language and terminology

The explanation of some topics has been intentionally simplified and phrased in normal everyday language, rather than in scientific terms. This has been done in order to make the document more accessible, readable and more usable in the practical domain, and also with the aim of making it more understandable for an international audience.

For example, the term ‘mistake’ is used in this book to refer to both mistakes and other kinds of error, even though human factors specialists commonly understand the term ‘mistake’ to mean a specific kind of error that is to do with judgement and decision‐making, as distinct from other kinds of error such as ‘slips and lapses’. The term 'mistake' is used generally in the book, but where specific types of error are being discussed then the specific appropriate terms are used where that aids clarity.

A more complete explanation of the traditional terminology of ‘human error’ commonly used by Human Factors specialists is given in Appendix 0.

1.3 Why Human Factors?

1.3.1 Major accidents associated with human performance

Human performance is a factor in almost every major process accident. The costs of major process accidents are well known: major injury, destruction of facilities, environmental damage, immense costs, reputational loss, closure.

BP's Texas City 2005 refinery explosion: 15 fatalities, 170 injured.

The compensation totalled billions of US dollars. Repairs and lost profits cost over US $1billion.

See section B.1

In those cases where obvious signs of poor Human Factors were found, stakeholder confidence in the company was greatly reduced and employee morale was destroyed.

The United States Chemical Safety and Hazard Investigation Board (CSB) investigation of the Texas City accident cited that previous accidents have shown that Human Factors plays a role in industrial accidents [14]. The Texas City event includes several examples of Human Factors. People had worked without rest for many weeks or worked excessively long days. In some cases, it was known that process instrumentation was unreliable or that critical information such as Piping and Instrumentation Diagrams were out of date, and that training on new control systems had not been provided.

This kind of evidence greatly undermines stakeholder trust in an organization and can cause loss of the “license to operate”.

1.3.2 It is more than common sense

Human Factors is more than common sense. People may make mistakes for many reasons. Many factors influence how people perform. Process operations can be complex and involve many difficult tasks. Technology is constantly changing.

“Work as done”

versus

“Work as imagined”

People who plan work and develop operating procedures should not be remote from the actual task. They need to understand how the tasks are carried out in the field. Authors should have a complete knowledge of the surrounding environment or operational requirements.

Time constraints and attention demands impact frontline managers and supervisors. These demands can prevent frontline managers and supervisors from spending time to understand how people are performing, and what is influencing their performance. Issues should not be overlooked or considered in a superficial way.

Businesses must prioritize and balance production, operations, maintenance, and budget. Human Factors appreciation can direct focus to human performance support. It can also aid in prioritizing schedule, and managing fatigue and workloads.

In a dynamic process environment, with many complex tasks and safety critical operations in flux, a high level of human performance needs to be achieved systematically. Process safety does not depend on a single person's view of what is “common sense”. Recognized and implemented good practice and guidance is necessary to achieve a high standard of human performance.