Human Factors Handbook for Process Plant Operations
Description
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.
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The Center for Chemical Process Safety (CCPS) has been the world leader in developing and disseminating information on process safety management and technology since 1985. The CCPS, an industry technology alliance of the American Institute of Chemical Engineers (AIChE), has published over 100 books in its process safety guidelines and process safety concepts series, and over 10 training modules through its Safety in Chemical Engineering Education (SAChE) series. CCPS is supported by the contributions and voluntary participation of more than 200 companies globally.
Content
Glossary xxiii
Acronyms xxv
Acknowledgements xxvii
Foreword xxix
Part 1: Concepts, principles, and foundational knowledge 1
1 Introduction 3
1.1 What is "Human Factors"? 3
1.2 Purpose of this handbook 4
1.3 Why Human Factors? 7
1.4 The structure of this handbook 9
2 Human performance and error 11
2.1 Learning objectives of this Chapter 11
2.2 An example of successful human performance 11
2.3 An example of unsuccessful human performance 13
2.4 Key learning points from this Chapter 17
3 Options for supporting human performance 19
3.1 Learning objective of this Chapter 19
3.2 Types of human performance 19
3.3 Types of human performance, errors and mistakes 21
3.4 Selecting options for supporting human performance 30
3.5 Key learning points from this Chapter 34
4 Supporting human capabilities 35
4.1 Learning objectives of this Chapter 35
4.2 Attention 35
4.3 Vigilance 36
4.4 Memory 37
4.5 Cognitive capacity 38
4.6 Cognitive heuristics/biases 39
4.7 Key learning points from this Chapter 41
Part 2: Procedures and job aids 43
5 Human performance and job aids 45
5.1 Learning objectives of this Chapter 45
5.2 An example of a major accident 45
5.3 The role of job aids in supporting human performance 46
5.4 Approach to developing effective job aids 48
5.5 Key learning points from this Chapter 52
6 Selecting a type of job aid 53
6.1 Learning objectives of this Chapter 53
6.2 Stage 1: Determining the need for a job aid 53
6.3 Stage 2: Selecting the type of job aid 62
6.4 Electronic job aids 67
6.5 Key learning points from this Chapter 68
7 Developing content of a job aid 69
7.1 Learning objectives of this Chapter 69
7.2 Outputs from task analysis 69
7.3 Outputs from Hazard Identification and Risk Analysis 72
7.4 User involvement 72
7.5 Validation of job aids 74
7.6 Keeping job aids up to date 75
7.7 Key learning points from this Chapter 76
8 Format and design of job aids 77
8.1 Learning objectives of this Chapter 77
8.2 Structure and layout 77
8.3 Navigation 82
8.4 Instructional Language 84
8.5 Pictorial information 87
8.6 Icons 88
8.7 Key learning points from this Chapter 90
Part 3: Equipment 91
9 Human Factors in equipment design 93
9.1 Learning objectives of this Chapter 93
9.2 Definitions 93
9.3 Major accident example 94
9.4 Error traps 96
9.5 How might poor equipment Human Factors cause error? 98
9.6 Example of poor equipment Human Factors 101
9.7 Supporting human performance by good equipment design 103
9.8 Mitigating poor design 111
9.9 Key learning points from this Chapter 113
Part 4: Operational competence 115
10 Human performance and operational competency 117
10.1 Learning objectives of this Chapter 117
10.2 What is competency? 117
10.3 Competency Management 118
10.4 An example of effective Process Safety Competency Management 121
10.5 An example of gaps in operational competency 122
10.6 Competency influencing factors 124
10.7 Key learning points from this Chapter 125
11 Determining operational competency requirements 127
11.1 Learning objectives of this Chapter 127
11.2 Identify and define safety critical competency: overview 127
11.3 Step 1: Identify safety critical tasks 128
11.4 Step 2: Identify required competency 130
11.5 Step 3: Define performance standards 132
11.6 Key learning points from this Chapter 136
12 Identifying learning requirements 137
12.1 Learning objectives of this Chapter 137
12.2 Competency gap analysis 137
12.3 Training Needs Analysis 138
12.4 Key learning points from this Chapter 142
13 Operational competency development 143
13.1 Learning objectives of this Chapter 143
13.2 Good practice in learning 143
13.3 Key learning points from this Chapter 149
14 Operational competency assessment 151
14.1 Learning objectives of this Chapter 151
14.2 Reasons for competency assessment 151
14.3 How to conduct assessment of competency 151
14.4 Reassessment 157
14.5 Managing competency gaps 158
14.6 Competency and learning records 160
14.7 Key learning points from this Chapter 160
Part 5: Task support 161
15 Fatigue and staffing levels 163
15.1 Learning objectives of this Chapter 163
15.2 A fatigue-related accident 163
15.3 Managing fatigue risk 168
15.4 Key learning points from this Chapter 178
16 Task planning and error assessment 179
16.1 Learning objectives of this Chapter 179
16.2 Incident example 179
16.3 Human Factors and task planning 180
16.4 Error assessment within task planning 182
16.5 Key learning points from this Chapter 187
17 Error management in task planning, preparation and control 189
17.1 Learning objectives of this Chapter 189
17.2 Overview 189
17.3 Preventing optimism bias in task planning: scheduling 190
17.4 Assigning safety critical tasks 194
17.5 Distractions and interruptions 195
17.6 Long and low demand tasks 199
17.7 The Human Factors of control of work packages 202
17.8 Team briefings 204
17.9 Human Factors of system isolation 205
17.10 Human Factors of managing interlocks and automatic trips 210
17.11 Key learning points from this Chapter 214
18 Capturing, challenging and correcting operational error 215
18.1 Learning objectives of this Chapter 215
18.2 Failing to spot, challenge, and recover from errors 215
18.3 Why do we fail to capture, challenge, and correct errors? 217
18.4 Coaching people to recognize risk of making errors 218
18.5 Error Management Training 220
18.6 Enabling challenge of task performance 224
18.7 Key learning points from this Chapter 231
19 Communicating information and instructions 233
19.1 Learning objectives of this Chapter 233
19.2 Incident example 233
19.3 Causes of poor communication 234
19.4 Human Factors of communications 235
19.5 Avoiding communication overload 237
19.6 Human Factors in shift handover 241
19.7 Key learning points from this Chapter 245
Part 6: Non-technical skills 247
20 Situation awareness and agile thinking 249
20.1 Learning objectives of this Chapter 249
20.2 What are situation awareness and agile thinking? 249
20.3 Accidents from poor situation awareness and rigid thinking 252
20.4 Causes of poor situation awareness and rigid thinking 253
20.5 Key learning points from this Chapter 256
21 Fostering situation awareness and agile thinking 257
21.1 Learning objectives of this Chapter 257
21.2 Training in situation awareness skills 257
21.3 Practical situation awareness tools and tactics 262
21.4 Recognizing loss of situation awareness 268
21.5 Fostering agile decision-making 270
21.6 Key learning points from this Chapter 275
22 Human Factors in emergencies 277
22.1 Learning objectives of this Chapter 277
22.2 An example accident 277
22.3 Supporting human performance in emergencies 281
22.4 Non-technical skills for emergency response 284
22.5 Key learning points from this Chapter 297
Part 7: Working with contractors and managing change 299
23 Working with contractors 301
23.1 Learning objectives of this Chapter 301
23.2 An accident involving contractors 301
23.3 Human Factors tactics for supporting contractors 304
23.4 Key learning points from this Chapter 307
24 Human Factors of operational level change 309
24.1 Learning objectives of this Chapter 309
24.2 What do we mean by operational level change? 309
24.3 Operational level change and major accidents 310
24.4 Recognizing operational level changes that impact human performance 311
24.5 Managing Human Factors of changes 314
24.6 Key learning points from this Chapter 317
Part 8: Recognizing and learning from performance 319
25 Indicators of human performance 321
25.1 Learning objectives of this Chapter 321
25.2 What are performance indicators? 321
25.3 Identifying human performance indicators 323
25.4 Examples of human performance indicators 324
25.5 Sharing and acting on human performance indicators 332
25.6 Key learning points from this Chapter 333
26 Learning from error and human performance 335
26.1 Learning objectives of this Chapter 335
26.2 The importance of understanding error 336
26.3 Examples of poor learning 338
26.4 Learning in high performing teams 340
26.5 Human Factors of investigating process 341
26.6 Selecting preventive Human Factors actions 356
26.7 Learning 359
26.8 Key learning points from this Chapter 362
Appendices
A Human error concepts 373
B Major accident case studies 383
C Human Factors Competency Matrix 397
D Competency performance standards 415
E Learning methods and performance 420
F Situation awareness and behavioral markers 425
G Human Factors change checklist 431
Index 437
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.
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...
