Workplace culture and human error are leading causes of death, injury and loss in process plants, as revealed in incident investigations and checklists.
A checklist based on typical incident causes, identified in multiple investigation recommendations, is used by some process plants during development of an integrated health and safety management system and audit protocol.
Process sheq officials could interview managers, supervisors, and operators separately, to complete three separate, identical checklists, and then compare results to prioritise areas of improvement in plant, procedures, training, communication and corporate safety culture.
Process culture checklist
A human factor checklist could fill a gap where a process safety management (PSM) standard and audit protocol is not yet in place. Such a checklist could focus on corporate culture factors and human factors directly related to a process plant, and could be modified by adding critical site, plant and process elements. Fill in ‘Y’ for Yes, or ‘N’ for No;
Safety critical communication
[ ] Does shift handover follow a defined structure, procedure, and log?
[ ] Is handover process always followed?
[ ] Are shift handover periods sufficient to communicate plant operating conditions detail?
Stress and fatigue risk
[ ] Is there a rule and procedure limiting overtime?
[ ] Do operators know overtime rules and requirements?
[ ] Is the overtime rule strictly followed?
[ ] Do overtime rules apply during shutdown, maintenance, construction?
[ ] Are emergency shutdown, gas and fire alarm switches guarded against inadvertent or unintentional operation, due to location, switch operation movements, covers, pens, stylus?
[ ] Do all process elements fail to safe during power failure or emergency stoppage?
[ ] Do switch labels identify discrete positions, like ON, OFF, OPEN, CLOSE?
[ ] Are equipment labels on vessels, piping, valves, instrumentation, clear and easy to read?
[ ] Are pump, valve and piping manifolds logically arranged and marked?
[ ] Could critical valves or equipment be closed or shut, from a safe location, in a timely manner?
[ ] Does site management understand the term ‘human factors’ as contributing to ‘human error’ and contributing to causes of incidents?
[ ] Are operators actively involved in reviewing operating procedures?
[ ] Is there a mature reporting culture, including potential incidents?
[ ] Are FERs reported honestly and openly?
[ ] Were all known plant leaks reported?
[ ] Is there intervention to cultivate use of FERs as leading indicators?
[ ] Are adequate resources available to promptly correct causes of unsafe behaviour?
[ ] Is management accountable for resource allocation?
[ ] Is the alarm system of manageable size and configuration?
[ ] Are critical alarms immune to power or computer failure?
[ ] Can each operator cope with his or her alarms?
[ ] Were alarm systems reviewed at every modification?
[ ] Were review recommendations implemented?
[ ] Are safety critical alarms displayed separately?
[ ] Are safety critical alarms hard wired, difficult to disengage?
[ ] Are all alarms installed as required by design?
[ ] Are alarms logically prioritised?
[ ] Do operators find alarm categories and priorities appropriate?
[ ] Are high priority alarms less than 5% of total alarms?
[ ] Are medium priority alarms less than 15% of total alarms?
[ ] Do safety critical alarms activate less than five times per shift?
[ ] Do medium priority alarms activate less than twice per hour?
[ ] Are repeating alarms useful, without disrupting work conditions?
[ ] Is a normal or steady state alarm rate less than 1 per 10 minutes?
[ ] Are all alarm frequencies below 1 per 5 minutes?
[ ] Do alarms direct operators to adequate supporting information?
[ ] Are alarm response procedures audited for compliance?
[ ] Is there an adequate alarm log and history?
[ ] How is alarm log information used?
[ ] Is the alarm list clear and easy to navigate?
[ ] Are alarm priorities distinguished by colour, sound, and position?
[ ] Do operators see a clear plant and process overview?
[ ] Do alarms display adequate alarm information detail?
[ ] Is the alarm state readable from standing behind the operator?
[ ] Can the alarm list be filtered by priority or plant area?
[ ] Do alarms require a relevant response before being reset?
[ ] Are alarms prioritised according to urgency of required response?
[ ] Do procedures specify required operator responses to each alarm?
• This process safety checklist is adapted from a Responsible Care process safety human factor checklist, intended for plants where a process safety management (PSM) system and audit protocol is not yet in place. This adaptation uses ‘positive’ questions to simplify use of completed lists by focusing attention on ‘N’ (No) responses.
Critical control points
Other than plant operation, process and plant activities that are prone to health and safety hazards, risk and error, according to a Resonsible Care circular, include;
• components specification
• equipment reception
• equipment installation
• operational procedure deviation
• training material updates
• predicting risk
• safety system design
• sustaining safeguards
• process change management.
‘Human error’ in context
Everyone can make errors, no matter how well trained and motivated they are. Sometimes we are ‘set up’ by a system to fail. The challenge is to develop error tolerant systems and cultures, said Chemicals and Allied Industries Association Responsible Care manager Dr Louise Lindeque in a full and reference presentation to the SA Process Safety Forum in Gauteng in February 2011.
“Failures arising from people other than those directly involved in operational or maintenance activities are important in incident causation. Managerial and design failures may lie hidden until they are triggered.”
Reducing human error involves far more than taking disciplinary action against an individual. “There are a range of measures which are more effective controls, including design of job and equipment, procedures, and training”, Dr Lindeque said.
“Paying attention to individual attitudes, motivation, design features, job design, and organisational culture, helps to increase procedural compliance.”
PHOTO; Process management is subject to several inherent risks, as well as workplace culture and human errors, as revealed in incident investigations following process disasters.