Presentation Objectives

1
(No Transcript)
2
Presentation Objectives

• Suggest a goal for you.
• Provide an introduction to human factors.
• Present The Dirty Dozen.
• Provide examples from pipelines.
• Lead you to think of examples.
• Suggest some Safety Valves.

3
Todays Goal for You

• Identify at least three of The Dirty Dozen that
  affect you.
• Write down how you can address them, so they do
  not affect you.
• Tell your manager about The Dirty Dozen and
  your goal.
• Tell your manager the results in one month.

4
Simple Definition of Human Factors

• Interaction of
• People with people
• People with procedures
• People with machines
• People with their environment

5
Human Factors Key Aspects!

• ORGANIZATION
• Strategy
• Culture
• Leadership
• Resources
• Work patterns
• Communications

Where are they working?
What are people being asked to do and where?

• JOB
• Tasks
• Environment
• Workload
• Displays controls
• Alarms
• Procedures

• INDIVIDUAL
• Riskperception
• Competence
• Skills
• Personality
• Attitude

Who is doing it?
6
Organizational Factors
Where are they working? What might cause problems?

• ORGANIZATION
• Inadequate work planning, leading to high work
  pressure
• Lack of safety systems and barriers
• Inadequate responses to previous incidents
• Inadequate leadership and management
• Inadequate communication
• Inadequate work standards
• Poor management of health and safety
• Poor safety culture

7
Job Factors
What are people being asked to do and where? What
might cause problems?

• JOB
• Poor design of equipment and instruments
• Constant distractions and interruptions
• Missing or unclear instructions
• Poorly maintained equipment
• Lack of parts and supplies
• High workload
• Noisy and unpleasant working conditions

8
Individual Factors
Who is doing it? What might cause problems?

• INDIVIDUAL
• Low skill and competence levels
• Low physical or mental capabilities
• Personal or family problems
• Tired and stressed
• Bored or discouraged
• Medical problems

9
What Can I Do?

• I can learn my capabilities and limitations.
• I can learn the ways I think, act, and behave.
• I can learn and avoid The Dirty Dozen.
• I can develop and use Safety Valves.
• I can understand that organizational and job
  factors are major contributors to accidents and
  errors.
• But I can take responsibility for my errors.

10
The Dirty Dozen

• Stress
• Fatigue
• Complacency
• Distractions
• Lack of Awareness
• Lack of Communication

• Lack of Assertiveness
• Lack of Knowledge
• Norms
• Pressure
• Lack of Teamwork
• Lack of Resources

11
(No Transcript)
12
Stress Effects

• Anxiety
• Difficulty concentrating on task
• Feeling overwhelmed
• Fatigue
• Health problems
• Memory problems
• Poor judgment

13
Stress Pipeline Example

• Pipeline controller who normally performed well.
• Makes several errors where he forgot to do a task
  at the correct time.
• Part of his action plan was to work with me on
  improving his work planning and ways to use
  reminders.
• He told me(hadnt told others) that
• He was having financial problems, and
• His wife and children had left him, and
• He was not sleeping much.

14
Stress Curve Model
High
Go Go Stress So So Stress
PERFORMANCE
Danger
No No Stress
Caution
Danger Distress
Capacity to Cope
Basic Job Stressors
Basic Living Stressors
Low
Medium
High
STRESS
Yerkes-Dodson Curve (1908) Adapted by G. Dupont
15
Stress Safety Valves

• Be aware of the effects of stress on your work.
• Most businesses provide educational materials.
• Discuss what is happening with someone.
• Ask a co-worker to check your work.
• Take time off take breaks regularly.
• Turn off your devices.
• Eat properly, rest adequately, exercise.
• Plan an appropriate course of action.

16
(No Transcript)
17
Fatigue Effects

• Make more mistakes.
• Delayed reactions.
• Difficult to maintain attention and awareness.
• Not able to handle much information.
• Every task becomes more difficult to perform.
• Doesnt want to talk or interact with people
• Irritable or bad mood.
• Involuntary lapses into sleep may occur.

18
Fatigue Pipeline Example

• During a shutdown, a crew worked 34 hours
  installing a new piping system.
• At hour 28, a laborer was trying to get two
  flanges aligned.
• He stuck his hand in the wrong place.
• Two fingers were cut and smashed.

19
Fatigue Pipeline Example

• Pipeline controllers a few NTSB reports
• Either the controllers do not react quickly to
  abnormal operating conditions, OR
• They do not react correctly.
• People who work rotating shifts have the effects
  of fatigue.
• Many examples from all over the world.
• Fatigue in todays world is a human problem, a
  socio-technical effect of the way we live.

20
Fatigue Safety Valves

• Get adequate amounts of sleep.
• 8 hours each day/night for most people.
• Educate self on causes and cures of fatigue.
• Many resources on fatigue management.
• Get a physical check-up annually.
• Address any sleep disorders.
• Eat properly and drink plenty of fluids.
• Use caffeine strategically.
• Exercise regularly.

21
(No Transcript)
22
Complacency Effects

• Letting your mind wander.
• Taking shortcuts and omitting steps.
• Fooling around or showing off.
• Thinking that everything will work perfectly.
• Working too long without a break.
• Taking the attitude that safety is someone elses
  job.
• Performing a task without using the procedures or
  recommended personal protective equipment.

23
Complacency Pipeline Example

• Corrective Maintenance Performed On Wrong System
• Familiarity and complacency with the work
  environment allowed workers to troubleshoot an
  electrical system that was not isolated.
• Opened wrong valve
• Person reported that he had performed task
  hundreds of times. Didnt think about task.
• Did not refer to procedure, and performed task
  incorrectly.

24
Complacency Safety Valves

• Understand the human factors involved
• We have a mental bias that allows our past
  experiences to guide present expectations.
• We dont use our brains fully in the situation
  since our present circumstances normally match
  our past circumstances
• We devote our brains to more interesting parts of
  a task, or to a more interesting task.
• Recognize that It cant happen to me is a wrong
  belief.
• Expect success, but be prepared for failure.

25
Complacency Safety Valves

• Always practice risk assessment.
• Use the 5 Questions
• Use STAR with every task.
• Practice independent verification.
• Follow all policies and procedures.
• Train continually and review often.
• Create mental challenges for yourself.
• Sustain a questioning attitude.

26
Complacency Safety Valves

• Five Questions Simple Risk Assessment
• Why am I doing this task at all?
• What could go wrong?
• How likely is it to happen?
• What effect could it have on me or others?
• What can I do about it?
• STAR

REVIEW
27
(No Transcript)
28
Distractions

• Interruptions
• How can interruptions cause an error?
• Multitasking is counterproductive. (CNN.com)
• Multitasking makes us stupid. (WSJ article)
• There is a time-cost to switching tasks.
• There is a switching-cost.
• One must change goals.
• What do I want to do now?
• One must change rules.
• What rules apply to this task?

29
Distractions Pipeline Examples

• Driving and Doing Other Things
• Vehicle accidents
• Near misses
• People talking on phones, surfing Internet, etc.
  and failing to notice that it is time to perform
  a task OR ignoring an alarm or other signal.
• Technician was interrupted during a task and did
  not return pressure switch to service. Caused
  damage to equipment, and an abnormal operation.

30
Distractions Safety Valves

• Minimize or eliminate distractions.
• Ask people to be quiet and leave your area.
• Finish the task if possible.
• Complete tasks step by step.
• Flag or tag all uncompleted work.
• Use STAR.
• Use memory aids.
• Focus by practicing mindful attention.

31
(No Transcript)
32
Lack of Awareness

• Perceive(see, hear, notice) the critical elements
  around you.
• Understand what those critical elements mean,
  particularly as they relate to the current task.
• Forecast what is going to happen in the near
  future.

33
Lack of Awareness - Pipeline
Example

• Excavation damage to pipelines
• Didnt know a pipeline was here.
• Thought the pipeline was a few feet over.
• Didnt think I would damage the line by digging
  with the hoe.

34
Lack of Awareness -
Pipeline Example

• Controller has no change in display, but field
  equipment has changed.
• Received brief explanation of change.
• Is aware he cannot rely on display as
  accurate.
• Relying on Controller to maintain awareness of
  change and make switch correctly.
• Controller did not make switch correctly.

35
Lack of Awareness Safety Valves

• Learn the principles and practices of situation
  awareness.
• Pay attention to your surroundings.
• Create a safety zone.
• Recognize that jobs and the requirements are
  complex.
• Understand that vigilance can deteriorate while
  performing a task.
• Learn and use human performance principles.

36
(No Transcript)
37
Lack of Assertiveness

• In group settings, some people are hesitant to
  express their opinions.
• Affects work planning, hazard analysis, safety
  concerns.
• New employees may not ask relevant questions,
  even when uncertain.
• Can cause accidents, rework, quality issues.
• Some employees will not contradict managers or
  experienced employees.

38
Lack of Assertiveness Example

• Younger employee knew more experienced employee
  was not following company requirements, BUT did
  not question AND nothing happened for months,
  until a tank overflow.
• Controller did not question temporary operating
  directions, which led to an abnormal operating
  condition.

39
Lack of Assertiveness Safety
Valves

• Practice your values and beliefs.
• Practice the companys values and beliefs.
• Refuse to compromise company and personal
  standards.
• Ask for what you need.
• Dont be afraid to express your opinion and
  ideas.
• Recognize your contributions matter.
• Learn how to be assertive on the job.

40
(No Transcript)
41
Lack of Communication

• Lack of communication affects performance
• Misunderstandings occur between workers.
• Hurt feelings lead to petty disagreements.
• Job doesnt get done or is delayed.
• Anger may affect individuals or groups.
• Loss of trust and respect
• Near misses or incidents may result.

42
Lack of Communication Example

• Field technician did not inform controller of a
  communication device failure, and the controller
  was not receiving accurate information.
  Abnormal event!
• Many, many, many other examples.

43
Lack of Communication Safety Valves

• Practice 3-way communication.
• Write down important information.
• Always conduct briefings before, during, and
  after jobs.
• Use the Management of Change process.
• Provide the right information to the right people
  at the right time.
• Assume nothing.
• Dont tell someone something when they are in the
  middle of doing something else.
• Give people your full attention when listening.
• Expect peoples full attention when talking.

44
(No Transcript)
45
Lack of Knowledge

• Factors contributing to lack of knowledge
• Inadequate training
• New equipment
• Procedures and regulations
• New technology.
• Provide adequate training and reference
  materials.
• Use resources like the expertise of other people
  on shift, other people, and the manufacturers
  manual.
• Teamwork and communication help to reduce the
  potential error due to the lack of knowledge.
• Address all changes, including temporary ones.

46
Lack of Knowledge Example

• Technician did not know the procedure for
  maintenance on electrical equipment, BUT did the
  task AND was injured.
• Operator did not know how to locate the pipeline
  and marked its location incorrectly, AND line got
  damaged.
• Controller did not receive training, after a
  change in operating procedures, AND product was
  contaminated.

47
Lack of Knowledge Safety Valves

• Get the necessary training.
• Use procedures and manuals.
• Dont do a task if you do not know how to do it
  safely and correctly.
• Ask someone who knows.
• Dont let pride get in the way.
• Be a lifelong learner.

48
(No Transcript)
49
Norms

• Norms can be positive or negative.
• Use procedures or not.
• Completing checklists or pencil whipping.
• Naps encouraged or punished.
• Norms exist for a reason
• Restaurants have signs requiring employees to
  wash their hands. Why?
• Sign in Nashville restaurant says wash hands
  twice. Why?
• Norms are set by the employees
• Pipeline example

50
Norms Example

• Do not shut the pipeline down for any reason.
• Every employee has the authority to shut the
  pipeline down if he or she suspects a problem.
• Which one of those is closer to the norm for your
  company?

51
Norms Safety Valves

• Recognize norms where we work and live.
• Work on removing bad habits and behaviors.
• Accentuate the positive, eliminate the negative.
• Dont use shortcuts.
• Abide by standards and requirements.
• Be a good example for others.
• Follow policies and procedures.
• Keep in mind the old way may not be
  the correct way.

52
(No Transcript)
53
Pressure

• Demands are sometimes made for workers to
• Meet unrealistic deadlines.
• Be multi-skilled.
• Do many tasks in a workday, while multitasking.
• Be as good or better than coworkers.
• Perform all tasks safely and without error.
• Over time or anytime, these pressures can cause
  performance problems.
• Can cause accidents and injuries.

54
Pressure Example

• For instance, during the 36-month period from
  January 1, 2001 through December 31, 2003, 18
  workers were injured and approximately 86 others
  were involved in near miss events.
• Often pressure to get the job done results in
  actions that can permit disastrous consequences
  (i.e., personal injury and/or property damage).
• This is from a DOE report.
• Technicians were pressured by managers to work
  excessive hours to repair a pump. The repair
  took longer because the technicians, being
  fatigued, made some mistakes that caused rework.

55
Pressure in Control Rooms

• Perform tasks when a protective device is not
  working properly or a safety device is inhibited.
• Take a shortcut in a procedure.
• Do things that may compromise safety or quality,
  for the sake of profitability.
• Work an extra shift or extra hours, when
  fatigued.
• Do too many tasks at once, or in a short time
  period.
• Stay at the console, when you need a break.
• Work in a stressful environment, even when
  improvements can easily be made.

56
Pressure Safety Valves

• Dont overwhelm yourself or others.
• Dont be afraid to ask for help.
• Communicate your concern to your manager and
  coworkers.
• Dont create a false sense of urgency.
• Dont take shortcuts do the job right.
• Say no to pressure.
• Develop good planning and coping skills.

57
(No Transcript)
58
Lack of Teamwork

• Roles and responsibilities, if not clear, cause
  confusion and frustration.
• Teamwork problems lead to performance issues.
• Decisions are made by one or two people in the
  group, without the teams knowledge.
• Problems and underlying issues may not be
  addressed.
• Trust and respect are compromised.
• Cynicism and sarcasm are present.

59
Lack of Teamwork Example

• Tank Volume Record Keeping Employee purposely
  recorded wrong volume to cover up his mistake.
  He got fired for lying.

60
Good Teamwork Example

• Tank Fire When lightning caused a tank fire,
  the regular drills with employees and local fire
  departments proved that teamwork and preparation
  was worthwhile.

61
What About Control Rooms?

• Is teamwork necessary?
• On shift
• Between shifts
• With field operations
• With support functions
• With management
• Does teamwork exist, in your control room?

62
Lack of Teamwork Safety Valves

• Clarify the team goals.
• Have an effective team plan.
• Clearly define the roles.
• Clear communication.
• Reward good team behavior.
• Punish poor team behavior.
• Use well-defined decision procedures.
• Balanced participation.
• Establish ground rules.
• Be aware of the group process.

63
(No Transcript)
64
Lack of Resources

• When supplies are not available, employees spend
  time trying to find substitutes.
• When parts are not available, delays are
  necessary while a part is ordered, made, or
  retrofitted.
• Employees are tempted to omit steps that require
  a missing resource.
• Employees may guess at a solution, if the
  correct resource is not available.

65
Lack of Resources Example

• Most pipeline companies I consult with are
  operating with fewer employees than they had a
  few years ago.
• The result is that employees are doing more
  tasks, driving more miles, working more overtime.
• Causes stress, pressure, fatigue.
• This can lead to errors, accidents, injuries.
• Most pipeline companies I consult with are
  reducing expense budgets.
• Fewer spare parts are available.
• Fewer supplies are available.
• Fewer dollars are available for training.

66
Lack of Resources

• Have the correct complement for the schedules
  required to operate the pipeline.
• Assess needs for new parts before beginning a
  job.
• Purchase and maintain critical parts inventory.
• Dont compromise standards if the correct
  resources are lacking.
• Dont use work arounds if you dont have the
  proper parts or supplies.

67
The Dirty Dozen

• Stress
• Fatigue
• Complacency
• Distractions
• Lack of Awareness
• Lack of Communication

• Lack of Assertiveness
• Lack of Knowledge
• Norms
• Pressure
• Lack of Teamwork
• Lack of Resources

68
Todays Goal for You

• Identify at least three of The Dirty Dozen that
  affect you.
• Write down how you can address them, so they do
  not affect you.
• Tell your manager about The Dirty Dozen and
  your goal.
• Tell your manager the results in one month.

69
Presentation Objectives

• Suggest a goal for you.
• Provide an introduction to human factors.
• Present The Dirty Dozen.
• Provide examples from pipelines.
• Lead you to think of examples.
• Suggest some Safety Valves.

70
(No Transcript)
71
(No Transcript)