I have written a few papers this year. I have decided to share two this year
1. Looking at the early stages of an emergency, pointing out that it is usually this is usually in the hands of your process operators, often with limited support. http://abrisk.co.uk/papers/
2. My views on Bowtie diagrams, which seem to be of great interest at the moment. I hope this might create a but of debate. http://abrisk.co.uk/papers/Bowties&human_factors.pdf
My last two Christmas emails included some of my ‘reflections’ of the year. When I came to write some for 2017 I found that the same topics are being repeated. But interestingly I have had the opportunity to work on a number of these during the year with some of my clients. As always, these are in no particular order.
This is still a significant issue for industry. But it is a difficult one to address. There really is no short cut to reducing nuisance alarms during normal operations and floods of alarms during plant upsets. Adopting ‘Alerts’ (as defined in EEMUA 191) as an alternative to an alarm appears to be an effective ‘enabler’ for driving improvements. It provides a means of dealing with something they think will be ‘interesting’ to an operator, but that is not so ‘important.’
During the year I have provided some support to a modification project. I was told the whole objective was simplification. But a lot of alarms were being proposed, with a significant proportion being given a high priority. Interestingly, no one admitted to being the person who had proposed these alarms, they had just appeared during the project, and it turned out the project did not have an alarm philosophy. We held an alarm review workshop and managed to reduce the count significantly. Some were deleted and others changed to alerts instead. The vast majority of the remaining alarms were given Low Priority.
I have had the chance to work with a couple of clients this year to review the way they implement process isolations. This has reinforced my previous observations that current guidance (HSG 253) is often not followed in practice. But having been able to examine some examples in more detail has become apparent that in many cases it is simply not possible to follow the guidance, and is some cases it would introduce more risk. The problem is that until we did this work people had ‘assumed’ that their methods were fully compliant both with HSG 253 and with their in-house standards, which were usually based on the same guidance.
I presented a paper at this year’s Hazards 27 on this subject, suggesting that keeping interlocks to the minimum and as simple as possible is usually better, whereas the current trend seems to be for more interlocks with increasing complexity. My presentation seemed to be well received, with several people speaking to me since saying they share my concerns. But, without any formal guidance on the subject it is difficult to see how a change of philosophy can be adopted in practice.
Human Factors in Projects
I presented a paper at EHF2017 on the subject of considering human factors in projects as early as possible. To do this human factors people need to be able to communicate effectively with other project personnel, most of whom will be engineers. Also, we need to overcome the widely held view that nothing useful can be done until later in a project when more detailed information is available.
I have had the opportunity to assist with several human factors reviews of project this year. Several were conducted at what is often called the ‘Concept’ or ‘Select’ phase, which is very early. These proved to be very successful. We found plenty to discuss and were able to make a number of useful recommendations and develop plans for implementation. It is still too early to have the proof, but I am convinced this will lead to much better consideration of human factors in the design for these projects.
This has been a concern of mine for a very long time (since Piper Alpha in 1988). But I am frustrated that the process industry has done so little to improve the quality of handovers. It just seems to fall into the ‘too difficult’ category of work to do. It is a complex, safety critical activity performed at least twice per day. We need to manage all aspects of the handover process well, otherwise communication failures are inevitable, and some of these are likely to contribute to accidents.
I have worked with a couple of clients this year to review and improve their shift handover procedures. It is good to know some are starting to tackle this subject, but I am sure many more have work to do.
I hope you find some of this interesting. To finish, I would like to point you to a free paper available from Loss Prevention Bulletin, presenting Lessons from Buncefield.