The past four decades in the chemical process industry have seen several watershed incidents which have been a source of many lessons for process safety and risk management. An important area of concern and debate is the role played by ‘human error’ as a cause of these incidents.
The study of incidents has been traditionally focused on what can be colloquially known as ‘hard’ factors. These include issues of process design, operations, maintenance, materials of constructions, facility and layout issues etc. The increased understanding of outstanding issues in these domains moved the focus to issues of management systems and the importance of safety culture, leadership and this can be viewed as a transition from a traditional ‘hard’ factors approach to management and other ‘soft’ factors.
Recent emphasis on the importance of the ‘softer’ factors of safety including human factors such as fatigue, stress, cognition etc. have attempted to demystify ‘human error’ by providing opportunities for improvement by offering systematic tools and framework to analyze systems to reduce the chance of these errors.
A keen focus of this is Procedures; operating and non-routine procedures play an important role in daily operations both as a preventive and mitigative barrier in case of abnormal situations. Incidents such as the Texas City refinery incident, Bhopal Gas Tragedy and even the Macondo Disaster, however have exhibited the gaps in the reliability of procedures and their application and management systems. In the Texas City incident, apart from the malfunctioning level sensor and the overfilling of the column, the fatigue related operator lapse was found to have contributed to the escalation of the situation. Additionally, it was found that operators deviated from startup procedures, not as a result of incompetence but as a result of established work practices to protect unit equipment and complete the startup in a timely manner. An ineffective management which did not updates procedures regularly, meant that the changes in the startup procedures were not reflected in the actual procedures used by operators .
Hence, a holistic re-assessment of the procedure eco-system has become the need of the hour, especially given the progress in both academic and industrial research on human factors and a rapid decrease in software development cost and deployment.
“If you think safety is expensive, try an accident.”
Adoption of new technology continues to remain a challenge especially in legacy operations traditionally run using a combination of paper based procedures and operator experience. The inertia of updating thousands of procedures in a facility and the inflexibility of paper based procedures to accommodate frequent changes contribute to procedure management issues. Further, the ease of use and accessibility of a procedure are hampered by using a ‘binder and shelf’ approach, since operators may be forced to improvise or delay referencing procedures due to dynamic operations requiring immediate attention. It is equally important to build the business case for investing into new procedure delivery and management systems to allow companies to make optimal decisions. As Trevor Kletz, a pioneer in process safety once said “If you think safety is expensive, try an accident.”
These issues present a new opportunity for industries to seek an effective and reliable solution to the procedure dilemma. The use of software tools for data analysis and visualization is a key development of the past decade. Facilities continue to be instrumented to higher levels of complexity, with reliable and sensitive instrumentation. This has led to a pipeline of voluminous data. Procedures, which are traditionally conceived as static tools which are reviewed based on regulations or internal policies, now can be dynamic with utilization of data, learning and efficient turn-arounds by moving to a virtual platform such as a DCS interfaces, mobile platforms and in the future even to wearables and VR.
The utilization of these new platforms could radically change the experience of an operator by reducing fatigue, increasing situational awareness and contributing towards a safer and productive work day. An example is the use of e-procedures, which could be integrated with the DCS. A pre-programmed algorithm could ‘Just-in-time’ display a particular procedure for an operation on the operator ‘s console. As the operator executes the steps, an abnormal situation detected by the instrumentation could trigger an emergency or non-routine procedure almost instantaneously allowing the operator easy access to make technical manuals for quick decisions. Further, in case of an infield procedure, the operator could drag and drop a procedure to a hand-held device and walk into the facility, and perform the task. Further, any recommended changes can be commentated and annotated from the field and electronically forwarded to management for approval. The ultimate goal is to have a ‘seamless’ environment for the operator to maximize their performance.
Meet the author: Pranav Kannan
In this new arena, some potential pitfalls need to be carefully considered. The role of the human or operator assumes new significance from being a ‘transducer’ of written instructions to a ‘steward’ of the process itself. This presents challenges about managing possible scenarios of cognitive overload, information flooding in the form of alarms and interface cues etc. The key to success will be the optimum balance of human abilities with digital tools. The ‘digitalization’ of procedures along with the use of data analytics may presents a new opportunity for preventing errors associated with procedures and balance the human – machine interaction in a process. Past incidents resulting from poorly developed and implemented procedures, provide learning opportunity which needs to be leveraged for the next generation of procedures. The next paradigm is in the convergence of systems which optimize the human facets of ‘pattern recognition’ and operational experience with the digital tools of enhanced situational awareness to truly realizing a 21st century active procedure delivery system.