1、 Human Factors Tool for Existing Operations API Human Factors Task Force Regulatory Analysis however, the Institute makes no representation, warranty, or guarantee in connection with this publication and hereby expressly disclaims any liability or responsibility for loss or damage resulting from its
2、 use or for the violation of any authorities having jurisdiction with which this publication may conflict. API publications are published to facilitate the broad availability of proven, sound engineering and operating practices. These publications are not intended to obviate the need for applying so
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5、ored in a retrieval system, or transmitted by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Contact the Publisher, API Publishing Services, 1220 L Street, N.W., Washington, D.C. 20005. Copyright 2006 American Petroleum
6、Institute FOREWORD Nothing contained in any API publication is to be construed as granting any right, by implication or otherwise, for the manufacture, sale, or use of any method, apparatus, or product covered by letters patent. Neither should anything contained in the publication be construed as in
7、suring anyone against liability for infringement of letters patent. Suggested revisions are invited and should be submitted to the Director of Regulatory Analysis and Scientific Affairs, API, 1220 L Street, NW, Washington, DC 20005. TABLE OF CONTENTS Page Introduction. 1 Objectives and Scope 2 Overv
8、iew. 2 Basic Process Steps. 3 Latent Conditions Checklist 4 Error-Likely Scenario Checklist . 6 Human Factors Tool for Existing Operations HUMAN FACTORS CONSIDERATIONS FOR EXISTING OPERATIONS Introduction Much of the existing human factors tools and guidance that is available today is intended prima
9、rily for incorporating human factors into initial plant design. The focus of this tool is on incorporating human factors considerations into existing equipment and tasks and requires little to no training to use. Human factors can be defined in many ways. The one that best de-mystifies human factors
10、 is the one coined by Dennis Attwood of RRS Engineering: “Human factors is about making it easy for people to do things right and hard for them to do things wrong.” In reference to the following model, human factors can be addressed initially with a focus on equipment and management systems (where l
11、atent conditions can be found) and people (error-likely scenarios). Incidents often occur when human action combines with a latent condition. Latent conditions can be defined as existing conditions that may lie unrecognized until combining with a human action to result in an incident. Examples inclu
12、de a failed process alarm or action, or inadequate labeling. Error-likely scenarios can be found in tasks or procedures that inadvertently incorporate the potential for human error. In other words, error-likely scenarios make it easy for someone to do something wrong. Refer to the checklist at the e
13、nd of this tool for examples of scenarios and latent conditions. API has adapted the Oil for example: Normal operations Start-up Shutdown Emergency procedures Special/abnormal operations/procedures Maintenance activities/procedures. If this activity is being conducted in conjunction with a PHA reval
14、idation, and if the revalidation has already been organized into sections, consider organizing this effort similarly. 5. For each section, brainstorm human error-likely scenarios and latent conditions that present a concern. Error-likely scenarios are those tasks where it is easy for someone to do s
15、omething wrong. Latent conditions are field traps waiting to combine with a human error to cause an incident. Questions to discuss during the brainstorming include: Have there been any near misses or incidents related to human error? How could human error cause an incident or unsafe condition? How c
16、ould human error prevent the proper corrective action in response to an event? n inished brainstorming, review the checklist at the end of this report to complete the Whe fntify brainstorming process. NOTE: DO NOT use the checklist during the brainstorming session as this likely would filter the rev
17、iew teams thought process. Allow the team to brainstorm first and then use the checklist to ideany scenarios the team may have overlooked. If necessary, consider touring the field locations on the list of concerns. 6. Utilize the What-If/Checklist methodology to analyze all concerns identified. Anal
18、yze for potential consequences, identify safeguards, risk-rank the cause-consequence scenario, and develop recommendations for elimination or mitigation of the hazards. 3 HUMAN FACTORS IN NEW FACILITY DESIGN TOOL LATENT CONDITIONS CHECKLIST Plant & Equipment 1. Are there areas of the process unit or
19、 key manifolds that are not labeled? 2. Are there areas with conflicting labels? 3. Are there labels that are incorrect? 4. Is there any equipment that often does not work as designed? 5. Is spare equipment tested and reliable? 6. Is there poor accessibility to any equipment? 7. How frequently is th
20、is equipment used? 8. Is the equipment expected to be operational during an emergency? 9. Are there any hazards associated with how equipment is guarded or how safety equipment has been installed? 10. Are any alarms disabled, bypassed or otherwise out of service? 11. Are alarms and shutdowns being t
21、ested routinely? 12. Is there a process for monitoring out-of-service alarms and returning them to service? 13. Are any existing equipment or process variable monitoring devices not easily visible? 14. Are control room or field control panels laid out in a manner that may cause confusion? 15. Are th
22、ere any process variable readouts that are inconsistent or that require the reader to convert readout into useable information such as direct PSIG reading vs. percentage of meter range output? 16. Does poor housekeeping present any hazards? 17. Are there any leaks? 18. Are clamps or any other leak r
23、epairs tracked? 19. Is there any staging or scaffolding that is not being used? 20. Is any equipment isolated or scheduled to be placed back into operation? 21. Is emergency equipment easily identifiable? 22. Is safety equipment inspected and tested periodically? 23. Are PSVs/PRDs bench-tested on a
24、periodic cycle appropriate to their criticality? Work Environment 24. Are there any work locations in which the lighting is insufficient? 25. Are there any work locations in which the noise is excessive? 26. Are there any work locations in which the ambient temperature is expected to be too high or
25、too low? 27. Are there any stresses consistently present that need to be addressed? 4 HUMAN FACTORS IN NEW FACILITY DESIGN TOOL 28. Are there opportunities to improve communications under normal and emergency operating conditions? 29. Do identified problems get corrected in a timely manner? Work Met
26、hod 30. Are people required to follow procedures? 31. Are routine duties well-defined? 32. Are there any shortcomings in the training program for becoming a qualified operator on this unit? 33. Are difficult, complex or high-risk tasks performed without the benefit of job aids or procedures? 34. Are
27、 there any procedures that are not accurate? 35. Are procedures accessible? 36. Are emergency procedures clear and easily accessible? 37. Have the proper tools been provided to accomplish assigned tasks? 38. Can task requirements be modified to eliminate or minimize hazards? 39. Do work permit proce
28、sses ensure the safety of non-routine maintenance, inspection and operating tasks? 40. Has a job safety/hazard analysis step been incorporated into task requirements? 41. Are there any shortcomings in the shift turnover communications? 42. Is out-of-service equipment identified? 43. Are you expected
29、 to perform any higher hazard tasks during 12-6 AM time slot? 44. What are these tasks and can the times the tasks are performed be changed? 45. Are there any obstacles to effective troubleshooting? Hazardous Materials 46. Are there any potential exposures to hazardous materials that can be avoided
30、or better mitigated? 47. Is the appropriate personal protective equipment provided when working in and around hazardous materials? 48. Is the environment at risk from potentially hazardous materials? Support Organization 49. Are there any opportunities to improve how process related information is p
31、resented? 50. Have the appropriate cues for human action been incorporated (such as alarms, warnings and cautions in procedures, etc.)? 51. Is the status of maintenance activities known and monitored? 5 HUMAN FACTORS IN NEW FACILITY DESIGN TOOL ERROR-LIKELY SCENARIOS CHECKLIST QUESTIONS EXAMPLESUnin
32、tended Slips of Attention/Lapses of Memory 1. Can human error cause an incident? Can wrong set points be entered into the control system that drive the variable out of range causing an upset? 2. Can human error prevent the proper corrective actions from being taken in response to an event? The contr
33、ol operator notices that the rundown temperature to tankage is getting higher and asks the field operator to take a fan off. This request is repeated several times until the control operator realizes they need to be adding fans instead of taking them off-line. 3. Is there an opportunity to minimize
34、the impact of or recover from a human error? The control operator has been asked to ramp up the feed rate to a large process unit. She intends to input 500 bph, but mistakenly inputs 5000 bph. The computer rejects her input and asks for verification because 5000 is outside of the acceptable input ra
35、nge. 4. Can a persons attention be distracted by some type of intrusion during the execution of the step? For example, a second person initiates conversation, or an alarm or external event shifts the persons focus off the task at hand. 5. Can a person be distracted so that a step is overlooked or sk
36、ipped? A driver answers his cell phone while fueling the tank on his car. Upon conclusion of the phone conversation, he drives off with the hose still in the tank. 6. Can a person lose focus and reverse or mis-order task steps? A mechanic starts the engine on a vehicle, then adjusts the radio volume
37、, puts the car into gear and attempts to drive forward without releasing the emergency brake. 7. Can a person execute a step at the wrong time? An operators next task step is to gage the level in a tank containing flammable liquids after waiting 30 minutes for static to dissipate. He does not wait a
38、nd a static charge on the surface of the liquid arcs to the grounded brass plum bob causing ignition of the vapors in the vapor space. 8. Can a person forget his intended actions? An operator turns air coolers off as the temperature of the stock increases. 6 HUMAN FACTORS IN NEW FACILITY DESIGN TOOL
39、 QUESTIONS EXAMPLES9. Can procedural steps be skipped during the restart of equipment after an emergency/ unplanned shutdown (while still hot)? A false trip activates (closes) the chopper valve on the fuel gas to a furnace/fired heater. During the restart, the operators do not communicate clearly an
40、d the fuel gas is not manually isolated either on the header or at the individual burners. The chopper valve is reset (opened), which prematurely introduces fuel gas into the hot fire box, causing an explosion. Mistakes 10. Can a person not have enough expertise to know what to do next? A new hire i
41、s observing for the first time an experienced operator drawing an LPG sample in a sample bomb. The more experienced operator gets called away and turns the incomplete task over to the new hire. 11. Is the procedure deficient in making sure that it is easy for someone to things right and hard for the
42、m to do it wrong? The procedure includes a cautionary statement about potential hazards associated with the performance of the step, but the cautionary statement appears on the next page, AFTER the step instructions. 12. Can wrong equipment be used? Wrong valves turned or wrong pump shutdown in an e
43、mergency. Intended Violations 13. Can a person elect to not follow a procedure for any reason without penalty? Even though labeling has been posted and procedures prohibit bicycle riding in the warehouse, everyone does ride in the warehouse including the warehouse supervisor. 14. Can a person receiv
44、e any unexpected and unknown assistance from an unlikely source causing a step to be executed improperly? A supervisor sees an alarm flashing and silences it without alerting the board operator. 15. Can an act of sabotage be committed? A spring loaded (dead man) lube oil reservoir charge valve is wi
45、red open and the operator fails to return in time to shut it off causing the reservoir to overfill and spill. General 16. Are there any problems with the persons capabilities in completing task/action? A new hire is only 5 0” tall, yet the valve wheel she needs to operate is located 7 6” above grade
46、. 17. Are the job aids adequate (including training)? Local labels at a manifold are hand-written and contain errors. 7 HUMAN FACTORS IN NEW FACILITY DESIGN TOOL QUESTIONS EXAMPLES18. Are the persons workload/time pressures excessive and therefore prevent adequate attention to the task? Do the two t
47、erminal employees on duty have multiple high priority tasks that compete for their time and attention, such as controlling the loading racks operation, taking a pipeline receipt, and overseeing one lockout/tagout job and one hot work permit, while also trying to talk to a salesman? 19. Have all pote
48、ntial reasons for making a conscious or sub-conscious decision to err been eliminated or addressed: procedures are up-to-date and trusted individuals value procedures use of shortcuts has been discouraged employees know the consequences of NOT following procedures critical tasks are not performed during periods of lower alertness Have Managements expectations for the use of procedures been clearly communicated, enforced and audited? Are procedures up-to-date and considered valuable? 8
