Here are my annual ‘reflections’ from 2018. They are based on my work with clients and other things that cropped up in the year that made me think about what we are doing in process safety and human factors. As always, they are in no particular order (apart from the first one).
We passed the 30 year anniversary of this disaster. It is probably the event that has most affected my career as it highlighted so many human factors and process safety issues. I know we have a better understanding of how accidents like Piper Alpha happen and how to control the risks but it is easy for things to get forgotten over time. I wrote two papers for the anniversary edition of Loss Prevention Bulletin. One looked at the role of ‘shared isolations’ (where an isolation is used for several pieces of work). The other was concerned with shift handover, which is one area where I worry that industry has still not properly woken up to.
Control room design
One of my main activities this year has been to rewrite the EEMUA 201 guidance document on design of control rooms and human machine interfaces in the process industry. I have investigated a range of aspects of design and made a point of getting input from experienced control room operators, control room designs, ergonomists and regulators. This has highlighted how important the design is for the operator to maintain the situational awareness they need to perform their job safely and efficiently; and to detect problems early to avoid escalation. This is not just about providing the right data in the right format; but also making sure the operator is healthy and alert at all times so that they can handle the data effectively. A complication is that control rooms are used by many different people who have different attributes and preferences. I found that currently available guidance did not always answer the designers’ questions or address the operators’ requirements but I hope that the new version of EEMUA 201, which will be published in 2019, will make a valuable contribution.
Arguably a bigger issue than original design is the way control rooms are maintained and modified over their lifetime. There seems to be a view that adding “just another screen” or allowing the control room to become a storage area for any paperwork and equipment that people need a home for is acceptable. The control room operator’s role is highly critical and any physical modification or change to the tasks they perform or their scope of responsibility can have a significant impact. We, quite rightly, put a lot of emphasis on designing effective control rooms and so any change needs to be assessed and managed effectively taking into account all modes of operation including non-routine and emergency situations.
Safety critical maintenance tasks
Whilst I have carried out safety critical task analysis for many operating tasks over the years it is only more recently that I have has the opportunity to do the same for maintenance tasks. This has proven to be very interesting. A key difference when compared to operations is that most maintenance tasks are performed without reference to detailed procedures and there can be almost total reliance on competence of the technicians. In reality only a small proportion of maintenance tasks are safety critical, but analysis of these invariably highlights a number of potentially significant issues.
I have written a paper titled “Maintenance of bursting disks and pressure safety valves - it’s more complicated than you think.” It will be published in the Loss Prevention Bulletin in 2019. This highlights that these devices are often our last line of defence but we have no way of testing them in situ and so have to trust they will operate when required. However, there are many errors that can occur during maintenance, transport, storage and installation that can affect their reliability.
Another example of a safety critical maintenance task is testing of safety instrumented systems. This is likely to be my next paper because it is clear to me that often the testing that takes place is not actually proving reliability of the system. Another task I have looked at this year was fitting small bore tubing. It was assumed that analysing this apparently simple task would throw up very little but again a number potential pitfalls were identified that were not immediately obvious.
Safety 2/Safety Different
I am bit bemused by this supposedly “new” approach to safety, or at least the way it is being presented. The advocates tell us that focussing on success is far better than the “traditional” approach to safety, which they claim is focussed mainly on failure (i.e. accidents). The idea is that there are far more successes than failures so more can be learnt. Also, finding out how work is actually done instead of assuming or imagining we know what really happens is another key feature of these approaches.
I fully agree that there are many benefits of looking at how people do their job successfully and learning from that. But I do not agree that this is new. It seems to me that the people promoting Safety 2/Different have adopted a particular definition of safety, which is does not in my opinion represent the full scope of what we have been doing. They suggest that safety has always been about looking at accidents and deciding how to prevent them happening again. There seems to be little or no acknowledgement of the many approaches taken in practice to manage risks. I certainly feel that I have spent most of my time in my 20+ year career understanding how people do their work, understanding the risks and working out the best way to support successful execution. And I have observed this in nearly every place I have ever worked. As an example, permit to work systems have been an integral part of the process industry for a number of decades. They encourage people to understand the tasks that are being performed, assessing the risks and deciding how the work can be carried out successfully and safely. This seems to fulfil everything that Safety 2/Different is claiming to achieve.
My current view is that Safety 2/Different is another useful tool in our safety/risk management toolbox. We should use it when it suits, but in many instances our “traditional” approaches are more effective. Overall I think the main contribution of Safety 2/Different is that it has given a label to something that we may have done more subconsciously in the past, and by doing that it can assist by prompting us to look at things a bit differently in order to see additional and/or better solutions.
Bow tie diagrams
I won’t say much about these as I covered this in last year’s Christmas email with an accompanying paper. But I am still concerned that bow tie diagrams are being oversold as an analysis technique. They offer an excellent way of visualising the way risks are managed but to do this need to be kept simple and focussed.
I had a paper published in Loss Prevention bulletin explaining how human bias can result in people have a misperception about how effective procedures can be at managing risk. This bias can affect people when investigating incidents and result in inappropriate conclusions and recommendations. The paper was provided as a free download by IChemE https://www.icheme.org/media/7205/lpb264_pg09.pdf.