Real Pipeline Controllers Tell How Dirty Dozen Affected Them

We perform assessments of pipeline control rooms from a human performance perspective.  The Dirty Dozen causes of errors and accidents are easily understood by people in hazardous industries.  I asked some pipeline controllers to tell me if any of the Dirty Dozen had affected them and/or caused an error, mistake, or near miss.  Some of what they said might apply to you

• Complacency:  On a day when not much was happening, I became complacent and created a near miss situation.
• Distractions: Phone calls and people talking in the control room have caused near misses.
• Lack of Knowledge:  I made an error and contaminated product when I did not completely understand a new procedure.
• Lack of Communication:  Communication at shift turnover was not sufficient and caused several near misses.
• Stress:   Stress from outside sources, such as my divorce and a death in my family, affected my job performance.
• Lack of Awareness and Complacency:  I had delivered four batches of #2 fuel oil into one terminal and the next batch of #1 fuel oil was to go to another terminal.  The first terminal was VU and the second terminal was VS.  The batch codes on the schedule looked very similar.  The #1 fuel oil batch was downgraded.
• Lack of Communication:  Information about an out of service valve was not provided at shift change.  I found out when I tried to use the valve.
• Fatigue:  I have less attention between 0300 and 0400 if things are not very busy.
• Pressure: A problem on one line segment caused me to miss an important task on another line segment.
• Lack of Awareness: I was taking allergy medication, which affected my reasoning, I think.  After I opened the wrong valve, I stopped using that medication.
• Distractions:  A phone call, just before a critical batch cut, almost caused me to miss the cut.  I learned to let the phone ring when something critical is imminent.

Posted October 23rd, 2010 in Dirty Dozen Articles, Human Factors

“Someone Somewhere Sees IT Coming”

IT is problems. Have you ever read Managing the Unexpected?   If you work in a hazardous industry, it should be required reading.  Karl Weick and Kathleen Sutcliffe state, on page 74, that “with every problem, someone somewhere sees it coming.”  Think about what people say after a problem, an accident, an error occurs. “I knew that was going to happen.”  If we suspect something is going to happen, why don’t we do something to prevent it from happening?

Weick and Sutcliffe say that the people who know “tend to be low rank, invisible, unauthorized, reluctant to speak up, and may not even know that they know something that is consequential.”  Does that describe you?

I have participated in hundreds of incident analysis and lessons learned sessions. Most could have been prevented with simple steps.  Almost always, a near miss had occurred before the incident, but was not reported or the cause wasn’t addressed.  A corrective action from a near miss will prevent an accident.  Organizations, even those who perform incident analysis, may not develop good corrective actions.   Our memories are short, and the pace of work seldom lessens till it comes to a screeching halt with an accident.

Speak up about problems, report near misses, correct hazards before they hurt you or others.  Do not be afraid to stop work if it is unsafe.

Posted October 19th, 2010 in Human Factors, Leadership, Observations, Operational Excellence

Empowering a Team, or a Group of People

I did some communications training last week for several groups of pipeliners.  These people are grouped into teams, but not all are on the field at the same time.  In some ways, they are individuals with specific skills, specialized knowledge, and mostly self-directed in their work.

Each person does need to speak up, be assertive, and give and receive feedback to one another.  Some had not been doing that well or at all.  It made me think about a book I read years ago:  Empowerment for High-Performing Organizations, by Bill Guillory and Linda Galindo.

The book contained some tips for empowering a team.  They work with teams, groups of individuals, and individuals.  But it requires intentional effort, and the process is painful to implement.  It is worth the effort and the pain.

1. The team is principally self-directed(even if they don’t want to be).
2. Individuals are expected to perform excellently in an interdependent network.(it’s hard for people to see the interdependence).
   
3. Personal responsibility, accountability, and authority are clearly defined.(easy to define, difficult to accept)
   
4. There are codes of conduct that govern expected team and individual behavior.(easy to develop a code and post on the wall, difficult to behave according to the code)
   
5. Trust, cooperation, and participation are valued.(difficult to earn, easy to lose)
   
6. Mastery of interpersonal skills is valued.(interpersonal skills are not valued as much as technical skills)
   
7. Diversity is valued.(believe diversity is valued, but people who are different than the majority experience difficulty fitting in).
   
8. There is alignment and commitment to common purposes, strategies, objectives, and goals.(this is difficult to define and to develop, but works when communicated well).

Posted October 19th, 2010 in Human Factors, Leadership, Operational Excellence