Dirty Dozen Causes of Errors – Lack of Teamwork

Two months are left in 2010.  I’m sure the next two months will be hectic and hurried as you and the teams complete necessary 2010 work, and enjoy holidays.   I always found it important to remind the employees that control and operate and maintain the pipelines to remember their own personal safety and the safety of the public while completing the necessary projects in the midst of vacations and other holiday events.

Those are reasons I made “lack of teamwork” the November emphasis.  Please distribute it to your team and to customers and to field operations who might benefit from the article.  Please download the article.   Lack of Teamwork

Posted November 3rd, 2010 in Dirty Dozen Articles, Human Factors, Leadership

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

Dirty Dozen Cause of Errors: Lack of Resources

This month’s article mentions “sensemaking” as a resource in an organization. Recent statements by PHMSA, Congress , and the NTSB about some 2010 leaks, spills, and explosions indicate that they want to determine whether or not the decisions and responses of pipeline companies is making sense or not. Pipeliners do not want leaks or spills or explosions, and this shapes our thinking in unusual situations. That’s why a conservative, disciplined operations philosophy and abnormal/emergency procedures are necessary resources that should be used.

Please read the article: Lack of Resources-Color

Posted October 19th, 2010 in Dirty Dozen Articles