The Elephant in the Control Room: The People Who Work 24-7-365

You’ve heard that saying about the elephant in the room, that enormous issue that few people want to acknowledge.

Pipeline control rooms in the USA have been discussing, debating, preparing, procrastinating, and thinking about a new pipeline safety regulations that require their control rooms to develop a human factors management plan by August 1, 2011.   The major concerns at the moment seem to be fatigue mitigation and alarm management.  We’ve been working with several companies on these issues this year.

Alarm management is a labor intensive task, but it is more manageable than fatigue mitigation.  Once all the alarms are documented, categorized, rationalized, and made part of a plan, the alarms do not change unless a manageable change is performed.  Alarms are not human.

Humans are the elephant in the control room.  There may be 20 controllers in a control room and I can document them, categorize them, and provide a rational basis for why we must manage fatigue.  I can develop a rigorous fatigue management plan that includes training and limits hours of work per day and per week to allow time for sleep and recovery rest through days off.   But people might not follow the plan.  Some will not follow the plan.  Anyone who is a human being knows that.

If I want to manage or lessen the risks of a fatigue related pipeline accident, I will take a risk based approach.  For my particular control room, I will identify the potential hazards, figure the consequences and probabilities, and develop preventative measures that include several layers of protection.  I will not rely solely  on training, policies, and procedures.  that is not wise.

I will make a presentation on this subject at the American Petroleum Institute Control Room Forum  November 18, 2010.  Please see below.

There’s an Elephant in the Control Room

Posted November 14th, 2010 in Human Factors, Managing Fatigue, Observations, Operational Excellence

“Push Start” on Gas Pump; I couldn’t find “Start”

The instructions on the gas pump LCD were simple to read:  1) Remove Nozzle; 2)  Push Start;  3)Pump Gas.   I could perform numbers one and three easily.   I could not find “Start,” and I do not think I was the first person with that problem.   After I quit staring dumbly at the LCD screen, I looked other places.  “Start” was not near the grades of gasoline or near the nozzle.   It was located the last place I looked!  It was right underneath the second LCD screen.   Notice that an employee of the station had relabeled it so that the customer knows to “Push Here” when the customer finds “Here.”  Do the displays where you work make it easy or difficult for the user?

Simple Instructions Hard to See

This everyday example illustrates why process control operators sometimes make mistakes in their interactions with more complex displays that do not present information in a user-friendly manner.  Use the standards and recommended practices for your industry.

Posted November 1st, 2010 in Human Factors, Observations

“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