Table Of ContentOCCUPATIONAL HEALTH & SAFETY HUMAN ERROR
T
a in
y
l
o
PROCESS PLANT
r
DESIGN
and
HUMAN ERROR PROCESS PLANT
in
OPERATIONS
DESIGN OPERATIONS
and
In contrast to nuclear plants and aerospace systems, human error is largely
A Practitioner’s Guide
ignored in quantitative risk assessment for petroleum and chemical plants.
Because of this, current risk analysis methods are able to calculate and predict
only about one-third of the accidents happening in practice. Human Error in
J. Robert Taylor
Process Plant Design and Operations: A Practitioner’s Guide shows you DH
how to develop a comprehensive risk assessment that includes human error. EU
Based on the well-known SRK model of human error, this book represents SM
a practical collection of examples and statistics from more than 30 years of IGA
study, with many examples of the practical application of methods. N
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The book provides a complete overview of the various types of human E
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error, including operator error, hindrances and inability to function, errors in n R
d R
observation, errors in performing standard procedures, errors in supervisory
control, errors in decision making and planning, infractions and violations, OO
design errors, and errors in procedures. It then goes on to identify human error PR
E
potential and probabilities, and discusses techniques and methodologies that i
n
R
can be implemented to minimize human errors and prevent accidents.
AP
The result of the author’s observations of human error over a lifetime of work as TR
I
an operator, as a commissioning coordinator, and as an operations manager, OO
the book demonstrates how to analyse, manage, and mitigate many types of NC
error. By taking advantage of the author’s experience and expert knowledge, SE
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and by applying the techniques and methodologies illustrated in this book, you
S
will be able to make changes which will make work easier, error free, clearly
understood, and more congenial. P
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HUMAN ERROR
in
PROCESS PLANT
DESIGN
and
OPERATIONS
A Practitioner’s Guide
HUMAN ERROR
in
PROCESS PLANT
DESIGN
and
OPERATIONS
A Practitioner’s Guide
J. Robert Taylor
Boca Raton London New York
CRC Press is an imprint of the
Taylor & Francis Group, an informa business
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2016 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20150529
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For Hanne Schøler Taylor, companion, friend,
scribe, editor, gentle critic and wife through
many years and many adventures
Contents
Preface......................................................................................................................xv
Acknowledgements .................................................................................................xix
About the Author ....................................................................................................xxi
Acronyms .............................................................................................................xxiii
Chapter 1 Introduction ..........................................................................................1
What Is Human Error? .........................................................................1
Can Errors Be Predicted? .....................................................................4
The Importance of Operator and Maintenance Error ..........................5
Complex Systems Theory ....................................................................7
Pushing the Limits ...............................................................................9
Slips, Lapses, Mistakes and Violations ..............................................10
Assessing the Probability of Operator Errors ....................................11
The Need for an Interdisciplinary Approach .....................................13
What Should We Do about Error Potential? ......................................13
Data Collection for This Book ...........................................................15
References ..........................................................................................16
Chapter 2 Models of Operator Error ...................................................................17
The Skills–Rules–Knowledge Model ................................................19
Skill-Based Activities .........................................................................21
Rule-Based Activities .........................................................................21
Knowledge-Based Processing ............................................................22
Status of the Skills–Rules–Knowledge Model ...................................22
Using the Model .................................................................................23
References ..........................................................................................23
Chapter 3 Hindrances and Inability to Function ................................................25
Operator Absence ...............................................................................25
Error-Reduction Measures for Absence from Work Location ......26
Hindrance ...........................................................................................26
Incapacitation .....................................................................................27
Error-Reduction Measures for Incapacitation ...............................27
Distraction ..........................................................................................27
Error-Reduction Measures for Distraction ....................................28
Attention Failure ................................................................................28
Error-Reduction Measures for Attention Failure...........................29
Overload and Priorities.......................................................................29
Error-Reduction Measures for Overload .......................................29
vii
viii Contents
Priority Error and Focus Error ...........................................................30
References ..........................................................................................30
Chapter 4 Errors in Observation .........................................................................31
Potential Operational Input Overlooked ............................................31
Complex or Unrecognisable Input ......................................................31
Error-Reduction Measures .............................................................32
Ambiguity and Misleading Signals ....................................................32
Mislearning ........................................................................................33
Failures of Instruments and Alarms ...................................................34
References ..........................................................................................34
Chapter 5 Errors in Performing Standard Procedures: Rule-Based Operation ...35
The Process of Rule-Based Operation ...............................................35
What Is a Procedure? .........................................................................38
Thought Processes in Procedure Execution .......................................38
Error Modes in Carrying Out Procedures ..........................................40
Causes of Errors in Carrying Out Procedures—Following Cues ......41
Causes of Errors in Carrying Out Procedures—Omission ................42
Errors in Procedure Execution—Wrong Procedure ...........................44
Errors in Procedure Execution—Too Much or Too Little ..................47
Errors in Procedure Execution—Too Long or Too Short Duration ...48
Errors in Action Performance ............................................................48
Risk-Reduction Measures for Errors in Executing Procedures .....50
References ..........................................................................................50
Chapter 6 Operator Error in the Field .................................................................51
Omission and Forgetting ....................................................................52
Errors in Procedure Execution—Wrong Object or Material .............53
Too Much Force..................................................................................57
References ..........................................................................................57
Chapter 7 Knowledge and Ignorance in Plant Operation ...................................59
Knowledge-Based Operation under Modern Conditions ...................61
Knowledge of Plant State ...................................................................62
Ambiguity of Input .............................................................................62
Knowledge, Belief and Judgement .....................................................63
A Little Knowledge Can Be Dangerous .............................................66
Planning New Procedures ..................................................................66
The Need for Judgements ...................................................................67
Knowledge of Plant Physics ...............................................................70
An Example of Accident Physics—Momentum ................................71
