Human Factors Handbook for Process Plant Operations

Table of Contents ix Glossary xxi Acronyms xxv Acknowledgements xxvii Foreword xxix Part 1: Concepts, principles, and foundational knowledge 1 1 Introduction 3 1.1 What is "Human Factors"? 3 1.2 Purpose of this handbook 4 1.3 Why Human Factors? 8 1.4 The structure of this handbook 10 2 Human performance and error 12 2.1 Learning objectives of this Chapter 12 2.2 An example of successful human performance 12 2.3 An example of unsuccessful human performance 14 2.4 Key learning points from this Chapter 18 3 Options for supporting human performance 19 3.1 Learning objective of this Chapter 19 3.2 Types of human performance 19 3.3 Types of human performance, errors and mistakes 21 3.4 Selecting options for supporting human performance 30 3.5 Key learning points from this Chapter 34 4 Supporting human capabilities 35 4.1 Learning objectives of this Chapter 35 4.2 Attention 35 4.3 Vigilance 36 4.4 Memory 37 4.5 Cognitive capacity 38 4.6 Cognitive heuristics/biases 39 Part 2: Procedures and job aids 43 5 Human performance and job aids 45 5.1 Learning objectives of this Chapter 45 5.2 An example of a major accident 45 5.3 The role of job aids in supporting human performance 46 5.4 Approach to developing effective job aids 48 5.5 Key learning from this Chapter 51 6 Selecting a type of job aid 53 6.1 Learning objectives of this Chapter 53 6.2 Stage 1: Determining the need for a job aid 53 6.3 Stage 2: Selecting the type of job aid 62 6.4 Electronic job aids 67 6.5 Key learning from this Chapter 68 7 Developing content of a job aid 69 7.1 Learning objectives of this Chapter 69 7.2 Outputs from task analysis 69 7.3 Outputs from Hazard Identification and Risk Analysis 72 7.4 User involvement 73 7.5 Validation of job aids 75 7.6 Keeping job aids up to date 75 7.7 Key learning from this Chapter 76 8 Format and design of job aids 77 8.1 Learning objectives of this Chapter 77 8.2 Structure and layout 77 8.3 Navigation 82 8.4 Instructional Language 84 8.5 Pictorial information 88 8.6 Icons 89 8.7 Key learning from this Chapter 91 Part 3: Equipment 93 9 Human Factors in equipment design 95 9.1 Learning objectives of this Chapter 95 9.2 Definitions 95 9.3 Major accident example 96 9.4 Error traps 99 9.5 How might poor equipment Human Factors cause error? 100 9.6 Example of poor equipment Human Factors 103 9.7 Supporting human performance by good equipment design 105 9.8 Mitigating poor design 113 9.9 Key learning from this Chapter 115 Part 4: Operational competence 117 10 Human performance and operational competency 119 10.1 Learning objectives of this Chapter 119 10.2 What is competency? 119 10.3 Competency Management 120 10.4 An example of effective Process Safety Competency Management 123 10.5 An example of gaps in operational competency 124 10.6 Competency influencing factors 126 10.7 Key learning points from this Chapter 127 11 Determining operational competency requirements 129 11.1 Learning objectives of this Chapter 129 11.2 Identify and define safety critical competency: overview 129 11.3 Step 1: Identify safety critical tasks 130 11.4 Step 2: Identify required competency 133 11.5 Step 3: Define performance standards 135 11.6 Key learning points from this Chapter 140 12 Identifying learning requirements 141 12.1 Learning objectives of this Chapter 141 12.2 Competency gap analysis 141 12.3 Training Needs Analysis 142 12.4 Key learning points from this Chapter 146 13 Operational competency development 147 13.1 Learning objectives of this Chapter 147 13.2 Good practice in learning 147 13.3 Key learning points from this Chapter 154 14 Operational competency assessment 155 14.1 Learning objectives of this Chapter 155 14.2 Reasons for competency assessment 155 14.3 How to conduct assessment of competency 155 14.4 Reassessment 161 14.5 Managing competency gaps 162 14.6 Competency and learning records 164 14.7 Key learning points from this Chapter 165 Part 5: Task support 167 15 Fatigue and staffing levels 169 15.1 Learning objectives of this Chapter 169 15.2 A fatigue-related accident 169 15.3 Managing fatigue risk 174 15.4 Key learning from this Chapter 184 16 Task planning and error assessment 185 16.1 Learning objectives of this Chapter 185 16.2 Incident example 185 16.3 Human Factors and task planning 186 16.4 Error assessment within task planning 187 16.5 Key learning from this Chapter 193 17 Error management in task planning, preparation and control 195 17.1 Learning objectives of this Chapter 195 17.2 Overview 195 17.3 Preventing optimism bias in task planning: scheduling 196 17.4 Assigning safety critical tasks 200 17.5 Distractions and interruptions 202 17.6 Long and low demand tasks 206 17.7 The Human Factors of control of work packages 209 17.8 Team briefings 211 17.9 Human Factors of system isolation 212 17.10 Human Factors of managing interlocks and automatic trips . 218 17.11 Key learning from this Chapter 223 18 Capturing, challenging and correcting operational error 225 18.1 Learning objectives of this Chapter 225 18.2 Failing to spot, challenge, and recover from errors 225 18.3 Why might we fail to capture, challenge, and correct errors? 227 18.4 Coaching people to recognize risk of making errors 229 18.5 Error Management Training 231 18.6 Enabling challenge of task performance 235 18.7 Key learning from this Chapter 243 19 Communicating information and instructions 245 19.1 Learning objectives of this Chapter 245 19.2 Incident example 245 19.3 Causes of poor communication 246 19.4 Human Factors of communications 247 19.5 Avoiding communication overload 250 19.6 Human Factors in shift handover 253 19.7 Key learning from this Chapter 258 Part 6: Non-technical skills 259 20 Situation awareness and agile thinking 261 20.1 Learning objectives of this Chapter 261 20.2 What are situation awareness and agile thinking? 261 20.3 Accidents from poor situation awareness and rigid thinking. 264 20.4 Causes of poor situation awareness and rigid thinking 265 20.5 Key learning from this Chapter 269 21 Fostering situation awareness and agile thinking 271 21.1 Learning objectives of this Chapter 271 21.2 Training in situation awareness skills 271 21.3 Practical situation awareness tools and tactics 277 21.4 Recognizing loss of situation awareness 283 21.5 Fostering agile decision-making 285 21.6 Key learning from this Chapter 290 22 Human Factors in emergencies 291 22.1 Learning objectives of this Chapter 291 22.2 An example accident 291 22.3 Supporting human performance in emergencies 295 22.4 Non-technical skills for emergency response 298 22.5 Key learning from this Chapter 314 Part 7: Working with contractors and managing change 315 23 Working with contractors 317 23.1 Learning objectives of this Chapter 317 23.2 An accident involving contractors 317 23.3 Human Factors tactics for supporting contractors 320 23.4 Key learning from this Chapter 323 24 Human Factors of operational level change 325 24.1 Learning objectives of this Chapter 325 24.2 What do we mean by operational level change? 325 24.3 Operational level change and major accidents 326 24.4 Recognizing operational level changes that impact human performance 327 24.5 Managing Human Factors of changes 330 24.6 Key learning from this Chapter 333 Part 8: Recognizing and learning from performance 335 25 Indicators of human performance 337 25.1 Learning objectives of this Chapter 337 25.2 What are performance indicators? 337 25.3 Identifying human performance indicators 339 25.4 Examples of human performance indicators 340 25.5 Sharing and acting on human performance indicators 349 25.6 Key learning from this Chapter 350 26 Learning from error and human performance 351 26.1 Learning objectives of this Chapter 351 26.2 The importance of understanding error 352 26.3 Examples of poor learning 354 26.4 Learning in high performing teams 356 26.5 Human Factors of investigating process 357 26.6 Selecting preventative Human Factors actions 372 26.7 Learning 375 26.8 Key learning from this Chapter 378 27 References 379 Index 453 Appendices A Human error concepts 391 B Major accident case studies 401 C Human Factors Competency Matrix 415 D Competency performance standards 429 E Learning methods and performance 435 F Situation awareness and behavioral markers 441 G Human Factors change checklist 447

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