Monday, January 29, 2007

Error detection

Ergonomics journal April 2006

'Error detection: a study in anesthesia' A Nyssen and A Blavier

Accident reporting system developed and used to collect information about error detection patterns. A significant relationship was found between the type of error and and error detection mode, and between the type of error and the level of training of the anesthetist who committed the error.

It is not possible to prevent every error, so reducing their consequences is important, which requires detection. This has not been studied much, and the most of the studies have been on simple tasks in laboratory settings.

Six modes of detection were identified
1. Standard check (routine monitoring of the environment)
2. Recognising outcome signs
3. Suspicion from knowledge
4. Interpolation (by someone else, not person who committed error)
5. Alarm sounds
6. By chance

Standard checks were found to be most prominent. This suggests checking has become part of the routine activity and because it is non-specific it enables to staff to pick up many different types of error. It was found that the risk associated with the operation made little difference to the detection strategies employed.

More experienced staff become better at detecting a wider range of error types. It is suggested this is because they have more control over what they are doing and so can do more diverse things. This is like an experience musician being able to improvise more.

The authors suggest the findings from this study could have significant implications for safety. At present when errors occur in complex systems the tendency is to increase policies and procedures, which restrict actions and reduce opportunities to action options. This does not reduce the complexity of the system, but may reduce the opportunities people have to detect errors. Therefore, it may be better to concentrate on improving experience in order to increase the likelihood of error detection, rather than restricting activities with more procedures.

, followed by recognising signs and alarm.

Error recovery

Ergonomics journal April 2006

'Error recovery in a hospital pharmacy' L Kanse, TW van der Schaaf, ND Vrijland and H van Mierlo

Field study involving confidential reports and follow up interviews on near miss incident where recovery had occurred.

Near misses have the same underlying failure factors as accidents. Sometimes by coincidence but more often by timely detection harm is avoided. Understanding recovery factors offers a way of improving safety in addition to preventing errors in the first place. This is achieved by introducing system characteristics that build in or strengthen opportunities for recovery.

Recovery involves detection followed by a combination of explanation of the causes and putting in countermeasures aimed at returning to normal or at least limiting the consequences.

Although there have only been limited studies they have shown that personal related factors such as experience and knowledge are important in recovery. But also technical factors such as the design of the workplace and equipment interfaces. As well as organisational factors such as culture, work design, procedures and management priorities. In fact the organisational factors may be the most important because they determine the context in which people work and hence are likely to affect other factors.

Planned and unplanned recoveries. Planned involve the activation of in built barriers, such automatic safety controls or procedures that are implemented under certain conditions. Unplanned recovery is more ad hoc and depend on creative problem solving capabilities of the people involved.

The factors that influence planned vs unplanned are likely to be quite different.

Looking at pharmacy errors the study found that procedural checks had started to lapse because people had perceived that so many checks were being carried out that it was too much, and people had become less aware of their importance. Other factors that influenced lack of recovery included management priorities, shortcomings or lack of procedures, insufficient transfer of knowledge and information, technical failures, factors related to the design of computer systems used for medication preparation. With shortcomings or lack of procedures being the most.

On the positive side a lot of the recovery were made by nursing staff, and not the pharmacy staff who made the error. This was down to procedural checks and in some cases where the knowledge of the staff realised something was wrong.

To improve recovery it is important that management make sure everyone understands how important procedural checks are. Near miss reporting systems is a useful way of demonstrating this.

Clearly, there are opportunities to improve procedures. Also, the computer system that could better help detect conflicts in data. Where the severity of errors is great, having double or even triple procedural checks is important, but as not all are forseeable employees must also have the knowledge to detect and recover from problems without the support of procedures. Special training may be needed using problem scenarios inspired by reported near misses to maintain everyones creative problem solving skills.

Andy Brazier

Executive's attitudes to their staff

Article in The Observer 28 January 2007

'What sort of boss gives a monkey's about his staff?' by Simon Caulkin

Survey by management consultancy Hudson found that three-quarters of senior executives would do an annual cull of their workforce to boost productivity and performance (although only 4% actually do this). One sixth think they could get rid of 20% without any damage to performance or morale; and nearly half think firing up to 5% of staff would be a good thing.

Another study by the Chartered Institute of Personnel and Development found 38% of employees feel senior managers and directors treat them with respect and 66% don't trust them. About a quarter of employees rarely or never look forward to going to work, and almost half are leaving or trying to. It is like 'a marriage under stress, characterised by poor communications and low levels of trust.'

Another study by Gallup finds poor management means workers become more disaffected the longer they are in a job so that 'human assets tha6t should increase in value with training and development instead depreciate as companies fail to maximise this investment.'

Some companies (GE and Microsoft) regularly rank staff performance with an eye to getting rid of the poor staff, but there is no evidence this works. This approach suggests that team performance is simply a sum of the parts, but this is rarely the case.

Sometimes companies do need to get rid of people, particularly if they have been incompetently recruited. However, if this a routine it creates fear and unhealthy competition. An example is quote from US nursing. Units with the most 'talented' nurses and an attitude that heads will roll if people make mistakes tend not to learn because errors are covered by and not reported. However, teams that are more able to all work together report more mistakes do learn and are actually safer.

This article is particularly interesting when some of my more recent posts to this blog concerning errors when working under stress and poor morale are considered.
See previous and previous

Andy Brazier

Friday, January 26, 2007

Capturing psychological mechanisms in error reports

Ergonomics journal April 2006

'From cognition to the system: developing a multilevel taxonomy of patient safety in general practice.' O Kostopoulou

In developing a taxonomy the author has raised a few interesting issues.

If a GP does not prescribe necessary medication for a patient it could be seen as his/her error or failure. But it may be that he could not read the handwritten request from the hospital so there is an external cause and performance shaping factors, but no psychological mechanism or immediate internal causes.

Suggested that it would be better to replace the terms 'error' and 'failure' with the term 'action' as this would be more constructive and blame free.

Other taxonomies, such as those based on the slips, lapses, mistakes framework can only be used to classify errors.

Fear of blame, particularly in the medical industry can severely reduce the likelihood of talking about and learning from patient safety events. Certainly where terms such as 'carelessness' or 'thoughtlessness' are included in a taxonomy. This can also be the case where classifications are allocated either to systems or humans, which can reinforce the blame culture by concentrating attention on the error producing human as distinct from the error inducing system.

Performance shaping factors are likely to change as policies, systems and technologies change. For example introducing an electronic prescription system will eliminate handwriting issues but introduce new opportunities for error, such as selecting the wrong item from an alphabetical list of medicines.

The study highlights the importance of identifying the psychological mechanism that led to an error. This requires an understanding of the cognitive basis of behaviour. In many cases reporting systems do not capture that sort of information and it will not be obtained unless incidents are followed up very quickly. The idea of the taxonomy is to capture that information.

Andy Brazier

Effects of stress and job control on errors

Ergonomics journal April 2006

'Work stress and patient safety: Observer-rated work stressors as predictors of characteristics of safety-related events reported by young nurses.' A Elfering, NK Semmer and S Grebner

Study used self-reporting and observation. Found the most frequent safety related stressful events included incomplete or incorrect documentation (40%), medication errors near misses (21%), delays in delivery of patient care (9.7%), violent patients (9.7%).

Familiarity of events and probability of occurrence was seemingly predicted by job stresses and low job control. These were shown to be risk factors for patient safety.

The results suggest that jobs should be redesigned to enhance job control and decrease stress. These interventions may be effective at improving patient safety.

Found that safety related events related to stresses, most notably onto concentration demands and lack of control. In other words people working under high demands and low control are more likely to have safety events. This is explained that secondary tasks such as second checking and documenting may not be tended to as well as they should. Also, stress can result in less competent social behaviour which may affect the behaviour of patients.

The relationship between work demands and patient safety need to be better understood so that nurses can be educated in self-management strategies for stressful situations.

Andy Brazier

Influence of stress and morale in medication errors and violations

Ergonomics journal April 2006

'Patient safety dring medication administration: the influence of organisational and individual variables on unsafe work practices and medication errors.' GJ Fogarty and M McKeon.

Used structural equation modelling to measure organisational climate to see how it affected unsafe medication administration behaviours including the role of stress and morale.

As in other high risk industries failure to follow procedures is a major contributor to medication errors with over half being due to violations. People who violate procedures are 1.4 times as likely to commit other types of errors (note - this study seems to have included violations as a type of error). The size of this influence and the suggestion that the psychological pathways to violations and errors are different has led people to say that they should be treated as different safety outcomes.

Violations are typically associated with attitude and behaviours whilst errors are associated with deficiencies in skill and information processing.

Another significant difference is that violations are intentional so that people know they are committing them whereas errors are unintentional so people do not always know they have made them. This means that people can self report violations and that may be a way of learning more about the organisation.

The study used self-reporting of perceptions of the organisation and of violations and errors.

Violations are intentional actions but not intended to do harm. This study has shown that violations are most likely when the individual is distressed and morale is low; and that these individual states are influenced by organisational climate.

It is proposed that more frequent monitoring of organisational and safety climate, and individual stress and morale will help in preventing violations.

Andy Brazier

Work courses 'wasting £75m'

Article in Sunday Times 21 January 2007 by Roger Eglin

Kaisen (business psychologists) has completed research into the benefits of development courses aimed at business leaders and concluded they are largely valueless. This was because most courses focused on educating through providing useful concepts and theories, whereas what was needed was skills such as how to act and behave, how to be more assertive and motivate people.

Learning behavioural skills requires practice in the workplace. Going on a course is like trying to learn to ski in a hotel by watching videos and reading course material.

Even the practical elements of courses were of little value because people were usually paired off, which given that all were there to learn meant inexperienced people were coaching each other. Also, courses emphasised self-awareness, which has its uses for the individual but does not help them understand their colleagues.

One-to-one coaching is probably much better than sending leaders on courses.

Andy Brazier

Tuesday, January 23, 2007

Glasgow accident analysis group

Looks like a lot of potentially useful information available at

Also, they have a conference in March 2007. Details and some of the papers at

Nissan improves safety

Article at

'Focus on safety begins to pay off for Nissan' by Erin Edgemon. This is interesting as it sounds like the programme being followed is most concerned with hazardous conditions, rather than behaviors.

Nissan North America decreased its reportable injuries at its manufacturing plants by nearly 72 percent from 2000 to 2005.

2000 Nissan North America had a recordable injury rate of 31.4 meaning that 31.4 out of every 100 people had an injury that required more than first aid treatment during the year. By 2005 that rate dropped to 8.9. Over the same time lost work time rate dropped from 6.3 to 1.6.

Nissan's safety program works because it gets everyone from top-level management to production technicians on the manufacturing floor involved. Nissan benchmarked other companies including receiving consultations from Dupont, which is known for its world-class safety program. It spent millions of dollars to improve safety in its plants from purchasing mats for technicians to stand on to installing lift assists and robots to do more physically demanding jobs.

“The intent of it was to enhance our safety program to become world class,” said Greg Daniels, senior vice president of Nissan’s U.S. manufacturing of the program. “We wanted our employees to come to work and leave the same way. It was critical to us.”

In order to make the program work, Daniels said employee mindset had to be changed to view safety as the first priority. Every employee is trained to spot problems and are expected to tell non-management safety committee members or management to have them corrected.

Workers inspect their work zones at least once a week. It takes a few hours to inspect for potential hazards and to talk to the employees in his area. The employees doing the inspections have the authority to fix problems or write-up work orders to have problems fixed.

Each zone on the manufacturing floor is audited for safety eight times a month due to the constantly changing environment, Dove said.

Now that Nissan has the basics perfected, more of the company’s focus has been placed on ergonomics and making the assembly of vehicles easier for employees.
"Most of our issues now are design issues," Dove said.

Andy Brazier

Wednesday, January 17, 2007

BP Baker Panel Report - Human Factors

The report identifies human factors as a key part of process safety. It also raises a number of human factors issues, which are summarised below.

For most of its incident investigations, BP uses a list of causal factors to analyze root causes. BP refers to this method as the Comprehensive List of Causes (CLC).

A list of human factors is also provided for use in conjunction with the CLC. This contains a guide to analyzing human behaviors, beginning with a determination of whether the identified behavior leading to a cause was intentional or unintentional and leading to the identification of external and internal influences and other conditions under which personnel are likely to make mistakes.

In the Panel’s experience, investigations typically use a checklist as a complete list of potential causes instead of a starting point for discussion of the deeper root causes and usually will not identify factors that are not on the list.

The Panel also believes that BP’s list of systemic factors related to engineering problems (e.g., “inadequate technical design”) appears somewhat superficial.

While inadequate technical design is a valid factor, BP should use it to invite more extensive inquiry: What is the design inadequacy? Why was it present? Why was it not discovered prior to the incident under investigation?

Many of the listed systemic factors do not represent systemic issues. Fatigue, for instance, is included as a systemic cause.

BP uses the CLC for both personal safety accidents and process safety accidents. In the Panel’s opinion, the causal factors involved in occupational or personal safety incidents and process safety incidents typically are very different.

The human error analysis, which focuses investigators’ efforts on personal safety aspects of incidents rather than all aspects of an incident, may introduce additional bias in the analysis toward finding behavioral root causes.

At the time of the Carson refinery technical review in May 2006, about half of process hazard analysis, or PHA, action items at Carson from 2001-2004 remained open.

Action items from facility siting and human factors checklists used in PHAs were not consistently tracked and implemented.

Andy Brazier

Tuesday, January 16, 2007

BP Baker Panel Report - Process Safety

Not all refining hazards are caused by the same factors or involve the same degree of potential damage. Personal or occupational safety hazards give rise to incidents—such as slips, falls, and vehicle accidents—that primarily affect one individual worker or each occurrence.

Process safety hazards can give rise to major accidents involving the release of potentially dangerous materials, the release of energy (such as fires and explosions), or both. Process safety incidents can have catastrophic effects and can result in multiple injuries and fatalities, as well as substantial economic, property, and environmental damage. Process safety refinery incidents can affect workers inside the refinery and members of the public who reside nearby. Process safety in a refinery involves the prevention of leaks, spills, equipment malfunctions, over-pressures, excessive temperatures, corrosion, metal fatigue, and other similar conditions. Process safety programs focus on the design and engineering of facilities, hazard assessments, management of change, inspection, testing, and maintenance of equipment, effective alarms, effective process control, procedures, training of personnel, and human factors. The Texas City tragedy in March 2005 was a process safety accident.

Andy Brazier

BP Baker Panel Report - Recommendations

BP’s corporate management must provide effective leadership on and establish appropriate goals for process safety.

BP should establish and implement an integrated and comprehensive process safety
management system that systematically and continuously identifies, reduces, and manages process safety risks at its U.S. refineries.

BP should develop and implement a system to ensure that its executive management, its
refining line management above the refinery level, and all U.S. refining personnel, including managers, supervisors, workers, and contractors, possess an appropriate level of process safety knowledge and expertise.

BP should involve the relevant stakeholders to develop a positive, trusting, and open
process safety culture within each U.S. refinery.

BP should clearly define expectations and strengthen accountability for process safety performance at all levels in executive management and in the refining managerial and supervisory reporting line.

BP should provide more effective and better coordinated process safety support for the U.S. refining line organization.

BP should develop, implement, maintain, and periodically update an integrated set of
leading and lagging performance indicators for more effectively monitoring the process safety performance of the U.S. refineries

BP should establish and implement an effective system to audit process safety performance at its U.S. refineries.

BP’s Board should monitor the implementation of the recommendations of the Panel and the ongoing process safety performance of BP’s U.S. refineries. The Board should also report publicly on the progress of such implementation and on BP’s ongoing process safety performance.

BP should use the lessons learned from the Texas City tragedy and from the Panel’s report to transform the company into a recognized industry leader in process safety management.

BP Baker Panel Report - Key findings

Released today. Review of BP's corporate safety culture, safety management systems,
and corporate safety oversight at its U.S. refineries following the Texas City Fire. Running to 374 pages, it will be a while before I have had the chance to read it all, but the executive summary is very interesting - almost exclusively regarding process safety - see separate post here for an explanation.

The full report is available here

The Report's Recommendations are summarised here.


The Panel believes that BP has not provided effective process safety leadership and has not adequately established process safety as a core value across all its five U.S. refineries.

BP has not provided effective leadership in making certain its management and U.S. refining workforce understand what is expected of them regarding process safety performance.

BP has emphasized personal safety in recent years and has achieved significant improvement in personal safety performance, but BP did not emphasize process safety.

BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its U.S. refineries. This created a false sense of confidence.

Process safety leadership appeared to have suffered as a result of high
turnover of refinery plant managers.

At Texas City, Toledo, and Whiting, BP has not established a positive, trusting, and open environment with effective lines of communication between management and the workforce

BP has not always ensured that it identified and provided the resources required
for strong process safety performance at its U.S. refineries.

Despite having numerous staff at different levels of the organization that support
process safety, BP does not have a designated, high-ranking leader for process safety dedicated to its refining business.

The company did not always ensure that adequate resources were effectively allocated to support or sustain a high level of process safety performance.

BP’s corporate management mandated numerous initiatives that applied to the U.S. refineries and that, while well-intentioned, have overloaded personnel at
BP’s U.S. refineries. This “initiative overload” may have undermined process safety performance at the U.S. refineries.

In addition, operations and maintenance personnel in BP’s five U.S. refineries sometimes work high rates of overtime, and this could impact their ability to perform their jobs safely and increases process safety risk.

The Panel also found that BP did not effectively incorporate process safety into management decision-making.

BP tended to have a short-term focus, and its decentralized management system and
entrepreneurial culture have delegated substantial discretion to U.S. refinery plant managers without clearly defining process safety expectations, responsibilities, or accountabilities.

BP has not demonstrated that it has effectively held executive management and refining line managers and supervisors accountable for process safety performance.

Although the five refineries do not share a unified process safety culture, each exhibits some similar weaknesses.

The Panel found instances of a lack of operating discipline, toleration of serious deviations from safe operating practices, and apparent complacency toward serious process safety risks at each refinery.

While all of BP’s U.S. refineries have active programs to analyze process hazards, the system as a whole does not ensure adequate identification and rigorous analysis of those hazards. The

The Panel observed that BP does have internal standards and programs for managing process but found that BP’s corporate safety management system does not ensure timely compliance with internal process safety standards. This included standards applying to rupture disks under relief valves; equipment inspections; critical alarms and
emergency shut-down devices; area electrical classification; and near miss investigations.

BP’s corporate safety management system does not ensure timely implementation of external good engineering practices that support and could improve process safety performance

BP’s system for ensuring an appropriate level of process safety awareness, knowledge, and competence in the organization has not been effective in a number of respects.

BP has not effectively defined the level of process safety knowledge or competency required of executive management, line management above the refinery level, and refinery managers.

BP has not adequately ensured that its U.S. refinery personnel and contractors have sufficient process safety knowledge and competence.

The implementation of and over-reliance on BP’s computerbased training contributes to inadequate process safety training of refinery employees.

BP’s corporate process safety management system does not effectively translate corporate expectations into measurable criteria for management of process risk or define the appropriate role of qualitative and quantitative risk management criteria.

BP has not effectively implemented its corporate-level aspirational guidelines and
expectations relating to process risk. Therefore, the Panel found that BP has not implemented an integrated, comprehensive, and effective process safety management system for its five U.S. refineries.

Significant deficiencies existed in BP’s site and corporate systems for measuring process safety performance, investigating incidents and near misses, auditing system performance, addressing previously identified process safety-related action items, and ensuring sufficient management and board oversight.

Many of the process safety deficiencies are not new but were identifiable to BP based upon lessons from previous process safety incidents, including process incidents that occurred at BP’s facility in Grangemouth, Scotland in 2000.

BP tracked some metrics relevant to process safety at its U.S. refineries. Apparently, however, BP did not understand or accept what this data indicated about the risk of a major accident or the overall performance of its process safety management systems.

BP has not instituted effective root cause analysis procedures to identify
systemic causal factors that may contribute to future accidents. When true root or system causes are not identified, corrective actions may address immediate or superficial causes, but not likely the true root causes.

BP has an incomplete picture of process safety performance at its U.S. refineries because BP’s process safety management system likely results in underreporting of incidents and near misses.

BP has not implemented an effective process safety audit system for its U.S. refineries based

The principal focus of the audits was on compliance and verifying that required management systems were in place to satisfy legal requirements. It does not appear, however, that BP used the audits to ensure that the management systems were
delivering the desired safety performance or to assess a site’s performance against industry best practices.

BP has sometimes failed to address promptly and track to completion process safety deficiencies identified during hazard assessments, audits, inspections, and incident investigations.

The Panel’s review found repeat audit findings at BP’s U.S. refineries, suggesting that true root causes were not being identified and corrected.

BP does not effectively use the results of its operating experiences, process hazard analyses, audits, near misses, or accident investigations to improve process operations and process safety management systems.

The company’s system for assuring process safety performance uses a bottom-up reporting system that originates with each business unit, such as a refinery. As information is reported up, however, data is aggregated. By the time information is formally reported at the Refining and Marketing segment level, for example, refinery-specific performance data is no longer presented separately.

The Panel’s examination indicates that BP’s executive management either did not receive refinery-specific information that suggested process safety deficiencies at some of the U.S. refineries or did not effectively respond to the information that it did receive.

A substantial gulf appears to have existed between the actual performance of BP’s process safety management systems and the company’s perception of that performance.

BP’s Board can and should do more to improve its oversight of process safety at BP’s five U.S. refineries.

The Report's Recommendations are summarised here.

Some comments are made about human factors in the report. They are summarised here

Andy Brazier

IET Health and safety information

A useful looking website from The Institution of Engineering and Technology. Includes briefings, a guide and news. May be a bit too regulatory led for my liking, but some of it looks very useful.

Briefings include

Behaviour-based safety
Blame Free Reporting
Contractor Management
Cost of Safety
Determining the Acceptability of Risk
Do Accidents and Ill-Health Really Cost Me Money?
Hazard Analysis (HAZAN)
Hazard and Operability Studies (HAZOP)
Indicators and Targets
Organisational Change and Safety
Permit to Work Systems
Failure Modes and Effects Analysis - FEMA
Event Tree Analysis - ETA
Fault Tree Analysis - FTA
Reasonably Practicable
Risk Based Inspection
Safety Culture

Andy Brazier

Tuesday, January 09, 2007

Detecting and responding to plant disturbances

Article in October 2006 edition of Ergonomics journal
Title 'Human process of control: tracing the goals and strategies of control room team'
By J Patrick, N. James and A. Ahmed

A study from the nuclear industry. Five shift operations teams were evaluated using a process simulator. Each team was made up of two control room operators and a supervisor.

The simulator was a full-scale mimic of operations.

The teams were set about normal operations and then asked to carry out a routine task of changing over boiler feed pumps. Whilst doing this task a small leak was initiated on one of the pumps. And on top of this a spurious fire alarm in an office was activated that required some action from the supervisor, although not the operators.

The simulated leak was considered to be a plant disturbance that would not create an immediate alarm. However, the leak would cause a drop of level in the dearator, which if undetected would cause a low level alarm and eventually a reactor trip.

The time taken to detect the level drop was recorded. The results were
Team A - 9 min 3 s
Team B - 4 min 6 s
Team C - 1 min 57 s
Team D - 6 min 3 s
Team E - 2 min 30 s
Expert judgement on the site that this scenario should be detected within 2 minutes. Therefore, from the results only Team C was successful.

To explain the long time taken to detect the event the researchers looked at how much attention the operators paid to the routine pump changeover task. Apparently, the normal procedure was that only one operator would be involved in the task, leaving the other to monitor the plant and the supervisor would have minimal involvement. The actual results for proportion of time spent on the task were
Team A - Op1 74% Op2 64% Super 12%
Team B - Op1 81% Op2 53% Super 0%
Team C - Op1 26% Op2 00% Super 16%
Team D - Op1 95% Op2 90% Super 44%
Team E - Op1 98% Op2 93% Super 23%
Clearly, with the exception of Team C, both operators were heavily involved in the routine task, and it is no wonder that they took so long to detect the leak because they would have had little time to monitor the rest of the plant. This is further exacerbated by the fact that in some teams the supervisors got quite involved in the task (which should not have been necessary) taking them away from the main supervisory tasks.
Delving deeper the researchers also found that in most teams, not only did they spend relatively little time monitoring the plant, when they did they were fairly poor at it. In other words the monitoring they did was not good enough to detect the leak quickly.
Overall the finding is that operators easily become fixated on procedural tasks at the expense of the wider, continuous task of monitoring. Also, that supervisors do not tend to intervene to re-orientate the operators (in this case making sure only one is involved in the routine task and the other is concentrating on monitoring) and also have a tendency to get involved where it should not be necessary.

Having detected the leak, the teams had to diagnose its cause and take appropriate action. This was also evaluated. The results for diagnosis and control were
Team A - 6 min 11 s
Team B - 3 min 23 s
Team C - 4 min 46 s
Team D - 1 min 58 s
Team E - 4 min 48 s
In trying to diagnose the problem each team developed a number of hypotheses. Interestingly the operators generated most of these, with relatively little input from the supervisor. It had been assumed that supervisors would lead diagnosis, which clearly did not happen.
Unfortunately none of the hypotheses covered the actual cause of the problem and none of the teams diagnosed the cause of the problem correctly from the control room and needed information from the plant (i.e. someone looking where the water was leaking from).
The researchers identified that the teams took significantly different approaches to dealing with this phase of the scenario in the way they spilt their time between problem solving, mitigating the consequences of the leak and keeping an eye on the rest of the plant. They concluded that none of the teams gave problem hypothesis generation and testing a high enough priority. This suggests a need for more training in diagnosis.

Andy Brazier

Monday, January 08, 2007

Room temperature and health risks

Article on BBC website explores why the death rate in the UK during winter due to cold is significantly worse than really cold countries. It is interesting because it points out that most UK deaths are not due to 'massive cold' where people are exposed to very cold temperatures, but to 'quite minor degrees of cold that people were getting every day.' The actual cause of death in these cases is stroke and heart attack because the blood is more liable to clot when cold.

Comfort and health issues are quoted from the West Midlands Public Health Observatory

24C - top range of comfort
21C - recommended living room temperature
Less than 20C - death risk begins
18C - recommended bedroom temperature
16C - resistance to respiratory diseases weakened
12C - more than two hours at this temperature raises blood pressure and increases heart attack and stroke risk
5C - Significant risk of hypothermia

People in cold countries keep their houses warmer and take outdoor clothing much more seriously.

Andy Brazier

Friday, January 05, 2007

Business continuity

A useful checklist for any business is available from London Prepared website

It covers building facilities, personnel, security, documents, equipment, IT, suppliers, customers and insurance.

Andy Brazier

Perceived risks of hydrogen

Article in November 2006 The Chemical Engineer
Titled "Hydrogen: a matter of perception" by Miriam Ricci, Paul Ballaby, Rob Flynn and Gordon Newsholme.

Hydrogen is being proposed as a fuel of the future for vehicles and other uses. Clearly it is a hazardous material, and there is the danger that this will be viewed in isolation and mean that it is not accepted by society. But this fails to compare the risks associated with hydrogen with those of currently accepted fuels or to consider the benefits of hydrogen. The authors claim that hydrogen should not be viewed according to its physical and chemical properties, but as "an energy carrier in a complex socio-technical system." This is because the risks will depend on how hydrogen is ultimately produced, transported, stored, delivered and used - much of this is currently unknown.

People perceive risks according to perceived benefits and costs (i.e. it is totally contextual). Trust has a lot to do with it, and the public can become uneasy about the motivation of the organisations involved and who is likely to benefit and who is likely to be at risk.

If the public can be persuaded that hydrogen is safe enough, or at least as safe as currently accepted fuels it may well be accepted. But this confidence will take a major hit if there is any sort of large hydrogen-related accident, particularly during transition to a hydrogen economy. This makes a case for not exaggerating the safety of hydrogen. But also, it highlights why industry needs to be very careful when introducing new technology as a loss of confidence due to failure to manage risks can deny society something that in the long term is beneficial.

Reference is made to a more indepth report available online Risk perception of emergency technology

Andy Brazier

The purpose of maintenance - creating change

Article in December 06/January 07 The Chemical Engineer
Article titles "Make the most of your assets" by Sandy Dunn

One of the major barriers to overcome if maintenance is to be improved is that its purpose is not just to repair equipment after it has broken. It is not even abut prediction and prevention - rather it is a holistic process that ensures equipment fulfills its intended business purpose. A key element of this is identification and elimination of the things that cause failures, and this goes far beyond the maintenance department. As a minimum they need to be working with operations and purchasing, and all need to have a shared common goal.

To achieve step-change improvements, the organisation needs to be ready to change to this holistic view. Many will not be, and will need a compelling reason for change.

The necessary change will be multi-dimensional. To achieve it you need to

* make sure people have access to the right tools and information, the authority to make decisions
* change the way performance is measured and rewarded
* rethink lines of reporting
* redesign jobs and procedures; and train people.

To get people on board you need to have a good answer to the question "what is in it for me?" This can be financial, self-esteem, recognition, job satisfaction, career growth, pride and many others. When these have been identified they should be emphasised frequently, although care is required to avoid creating unreasonable expectations.

A rule of thumb says that if there are no tangible benefits following a change within six months support will halve and barriers will double. Therefore the program of change needs to ensure benefits will be achieved throughout as people may not be prepared to wait until the end to see them.

Quoting Dunn. "Newton's Third Law was never so true: an object at rest tends to stay at rest until acted upon by external forces. In change projects, inertia is to be avoided. It is too easy for stakeholders to remain exactly where they are, especially if they are anxious about the change project. Stakeholders need continuous invitations to become involved, constant reassurance that they will get their wins."

Andy Brazier

Change management when introducing new IT

Article in December 06/January 07 The Chemical Engineer.
Titled 'All aboard' and written by Christopher Abiodun of IBM Global Business Services.

Concerned development of the Enterprise Asset Management system for BP's Greater Plutonio oil field operations in Angola. The system was intended to manage maintenance, but was also integrated with materials management, purchasing and supply chain management.

As well as teams dealing with the system's main functions, a change management team was put in place to assist with the people issues such as stakeholder management, project awareness, communications, and training - to ensure engagement with end users. It was felt that this was invaluable in keeping stakeholders engaged, raising awareness of the project, and assessing and communicating to the end users how the system would change current ways of working.

A key functions of the change management team was to analyse training needs and ensure that users got the training they needed. The team found that training was required in using the new system, but also in the underlying business processes. This was to help users understand why the system was designed in the way it was and how to get the most out of it. Also, it reduced intertia and resitance to change.

Abiodun writes "The importance of using change management from the early days of the project through to its conclusion to ensure engagement by stakeholders cannot be overemphasised. It was a key factor in engaging over 200 geographically-dispersed users across two continents to adopt the new system.... The effort this takes should not be underestimates; assessing the impact of change brought about by the new system, developing change strategies and executing them took hard work and dedication."

There is an element of risk in everything. By assessing this early on the risks can be managed. For this project the number 1 risk was reliance on network communications to a deepwater offshore facility. The project had enough time to identify, evaluate and assess a number of potential solutions.

Final quote from Abiodun. "A well-equipped and motivated team of seemingly ordinary people can achieve extraordinary results - although it helps to have the odd one or two extraordinary players in the team."

Andy Brazier