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PRISM Seminar, Bratislava. Slide 2. 300 offices in 100 countries5,500 employees
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1. Approaches to integrating human factors in Seveso II safety cases Rob Cotterill
DNV Consulting
2. PRISM Seminar, Bratislava Slide 2 DNVs worldwide network
3. PRISM Seminar, Bratislava Slide 3 Development and implementation of safety management systems
Identification and assessment of the risks from major hazards
Innovative safety cases
Human factors of major accident prevention
Behavioural safety/culture change
Environmental performance improvement
DNV and Safety Management
4. PRISM Seminar, Bratislava Slide 4 The risk management agenda
5. PRISM Seminar, Bratislava Slide 5 Top Ten HF Issues
6. PRISM Seminar, Bratislava Slide 6 Understanding human failure
7. PRISM Seminar, Bratislava Slide 7 HF approaches to risk assessment Method 1: HF in the Safety Case
Top down approach
All human operations
Part of Seveso safety case
Method 2: HF in major accident hazards
Bottom up approach
Concentrating on MAH scenarios
Implemented into safety case
8. PRISM Seminar, Bratislava Slide 8 Method 1: HF in the Safety Case Part of overall COMAH assessment:
Descriptive Elements
Predictive elements
MAPP & SMS
Technical elements
Emergency response
Source information
HF aspects in several elements
Supporting appendix of HF information
Referred to in all relevant sections
9. PRISM Seminar, Bratislava Slide 9 Human factors Appendix Description of the human factors assessment of the plant
Aim:
To demonstrate that human factors issues have been taken account in the risk assessment
To show that their potential effect has been considered as a contributor to the overall risk levels arising from the day to day operation
10. PRISM Seminar, Bratislava Slide 10 Human factors Appendix Identification and consideration of specific human factors issues that have led to major incidents in the past.
Application of task analysis and human error identification techniques for the assessment of safety critical operations and maintenance tasks.
Identification of the potential for violations of procedures to increase risk levels on site.
Organised according to key human factors issues :
Identification of potential for human failures.
Demonstration of control measures.
Justification of the reliance on human reliability.
11. PRISM Seminar, Bratislava Slide 11 Data collection Review of MAH tables.
Site tour including discussion of activities in the following areas:
Fuel receipts.
Tank farms.
Interceptors.
Tanker loading bays.
Interviews with:
Terminal manager.
Operations staff.
Maintenance manager.
Security staff.
Demonstration of operations in the control room.
Review of site held documentation including:
Safety management system.
Key risk control systems.
Site HAZOP.
12. PRISM Seminar, Bratislava Slide 12 Error Analysis: Sherpa technique
13. PRISM Seminar, Bratislava Slide 13 High potential human error operations Road tanker loading
Recovery from a compartment overfill (contained).
Recovery from an overfill resulting in product spillage.
Fuel receipts
Filling COC tank.
Operations tasks in and around the tank farm.
Pump inspection.
Inspection of loading bays.
Testing of Fire pumps.
14. PRISM Seminar, Bratislava Slide 14 Demonstration of existing control measures Risk ranking of human errors
Linking human errors to MAH scenarios
Identifying severity of consequence & likelihood
Implementation of Control Measures and Safeguards
Driver training
Behavioural observations
Maintenance control (PtW)
Vehicle / equipment inspections
Etc.
15. PRISM Seminar, Bratislava Slide 15 Method 2: HF in major accident hazards
16. PRISM Seminar, Bratislava Slide 16
17. PRISM Seminar, Bratislava Slide 17 Procedure Checklist
18. PRISM Seminar, Bratislava Slide 18 Alarm checklist
19. PRISM Seminar, Bratislava Slide 19 Concurrent Task Analysis
20. PRISM Seminar, Bratislava Slide 20 Staffing assessment
21. PRISM Seminar, Bratislava Slide 21 Example: Automated continuous plant General control room duties difficult to assess
Selected a manual task, and looked at links to control room activities
e.g., communications, data entry & decision making
Example taking sample of reactor contents
Error: fail to close circulation valve on sample cooler
Consequence:
Unrepresentative sample taken - status of reactor unknown
Potential runaway reaction
Recommendations:
Ensure all operators understand importance of sampling
Improve labelling of valves
Investigate linking valves to sample point
22. PRISM Seminar, Bratislava Slide 22 Example: Design phase of new plant Multi-disciplinary team established during design phase
Applied methodology to proposed design:
Identified how plant will operate
Identified design problems before too late
Identified manning levels
Most importantly
ensured employee involvement
Example connect road tanker to off-load point
Error: driver connects to wrong point
Consequence:
Incompatible substance into storage tank - exothermic reaction
Recommendations:
Tanker drivers not allowed on site unaccompanied
2 x paperwork checks
Off-load points locked
23. PRISM Seminar, Bratislava Slide 23 Method 1: Bottom up approach Pros:
identifies main activities
Covers many activities
Quick
Low manpower requirements Cons:
Can be superficial
Hard to find people when you need them
Might miss certain root causes
24. PRISM Seminar, Bratislava Slide 24 Method 2: top down approach Pros:
Very thorough
Based on severity of MAH scenario
Involves workers and supervisors
High face validity
Information rapidly gathered Cons:
Time consuming
Significant commitment from all involved
Understanding of error mechanisms is required
25. PRISM Seminar, Bratislava Slide 25 Conclusions Human errors are predictable
Task analysis approach helps identify causes and consequences.
Complexity of operation should drive HEA
More complex plant requires more complex process
Commitment of time and people required for any aproach.
26. PRISM Seminar, Bratislava Slide 26 Any Questions? Jakýkoliv otázky?