Holistic Approach to Safety

1. Holistic Approach to Safety Bart Winters Honeywell May 24, 2006

2. Presenter • Bart Winters • BS Manufacturing Engineering Brigham Young University • 22 Years Honeywell Process Solutions • Software Development HMI & Alarm/Event Management • Batch & SCADA Project Engineering • Engineering Management • Batch Product Management • Alarm Applications Product Management • Asset & People Effectiveness Business Consultant

3. History Lesson • Pat McLaughlin and Peter O’Reilly • 1859 Six-Mile Canyon, Nevada • Find a vein of quartz crystal laced with gold • Biggest problem mining the gold was -- bluish-gray mud/clay that stuck to everything • Discarded in huge piles outside the mines

4. History Lesson (cont.) • John Mackay a miner with geology and mineral training recognizes the “mud” • Assayed a sample of the bluish-gray mud • Buys several of the “spent” mines • Result: • Silver content worth $2500-$3000 per ton in 1859 dollars • Annual silver production from $6M to $60M / year 50 : 1 silver to gold production

5. When You Think Safety…Do You Think? • Regulatory controls • Safety instrumented systems • Fire and gas systems • Burner management systems • Compressor / turbine monitoring systems • Manually activated protective functions (e.g., remote isolation valves, water curtains/cannons)

6. Standards Help But…Are We Safe Enough? • Many Regulatory Requirements & Standards • OSHA (US) or HSE (UK) etc. • EPA • International Organization for Standardization (ISO) • Instrumentation, Systems, and Automation Society (ISA) • American Petroleum Institute (API) • National Fire Protection Association (NFPA) • International Electrotechnical Commissions (IEC) • Engineering Equipment and Materials Users Association (EEMUA) • American Institute of Chemical Engineers (AIChE)

7. Consider the Following… $314M $500M $412M $20B Annual Preventable Abnormal Situations is US Alone $2,000M+ $1,400M $100M $275M $139M Source: ASM Consortium

8. Charter: Research the causes of abnormal situations Guidelines and best practices Technologies to address this problem Deliverables: Technology, best practices, application knowledge, prototypes, metrics History: Started in 1994 Co-funded by US Govt (NIST) Budget: +$16M USD Abnormal Situation Management Consortium www.asmconsortium.com

9. Human Factors Are at the Core… • 42% of Abnormal Situations People Related ASM Consortium Research • “In systems where a high degree of hardware redundancy minimizes the consequences of single component failures, human errors may comprise over 90% of the system failure probability.” “A Manager’s Guide to Reducing Human Errors” API Publication 770, March 2001 • “Human failures are responsible for up to 80% of all types of accident” UK Health & Safety Executive (HSE) Human Factors Briefing Note No. 1 Introducing Human Factors

10. Tendency to ‘Blame’ The Operator

11. Management Responsibility • Most mistakes are committed by skilled, careful, productive, well-meaning employees. • Rather than blaming the individual involved attempt to identify the root causes of the error in the work situation and implement appropriate corrective actions.” “A Manager’s Guide to Reducing Human Errors” API Publication 770, March 2001

12. Components of Human Factors Actions or inactions of individuals are influenced by: • Organizations structure & culture (formal & informal) • Procedures & work processes (formal & informal) used to perform their  activities • Automation and equipment involved in these activities (software and hardware) • Environments in which the individual conducts activities (control room, field, etc)

13. ASM Guidelines

14. Reducing Frequency & Impact of Abnormal Situations x 10000 4 3 1) Initiating Event 2) Normal Detection & Intervention 3) Mistakes 4) Lapses (Misses Event) 5) Ideal Detection & Intervention x 1000 x 100 Impact (Cost) 2 x 10 5 1 x 1 0 Time *Gartner group

15. Learnings from ASM Member Companies & Best Practices • Simulation & Training • ASM Operator Interface • Operating Envelop Management • Alarm Management • Procedure Operations

16. Learnings from ASM Member Companies & Best Practices • Simulation & Training • ASM Operator Interface • Operating Envelop Management • Alarm Management • Procedure Operations

17. Unwanted By-products of Automation(or how to make people stupid) • Disabling expertise • Slowing the rate of learning • Teaching dysfunctional skills

18. Is Situation Typical?(Prototype or Analogue) DiagnoseFeature Matching Action 1…n Evaluate Action(Mental Simulation) Expectancies Relevant Clues No Modify PlausibleGoals Typical Action Will it work? Yes Yes, But Implement Action Implement Action Recognition Primed Decision (RPD)Model (Klein) Perceived as typical (Prototype or Analogue) Recognition Implement Action Additional Steps Due to Lack of Expertise

19. Experts Under Pressure Good 3.2 Experts 3.0 Decision Quality 2.8 Novices 2.6 Poor 6 seconds 2.25 min Time allowed for Decision

20. ASM Effective Operations PracticesCategory 3: Knowledge & Skills Development • Continuous learning not one-time activity • Define competency model • Link to your site major accident risk assessment • Team based – with clear roles & responsibilities • Frequent study and incorporation of historical upsets and near misses • Use of training simulator for best results

21. Learnings from ASM Member Companies & Best Practices • Simulation & Training • ASM Operator Interface • Operating Envelop Management • Alarm Management • Procedure Operations

22. An “Effective” Graphic?

23. Consider • Tasks being performed • Use of color (salience) • Display navigation • Number of keystrokes • Use of symbols & process connections • Use of text and numbers • Memory limitations • Visual coding (pattern recognition) • Impact of shift work • Work environment (lighting, noise, etc.)

24. ASM User InterfaceWorth 1M$/yr for ethylene plant • Comparing ASM designed operator interface vs traditional standard operator interface • Operators with similar experience on identical units measured with simulation based scenarios • >38% improvement in recognition of process deviations before the 1st alarm • 26% improvement in their ability to successfully resolve problem • 35-48% improvement in overall operator response time to deviations Source: ASM Meeting report – Oct. 2004see also http://www.chemicalprocessing.com/articles/2006/041.html

25. Learnings from ASM Member Companies & Best Practices • Simulation & Training • ASM Operator Interface • Operating Envelop Management • Alarm Management • Procedure Operations

26. Quotes from Longford • “... operating in alarm mode was sometimes necessary to meet the gas order” • “Informal rules evolve … to achieve goals quite different from those originally intended by the system designers”

27. Environmental Process Design Safety Procedures Operating Alarms Maintenance Rounds Corrosion Environmental Monitoring APC Limit Operational Target Joe Operator UserAlert Limit PVLO Alarm Limit Determining Safe Operating Boundaries Source of Limits Location of Limits Users of Limits Reliability xxx yyy

28. Critical High Standard High Target High Target Low Standard Low Critical Low Boundary Management EquipmentConstraints Operating Boundaries Application Limits • Consistent reference point based on facts, documented and available to the entire operating team and other applications • Thorough PHA, HAZOP, and alarm system design with cross functional team • Clear definition of safe upper and lower limits (OSHA 1910.119) • Identify what to monitor (alarms, alerts, production targets) • Captured and make available knowledge from PHA, HAZOP, AOA, other processes Hi Hi Alarm Limit (Safety) Design Safety Corrosion Proces Reliability Environmental Manager UserAlert Hi-Hi Alert Limit HI Alarm Limit (Reliability) Environmental Engr. UserAlert Limit APC Limit Operational Target Limit Operator X UserAlert Limit Lo Lo Alarm Limit (Safety)

29. Do You Know Your Limits?Does the Operator Know? • Information from HazOp and other critical processes captured and used to design for operability • What are the limits? • How to respond to deviations

30. Operator Feedback • “We can’t set our targets out of the unit limits” • “Thought I knew everything - learned something from this work” • “No more "just do it" - now why is explained”

31. Operating Envelope Management Improves Operational Reliability • Management of Alarm Limits • Alarm rationalization (# of alarms) • Integrity of alarm limits (understanding context) • Expected actions in response to alarms • Mode-based alarming • Alarm enforcement • Management of change • Improve Operator Workflow, Data Access and Visibility • Shift/daily operating plan • Operating procedures • Operator task management • Improve communication between operators • Checklist shift handover • Electronic logbook • Validate operating plan against “operating envelope” boundaries • Provide analysis tools for continuous improvement

32. Learnings from ASM Member Companies & Best Practices • Simulation & Training • ASM Operator Interface • Operating Envelop Management • Alarm Management • Procedure Operations

33. Alarm Management Risk Factors • High alarm rates • High # of standing/stale alarms • High # of disabled alarms • Little or no priority distribution • Temporary changes become permanent • No rationalization and documentation information • No operator guidance or alarm help

34. Control Define Measure Analyze Implement Incident investigation & continuous improvement Root cause analysis & rationalization Document results & monitor progress Benchmark & Plan Identify problem areas with detailed analysis Alarm Management Life Cycle Drill Down Level of Effort Required for Analysis Performance Monitoring Root Cause Event Analysis Dynamic Analysis Static Configuration Reports Alarm Documentation Industry Benchmarks Alarm Enforcement Unit Benchmarking

35. Learnings from ASM Member Companies & Best Practices • Simulation & Training • ASM Operator Interface • Operating Envelop Management • Alarm Management • Procedure Operations

36. Procedure Challenges • Ensure procedures are followed correctly and consistently for safety, increased production and best on-spec product • Capturing the knowledge of staff due to retirement and change • Improve transitions between operating modes or feed-stocks in response to market demand • Reduce operator workload in non-value added areas, to consolidate the work-force, thereby, allowing operators to have more time to focus on cost control and profit maximization.

37. Procedures on Continuous Processes Shutdown/Startup – seldom executed therefore subject to error or inconsistencies Grade Change – Normal production change (grades, rates, equipment, etc…) Abnormal Condition resulting in SafePark – Bringing the plant to a safe holding point that may be resumed by Operations, or subsequently to Shutdown the plant. Cyclic Planned Activities – Tasks repeated based upon well defined criteria, normal operations (regeneration, pump changeover, decoking, etc…)

38. Procedure Identification Procedure HAZOP Expert Judgment Complexity Consequence Frequency In-task Review Resource Field or Console Inputs Interaction Techniques (Paper and Electronic) - Procedure Content - Procedure Structure - Procedure Format - Navigation - Terminology - Status Format - Data Entry Effective Procedure Design for Context of Use Outputs

39. Effective Interaction w/ ProceduresSolution Concepts • Paper-based procedures – Typically in a binder or printed as needed from database • On-line static procedures – Viewed in on-line; can be browsed and printed. • On-line interactive procedures – Can be tracked, updated, and status information may be presented from various sources; automated workflow • On-line hybrid procedures – Provide feedback on status and can execute actions automatically or initiated by the operator

41. Conclusions

42. When You Think Safety Do You Think Human Factors? • Are human factors considered in all the aspects of safety engineering? Is it part of your culture? • Identification • Assessments • Mitigation • Standards a necessity but remember the big picture • Remember the 50:1 Ratio

43. Questions?