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Human Error in Process Plant Design and Operations: A Practitioners Guide [Kõva köide]

(Consultant, Alleroed, Denmark)
  • Formaat: Hardback, 300 pages, kõrgus x laius: 234x156 mm, kaal: 754 g, 16 Tables, black and white; 16 Illustrations, color; 35 Illustrations, black and white
  • Ilmumisaeg: 11-Dec-2015
  • Kirjastus: CRC Press Inc
  • ISBN-10: 1498738850
  • ISBN-13: 9781498738859
Teised raamatud teemal:
  • Formaat: Hardback, 300 pages, kõrgus x laius: 234x156 mm, kaal: 754 g, 16 Tables, black and white; 16 Illustrations, color; 35 Illustrations, black and white
  • Ilmumisaeg: 11-Dec-2015
  • Kirjastus: CRC Press Inc
  • ISBN-10: 1498738850
  • ISBN-13: 9781498738859
Teised raamatud teemal:
In contrast to nuclear plants and aerospace systems, human error is largely 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 Process Plant Design and Operations: A Practitioners Guide shows you how to develop a comprehensive risk assessment that includes human error. Based on the well-known SRK model of human error, this book represents a practical collection of examples and statistics from more than 30 years of study, with many examples of the practical application of methods.

The book provides a complete overview of the various types of human error, including operator error, hindrances and inability to function, errors in observation, errors in performing standard procedures, errors in supervisory control, errors in decision making and planning, infractions and violations, design errors, and errors in procedures. It then goes on to identify human error potential and probabilities, and discusses techniques and methodologies that can be implemented to minimize human errors and prevent accidents.

The result of the author's observations of human error over a lifetime of work as an operator, as a commissioning coordinator, and as an operations manager, the book demonstrates how to analyse, manage, and mitigate many types of error. By taking advantage of the author's experience and expert knowledge, and by applying the techniques and methodologies illustrated in this book, you will be able to make changes which will make work easier, error free, clearly understood, and more congenial.

Arvustused

"a comprehensive overview of the several types of human errors that can occur in any industrial plant or research lab. The result of the author's observations of human error over 36 years of work as an operator illustrated in this book make this book unique and very useful for both academia and industry." Nayef Ghasem, United Arab Emirates University

"explores a broad range of practical plant and facility operation issues and considerations, providing explanations for human errors which better enable us to prevent similar or repeat incidents from human errors. The general focus on worker attitudes, training and competency assurance, workplace supervision, management, operating procedures and design, promises the reader an interesting introduction into understanding human errors in the workplace." Dr. Chit Lutchman, Safety Erudite, Inc.

"The author has done a good job organizing and illustrating the various types of human error. I found the chapters on design errors and management errors especially enlightening. My experience in incident investigation has told me that these areas of human error are often not adequately addressed during root cause incident investigation. I recommend this book to those involved in designing and operating chemical processes as well as those involved in incident investigation." Process Safety Progress, December Issue 2016 "a comprehensive overview of the several types of human errors that can occur in any industrial plant or research lab. The result of the author's observations of human error over 36 years of work as an operator illustrated in this book make this book unique and very useful for both academia and industry." Nayef Ghasem, United Arab Emirates University

"explores a broad range of practical plant and facility operation issues and considerations, providing explanations for human errors which better enable us to prevent similar or repeat incidents from human errors. The general focus on worker attitudes, training and competency assurance, workplace supervision, management, operating procedures and design, promises the reader an interesting introduction into understanding human errors in the workplace." Dr. Chit Lutchman, Safety Erudite, Inc.





"The author has done a good job organizing and illustrating the various types of human error. I found the chapters on design errors and management errors especially enlightening. My experience in incident investigation has told me that these areas of human error are often not adequately addressed during root cause incident investigation. I recommend this book to those involved in designing and operating chemical processes as well as those involved in incident investigation." Process Safety Progress, December Issue 2016

Preface xv
Acknowledgements xix
About the Author xxi
Acronyms xxiii
Chapter 1 Introduction
1(16)
What Is Human Error?
1(3)
Can Errors Be Predicted?
4(1)
The Importance of Operator and Maintenance Error
5(2)
Complex Systems Theory
7(2)
Pushing the Limits
9(1)
Slips, Lapses, Mistakes and Violations
10(1)
Assessing the Probability of Operator Errors
11(2)
The Need for an Interdisciplinary Approach
13(1)
What Should We Do about Error Potential?
13(2)
Data Collection for This Book
15(1)
References
16(1)
Chapter 2 Models of Operator Error
17(8)
The Skills--Rules--Knowledge Model
19(2)
Skill-Based Activities
21(1)
Rule-Based Activities
21(1)
Knowledge-Based Processing
22(1)
Status of the Skills--Rules--Knowledge Model
22(1)
Using the Model
23(1)
References
23(2)
Chapter 3 Hindrances and Inability to Function
25(6)
Operator Absence
25(1)
Error-Reduction Measures for Absence from Work Location
26(1)
Hindrance
26(1)
Incapacitation
27(1)
Error-Reduction Measures for Incapacitation
27(1)
Distraction
27(1)
Error-Reduction Measures for Distraction
28(1)
Attention Failure
28(1)
Error-Reduction Measures for Attention Failure
29(1)
Overload and Priorities
29(1)
Error-Reduction Measures for Overload
29(1)
Priority Error and Focus Error
30(1)
References
30(1)
Chapter 4 Errors in Observation
31(4)
Potential Operational Input Overlooked
31(1)
Complex or Unrecognisable Input
31(1)
Error-Reduction Measures
32(1)
Ambiguity and Misleading Signals
32(1)
Mislearning
33(1)
Failures of Instruments and Alarms
34(1)
References
34(1)
Chapter 5 Errors in Performing Standard Procedures: Rule-Based Operation
35(16)
The Process of Rule-Based Operation
35(3)
What Is a Procedure?
38(1)
Thought Processes in Procedure Execution
38(2)
Error Modes in Carrying Out Procedures
40(1)
Causes of Errors in Carrying Out Procedures---Following Cues
41(1)
Causes of Errors in Carrying Out Procedures---Omission
42(2)
Errors in Procedure Execution---Wrong Procedure
44(3)
Errors in Procedure Execution---Too Much or Too Little
47(1)
Errors in Procedure Execution---Too Long or Too Short Duration
48(1)
Errors in Action Performance
48(2)
Risk-Reduction Measures for Errors in Executing Procedures
50(1)
References
50(1)
Chapter 6 Operator Error in the Field
51(8)
Omission and Forgetting
52(1)
Errors in Procedure Execution---Wrong Object or Material
53(4)
Too Much Force
57(1)
References
57(2)
Chapter 7 Knowledge and Ignorance in Plant Operation
59(20)
Knowledge-Based Operation under Modern Conditions
61(1)
Knowledge of Plant State
62(1)
Ambiguity of Input
62(1)
Knowledge, Belief and Judgement
63(3)
A Little Knowledge Can Be Dangerous
66(1)
Planning New Procedures
66(1)
The Need for Judgements
67(3)
Knowledge of Plant Physics
70(1)
An Example of Accident Physics---Momentum
71(3)
Knowledge-Based Operating Errors
74(2)
Predicting Knowledge-Based Errors
76(1)
References
77(2)
Chapter 8 Errors in Supervisory Control
79(12)
Errors in Supervisory Control---Checking Values
80(1)
Checking a Complex Precondition
81(1)
Responding to Abnormal Conditions
82(1)
Operations with Failed Instruments
83(1)
Improvisation and Operation under Abnormal Conditions
84(2)
Shutdown Decisions
86(1)
Operator Performance under Abnormal Conditions
87(1)
Operator Errors in Abnormal Situations
88(1)
Reducing Error in Abnormal Situations
89(1)
Reference
89(2)
Chapter 9 Emergency Response and Disturbance Control
91(12)
Emergency Response
92(4)
Errors in Emergency Response
96(3)
Analysis for Emergency Response
99(1)
Errors in Emergency Response
100(1)
Reducing the Potential for Error in Emergency Response
100(1)
References
101(2)
Chapter 10 Diagnosis of Plant Disturbances
103(8)
Diagnostic Strategies
105(3)
Immediate Associative Recognition
105(1)
Respond First, Then Explain
106(1)
Backwards Simulation
106(1)
Assumption of Repetition of an Earlier Disturbance
107(1)
Brain Searching and Brainstorming
107(1)
Systematic Causal Search
108(1)
Instrument Errors
108(1)
Fixation
109(1)
Complex Equipment Units
109(1)
Errors in Diagnosis
110(1)
Reducing Error Potential in Diagnosis
110(1)
References
110(1)
Chapter 11 Errors in Decision Making and Planning
111(12)
Risk Taking and Risk Blindness
113(2)
Risk Habituation
115(1)
Deliberate Risk Taking
116(1)
Risk Taking and Risk Blindness in Maintenance
117(2)
Necessary Risk Taking
119(1)
Institutionalised Risk Taking
120(1)
Assessing Risk-Taking Hazards
121(1)
Reducing the Potential for Risk-Taking Errors
122(1)
References
122(1)
Chapter 12 Infractions and Violations
123(8)
Housekeeping and Everyday Hazards
123(1)
Unauthorised Improvisations
123(2)
Unauthorised Equipment
125(1)
Macho Behaviour
125(3)
Horseplay
128(1)
Illicit Behaviour
128(1)
Deliberate Fraud
128(1)
Vandalism and Sabotage
129(1)
Preventing Violations
129(2)
Chapter 13 Management Error
131(22)
Errors of Omission in Plant Management
132(1)
Inadequacies in Safety Management Procedures
132(1)
Violations
133(1)
Mistrust of Safety Analysis and Safety Management
133(3)
Lack of Knowledge of Process Safety
136(1)
Dangerous Decisions
137(2)
Patching Up and Making Do
139(2)
Downsizing and Outsourcing
141(2)
Optimum Safety? Problems with the ALARP Principle
143(1)
Pity the Poor Plant Manager
144(1)
The Parachute Manager
144(1)
Leadership
145(2)
Safety Culture
147(1)
Drift into Failure
147(2)
High-Integrity Organisations
149(1)
Assessment of Management Error?
150(1)
References
151(2)
Chapter 14 Communication Errors
153(8)
Communication Error Types
154(1)
Language Difficulties
155(1)
Drawings as a Means of Communication
155(1)
Warning
156(1)
Shift Handover
156(1)
Permit to Work as a Source of Plant State Knowledge
157(2)
Safeguards against Communication Errors
159(1)
Reference
159(2)
Chapter 15 Error Syndromes
161(18)
Improvisation
162(1)
Shortcuts
162(3)
Abandoning the Task
165(1)
Reversion to Stereotype
165(1)
Omission Due to Distraction
165(1)
Procedure Shift
166(1)
Neglecting Side Effects
166(1)
Overlooking a Precondition or Latent Hazard
167(1)
Too Narrow Basis for a Decision: Tunnel Vision
168(1)
Fixation
168(1)
Shift Change Errors
169(1)
The Forget--Remember Syndrome
169(1)
Repairing the Wrong Item, Dismantling the Wrong Equipment
170(1)
The Eager Beaver Effect
171(1)
Perfect Traps
172(1)
Reinterpretation of Instrument Failure as Normal
173(1)
Information Overload
174(1)
Ignoring `Nuisance Alarms'
175(1)
Switching Off Safety Systems
175(1)
Personalised Emergency Procedures
175(1)
Hidden Warnings
175(1)
Individual Specialties
175(1)
Piling on the Gas
176(1)
Using Safety Devices as Controllers
177(1)
Instrument Bypass
177(1)
Cleanup and Closeout
178(1)
Using Error Syndrome Patterns in Error Analysis
178(1)
References
178(1)
Chapter 16 Design Error
179(16)
The Design Process
179(3)
Design Thinking
182(4)
Design Errors Due to Lack of Knowledge
186(4)
Preventing Design Error
190(2)
Design Review
192(1)
References
193(2)
Chapter 17 Errors in Procedures
195(8)
Writing Operating Procedures
195(2)
Maintenance Manuals
197(1)
Method Statements
198(1)
Errors in Procedures
198(1)
Checking Written Procedures
199(1)
Procedural Drift
199(3)
Reducing Procedural Error
202(1)
References
202(1)
Chapter 18 Identifying Human Error Potential
203(22)
Action Error Analysis
204(1)
Latent Hazard Analysis
205(2)
Error Consequences
207(1)
Recovery
207(1)
Action Error Cause Analysis
207(4)
Risk Analysis of the Errors
211(1)
Risk Reduction
211(1)
Example of Action Error Analysis---Removing a Scraper from a Scraper Trap (Pig Receiver)
212(10)
Risk Reduction for the Scraper Trap Operation
222(1)
Tracking of Operational State against a Mental Model
223(1)
Observations on the Example Analysis
223(1)
References
224(1)
Chapter 19 Error Probabilities
225(40)
Why Do We Need to Quantify Error Probability?
225(1)
Risk Determination Based on Statistics
226(1)
Detailed Error Probability Determination
227(3)
Frequency of Latent Hazard Events
230(1)
Anchor Points
230(1)
Anchor Point Data---Examples
231(13)
An Error of Omission---Too Late Check
231(1)
Premature Termination of Production
232(1)
An Error of Omission
232(1)
Omission---Forgetting to Close Manifold Valves and Overlooking the Signs of Overflow
233(1)
Omission---Overlooking a Level Alarm
234(1)
Wrong Object---Confusion of the Item to Be Operated
235(1)
Wrong Object---Maintenance of the Wrong Item
236(1)
Too Late---Pump Draining
237(1)
Too Late---Tank Truck Filling
237(1)
Too Fast---Rough Operation
238(1)
Double Charging
238(1)
Overlooking Low Suction Pressure
239(1)
Failure to Respond in Time to a Power Failure
239(1)
Restarting Plant Operation with Tests Incomplete
239(1)
Failure to Remove Trip Bypasses
239(1)
Release Misjudgement
240(1)
Opening a Filter
240(1)
Risk Taking in Construction
241(1)
Commissioning Oversight
241(1)
Driveaway without Decoupling a Hose, an Oxygen Plant and an Ammonia Plant
241(1)
Walking Away with Tank Draining
242(1)
Forklift Truck Driving Too Fast or Too Unstable Load
242(1)
Piling on the Gas, Gasoline Transfer
242(1)
Erroneous Closure of a Drain Line
242(1)
Performance-Shaping Factors and Error Causes
243(1)
Simulators as a Source of Error Probability Data
244(1)
Summary of Anchor Point Frequencies
244(14)
Using the Human Error Probability Data
258(4)
Error Recovery
262(1)
Validation
263(1)
References
264(1)
Chapter 20 Examples of Human Error Analysis
265(16)
Action Error Analysis for Fuel Transfer to a Tank
265(5)
Task Risk Assessment
270(2)
Task Risk Analysis for Equipment Isolation
272(7)
References
279(2)
Chapter 21 Human Error Risk Reduction
281(6)
Operator Error Minimisation
281(1)
Training for Reliable and Safe Operation
281(1)
Good Displays
281(1)
Alarms and Trips
282(1)
Interlocks (Permissives)
283(1)
Permit to Work Systems
283(2)
Human Factors
285(1)
References
286(1)
Chapter 22 Conclusion
287(2)
Bibliography 289(2)
Index 291
J. Robert Taylor is the author of the QRA Open software, an open system for quantitative risk assessment, and the HAZEX software for manual and semi-automated HAZOP and Human error analysis, all open systems. He also prepared the database Hazardous Materials Release and Accident Frequencies for Process Plant. This is his third book on risk analysis and safety engineering topics. He now lives in Denmark, carrying out research on design error and the quality of risk analysis and occasional safety consultancy.