Index terms Links A - UFUftp.feq.ufu.br/Luis_Claudio/Books/E-Books/Safety/Guidelines_Preventing... · solvent mischarge in batch plant described 307 standard operating procedure design

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Index

Index terms Links

A Accident causation analysis. See also Root cause analysis system

(RCAS) data collection systems and 255 261 262 human error concept of 41 onion model of 262

Accountability, design process implementation guidelines 347

Action oriented techniques 162 decision/action flow diagram 169 hierarchical task analysis (HTA) 162 operational sequence diagram (OSD) 172 operator action event tree (OAET) 167 signal-flow graph analysis 176

Active human error accident causation analysis 41 defined xvii 43

Activity analysis, error prediction and reduction, data acquisition techniques 157

Age, performance-influencing factors 141

Alarms, control panel design 123

Allocation of function, human factors engineering/ergonomics 63

Anonymity, data collection systems, cultural factors 259

Atmospheric conditions, performance-influencing factors 112

Audit techniques MANAGER, sociotechnical systems 90 93 offshore emergency blowdown operations, case study 334

380 Index terms Links

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Audit techniques (Continued) system-induced error approach, performance optimization 21 traditional safety engineering 54

Authority, performance-influencing factors 145

Automation human factors engineering/ergonomics 63 offshore emergency blowdown operations, audit, case study 340 342

B Behavior modification, traditional safety engineering 48

Black box model 67 68

Blame and punishment corporate culture and 249 253 design process implementation guidelines 347 356

C Case studies 291

approach of 17 22 hydrocarbon leak from pipe 292 offshore emergency blowdown operations, audit 334 overview 291 solvent mischarge in batch plant

described 307 standard operating procedure design for 314

visual display unit design 325

Causation. See Accident causation analysis; Root cause analysis system (RCAS)

Change analysis, root cause analysis system, data collection 284

Checks, performance-influencing factors, task characteristics 127

Chemical process quantitative risk analysis (CPQRA) data collection systems 253



Chemical process quantitative risk analysis (CPQRA) (Continued) over reliance on, performance-influencing factors (PIFs) 146 task analysis, cognitive 181 186

Circadian rhythm, performance-influencing factors 116

Clarity of instruction, performance-influencing factors, task characteristics 126

Classification of error, cognitive systems engineering 68

Cognitive systems engineering 67 applications of 78

conclusions regarding 84 error prediction 79 error reduction 79 generally 78 root cause analysis using sequential error model 81 summarized 81

classification of errors 68 74 error recovery 76 knowledge-based mistakes 76 rule-based mistakes 74 slips and mistakes 74

generic error modeling system (GEMS) 70 human error perspective of 46 overview of 67 prediction 68 skill-, rule-, and knowledge-based classification 69 71 72 stepladder model

case example 94 described 76

Cognitive task analysis techniques 179 critical action and decision evaluation technique (CADET) 180 influence modeling and assessment systems (IMAS) 183



Cognitive task analysis techniques (Continued) overview of 179

Cognitive "tunnel vision", defined xvii

Communication offshore emergency blowdown operations, audit, case study 337 performance-influencing factors (PIFs) 142

Complexity, performance-influencing factors 110

Consciousness raising, of human error 3

Consequence analysis, risk assessment 216

Consultants, error prediction and reduction 155

Control actions, human-machine interface 62

Control panel design, performance-influencing factors 121

Corporate culture. See Cultural factors

Critical action and decision evaluation technique (CADET) 180

Critical Human Action Profile (CHAP) 282

Critical incident technique, error prediction and reduction 156

Critical task identification and screening analysis, risk assessment 209 211

Cultural factors blame and punishment 249 253 data collection 259 289 design process implementation guidelines 356 error-inducing conditions 18 rule book culture xix 146

D Danger, performance-influencing factors 110

Data acquisition techniques 154 See also Data collection activity analysis 157 critical incident technique 156 documentation 157



Data acquisition techniques (Continued) expert consultation 154 observation 156 simulators and mock-ups 158 withholding information technique 160

Data collection 247 See also Data acquisition techniques data types 260

chemical processing industry 260 generally 260

defined 247 implementation and monitoring 287 interpretation 268 methods 266

major incident analysis 267 personnel responsible for 266 reporting form design 266 storage and retrieval 267

organizational factors 255 overview of 247 root cause analysis system 270

change analysis 284 evaluation 285 generally 270 human performance investigation process (HPIP) 278 282 Management Oversight and Risk Tree (MORT) 273 274 root cause coding 275 278 279 sequentially timed events plotting procedure (STEP) 273 275 tree of causes/variation diagram 270

set-up 288 systems, generally 249 system types 251



Data collection (Continued) generally 251 254 incident reporting systems (IRS) 252 near miss reporting system (NMRS) 252 quantitative human reliability data collection system 253 root cause analysis system (RCAS) 253

Decision/action flow diagram, described 169

Decision-making stage human-machine interface 61 offshore emergency blowdown operations, audit, case study 338 340

Demand-resource mismatch view, of human error 15

Design factors error-inducing conditions 18 performance-influencing factors and 106 120 visual display unit design, case study 325

Disciplinary action, traditional safety engineering 53

Documentation error prediction and reduction, data acquisition techniques 157 predictive human error analysis (PHEA) 192

E Emergency situations, performance-influencing factors 149

Emotional control, performance-influencing factors 140

Encystment, defined xvii

Engineering. See Cognitive systems engineering; Human factors engineering/ergonomics; Process safety review procedures; Reliability engineering; Traditional safety engineering

Equipment design, performance-influencing factors 120

Ergonomics checklists 196 See also Human factors engineering/ergonomics (HFE/E) application of 196



Ergonomics checklists (Continued) examples of 196

Error. See Human error

Error-inducing conditions/ described 18

Error prediction and reduction 153 See also Predictive human error analysis (PHEA) cognitive systems engineering 68 79 81

83 data acquisition techniques 154

activity analysis 157 critical incident technique 156 documentation 157 expert consultation 154 observation 156 simulators and mock-ups 158 withholding information technique 160

ergonomics checklists 196 human error analysis techniques 189

overview of 189 predictive 190 work analysis 194

overview of 153 program benefits 10 risk assessment and 201

See also Risk assessment system-induced error approach, performance optimization 20 21 task analysis 161

action oriented techniques 162 applications of 161 cognitive techniques 179 evaluation of 187



Error prediction and reduction (Continued) purpose of 161

Error recovery, cognitive systems engineering 76

Events and Causal Factors Charting (ECFC) 282

Event tree, THERP case study 229

Experience, performance-influencing factors 133

Expert consultation, error prediction and reduction 154

External error mode, defined xvii

Externals, defined xvii

F Failure model, risk assessment, quantification process 225

Failure modes effects and criticality analysis (FMECA) over reliance on, management policies 146 performance-influencing factors and 109

False assumptions, case study illustrating 27

Fatigue, performance-influencing factors 115

Fault diagnostic support, performance-influencing factors 128

Fault tree construction human reliability role 202 representation 219

Feedback cognitive systems engineering, stepladder model 76 data collection 259 289 human error 8

G Generic error modeling system (GEMS) 70

Goals, design process implementation guidelines 347

Groups, performance-influencing factors 145



H Hazard and operability (HAZOP) study

hazard identification by 19 over reliance on, performance-influencing factors (PIFs) 146 performance-influencing factors and 109 risk assessment

critical task identification and screening analysis 211 human reliability role 202 205 206

Hazard identification, HAZOP 19

Health & Safety Executive Research Program (U.K.) 90

Hierarchical task analysis (HTA) case study, solvent mischarge 315 described 162

Hours of labor, performance-influencing factors 113

Human error 1 See also entries under Error benefits of elimination program for 10 case studies of 22 concepts of 39

accident causation analysis 41 generally 39 reliability engineering 40

costs of 5 demand-resource mismatch view of 15 neglect of, rationale for 10 overview of 1 perspectives on 44

cognitive systems engineering 46 67 See also Cognitive systems engineering human factors engineering/ergonomics 44 55 See also Human factors engineering/ergonomics



Human error (Continued) sociotechnical systems 46 85 See also Sociotechnical systems traditional safety engineering 44 47 See also Traditional safety engineering

probability, defined xvii role of, in accidents 4 system-induced error approach

case study approach illustrating 17 overview of 12 20 practical applications 19

Human error analysis techniques 189 overview of 189 predictive 190 work analysis 194

Human factors assessment methodology (HFAM) data collection systems and 265 design process implementation guidelines 356 performance-influencing factors and 105 109 sociotechnical systems 87 93

Human factors engineering/ergonomics (HFE/E) 55 See also Ergonomics checklists automation and allocation of function 63 evaluation of 67 human error perspective of 44 human-machine interface

control actions 62 decision-making stage 61 generally 56 perception stage 60

information processing and mental workload 62



Human factors engineering/ergonomics (HFE/E) (Continued) overview of 55 system-induced error approach, performance optimization 19 system reliability assessment and error 65

Human information-processing defined xvii human factors engineering/ergonomics 62

Human-machine interface defined xvii ergonomics checklists 197 human factors engineering/ergonomics 56

control actions 62 decision-making stage 61 generally 56 perception stage 60

inadequate, case study illustrating 24

Human performance evaluation system (HPES) cultural factors 259 personnel responsible 266

Human performance investigation process (HPIP) 278 282

Human reliability assessment methodology for, SPEAR 207 210 defined xvii

Hydrocarbon leak, case study 292

I Identifications, inadequate, case study illustrating 27

Implementation, data collection system 287

Implementation guidelines 345 design process 346

accountability, objectives, and goals 347



Implementation guidelines (Continued) change management 352 generally 346 incident investigations 356 process and equipment integrity 353 process safety review procedures 348 risk management 351 training and performance 354

overview 345 set-up 357

Incident reporting systems (IRS), described 252

Influence diagram approach (risk assessment) calculations for 241 quantification techniques 238

Influence modeling and assessment systems (IMAS), described 183

Information processing, human factors engineering/ergonomics 62

Inspection, design process implementation guidelines 353

Instruction, clarity of, performance-influencing factors 126 See also Training

Instrumentation scales, inappropriate, case study illustrating 27

Interface. See Human-machine interface

Internal error mechanism, defined xviii

Internal error mode, defined xviii

Internals, defined xviii

International Safety Rating System (ISRS) 54

Investigation management data collection types 262 design process implementation guidelines 356



J Job aids and procedures, performance-influencing factors 123

K Knowledge-based classification. See Skill-, rule-, and knowledge-based

classification (SRK)

Knowledge-based level of control, defined xviii

Knowledge-based tasks cognitive systems engineering, classification of errors 76 visual display unit design, case studies 328 332

L Labeling

equipment design, performance-influencing factors 120 inadequate, case study illustrating 26

Latent human error accident causation analysis 41 42 data collection and 257 defined xviii 43

Leadership, performance-influencing factors 145 See also Management policies

Lighting, performance-influencing factors, operating environment 111

Locus of control defined xviii performance-influencing factors (PIFs), personality factors 140

M Maintenance, design process implementation guidelines 353

Major incident analysis, data collection methods 267



Management Oversight and Risk Tree (MORT), root cause analysis system, data collection 273 274 278 284

Management policies design process implementation guidelines 352 error-inducing conditions 18 implementation guidelines, set-up 358 performance-influencing factors (PIFs), organizational and social

factors 145 root cause analysis system, data collection 286

MANAGER performance-influencing factors 105 sociotechnical systems 90 93

Manual variability, defined xviii

Mental model, human factors engineering/ergonomics 61 64

Mental workload, human factors engineering/ergonomics 62

Mindset syndrome cognitive systems engineering 76 defined xviii

Mistakes cognitive systems engineering 74 defined xviii

Mock-ups, error prediction and reduction 158

Monitoring data collection system 287 human factors engineering/ergonomics, automation 64

Motivation, performance-influencing factors 136

N Near miss reporting system (NMRS)

data collection systems 257



Near miss reporting system (NMRS) (Continued) described 252

Night work, performance-influencing factors 116

Noise, performance-influencing factors 111

O Objectives, design process implementation guidelines 347

Observation, error prediction and reduction 156

Offshore emergency blowdown operations, case studies 334

Operating environment, performance-influencing factors 109

Operating procedures, flawed, case study illustrating 30

Operational sequence diagram (OSD), described 172

Operator action event tree (OAET), de-scribed 167

Operator characteristics 133 experience 133 personality factors 135 physical condition and age 141

Organizational factors data collection

chemical processing industry 265 generally 255

error-inducing conditions 18 failures, case study illustrating 35 human error and 5 ineffective, case study illustrating 32 performance-influencing factors (PIFs) 142 system-induced error approach and 22

Organizational learning, performance-influencing factors 147



P Partitioned operational sequence diagram (OSD), described 175

Perception stage, human-machine interface 60

Performance-influencing factors (PIFs) 103 applications of 105 classification structures for 107 data collection systems and 264 defined xviii interactions of factors in 148 operating environment 109

chemical process environment 109 physical work environment 111 work pattern 112

operator characteristics 133 experience 133 personality factors 135 physical condition and age 141

organizational and social factors 142 teamwork and communication 142

overview of 103 risk assessment

qualitative human error analysis 212 success likelihood index method (SLIM) 234

task characteristics 120 control panel design 121 equipment design 120 job aids and procedures 123 training 128

variability of performance, normal and emergency situations 149

Performance optimization, system-induced error approach 19



Performance-shaping factors (PSFs) 103 See also Performance-influencing factors (PIFs)

Personality, performance-influencing factors 135

Personal protective equipment (PPE) performance-influencing factors 120 safety campaigns, traditional safety engineering 51

Physical condition and age, performance-influencing factors 141

Physical work environment, performance-influencing factors 111

Plant investigation, human performance investigation process (HPIP) 282

Policy factors, error-inducing conditions 18 See also Management policies

Population stereotype, defined xviii

Prediction. See Error prediction and reduction

Predictive human error analysis (PHEA) case study, solvent mischarge 319 321 described 190 risk assessment

qualitative analysis methods 218 219 qualitative human error analysis 213

Prevention. See Error prediction and reduction

Probabilistic safety analysis (PSA) 104

Problem solving, implementation guidelines 346

Procedures, performance-influencing factors 123

Process safety review procedures, design process implementation guidelines 348

Production requirements, safety requirements versus 129

Protocol analysis, expert consultation 155

Psychology personality, performance-influencing factors 135 root cause analysis system 286

Punishment. See Blame and punishment



Q Qualitative human error analysis 211

case study, in SPEAR 217 consequence analysis 216 error reduction analysis 217 overview of 211 performance influencing factor analysis 212 predictive human error analysis (PHEA) 213 task analysis 212

Quality assurance, Total Quality Management (TQM) 253

Quantification, risk assessment, human reliability role in 206 See also Risk assessment: quantification

Quantitative human reliability data collection system 253

Quantitative risk assessment (QRA) 103

R Reactance, defined xviii

Recovery analysis, predictive human error analysis 216

Recovery error, defined xviii 43

Reliability engineering, human error concept of 40

Reporting form design, data collection methods 266

Representation, risk assessment 219

Responsibility failures in, case study illustrating 34 performance-influencing factors 144

Rest pauses, performance-influencing factors 113

Retrieval methods, data collection 267

Risk assessment 201 critical task identification and screening analysis 209 211 defined xviii design process implementation guidelines 351



Risk assessment (Continued) human reliability role in 202

case study 202 error implications for 205 quantification aspects 206

implementation guidelines 346 overview of 201 qualitative human error analysis 211

case study, in SPEAR 217 consequence analysis 216 error reduction analysis 217 overview of 211 performance influencing factor analysis 212 predictive human error analysis (PHEA) 213 task analysis 212

quantification 222 human reliability role in 206 overview of 222

quantification process 224 quantification techniques 225

influence diagram approach 238 238 success likelihood index method (SLIM) 233 technique for human error rate prediction (THERP) 226

representation 219 system for predictive error analysis and reduction (SPEAR) 207 210

Risk homeostasis, defined xviii

Risk homeostasis theory (RHT), performance-influencing factors 138

Risk-taking, performance-influencing factors 137

Role ambiguity, defined xix

Role conflict, defined xix



Root cause analysis of, using sequential error model 81 case study, hydrocarbon leak, STEP 297 defined xix

Root cause analysis system (RCAS) See also Accident causation analysis data collection 264 270

change analysis 284 evaluation 285 generally 270 human performance investigation process (HPIP) 278 282 Management Oversight and Risk Tree (MORT) 273 274 root cause coding 275 278 279 sequentially timed events plotting procedure (STEP) 273 275 tree of causes/variation diagram 270

described 253

Root cause coding 275 278 279

Routine violations, case study illustrating 30

Rule-based classification. See Skill-, rule-, and knowledge-based classification (SRK)

Rule-based level of control, defined xix

Rule-based tasks error classification, cognitive systems engineering 74 visual display unit design, case studies 326 328 330

Rule book culture defined xix performance-influencing factors 146

Rules and procedures, performance-influencing factors 123



S Safety campaigns, traditional safety engineering 50

Safety management system audits, traditional safety engineering 54

Safety requirements, production requirements versus 129

Scheduling, performance-influencing factors 116

Sequential error model. See Skill-, rule-, knowledge-based classification (SRK)

Sequential Timed Event Plotting (STEP) case study, hydrocarbon leak 292 data collection system and 264 design process implementation strategies 357 root cause analysis system 273 275

Shift rotation, performance-influencing factors 116

Signal-flow graph analysis, described 176

Simulators and mock-ups, error prediction and reduction 158

Skill(s) deterioration of, human factors engineering/ergonomics 63 level of, performance-influencing factors 133

Skill-, rule-, knowledge-based classification (SRK) case examples 96 cognitive systems engineering 69 71 72 root cause analysis using 81

Skill-based level of control, defined xix

Skill-based task, visual display unit design, case studies 326 329

Sleep deprivation, performance-influencing factors 113

Slips cognitive systems engineering 74 defined xix

Social factors, performance-influencing factors 142

Sociotechnical approach to human reliability (STAHR). See Influence diagram approach (IDA)



Sociotechnical systems 85 comparisons among approaches of 93 human error perspective of 46 human factors analysis methodology 87 overview of 85 performance-influencing factors and 105 TRIPOD approach 86 U.K. Health & Safety Executive Research Program 90

Solvent mischarge, in batch plant, case studies 307

Spatial operational sequence diagram (OSD), described 176

Standard operating procedures (SOPs), solvent mischarge in batch plant, case studies 314

Stepladder model case example 94 described 76

Stereotype fixation, defined xix

Stereotype takeover, defined xix

Stimulus operation response team (SORTM) 282

Storage methods, data collection 267

Stress case study illustrating 23 performance-influencing factors

emergency situations 149 operator characteristics 134

risk assessment 235

Success likelihood index method (SLIM) 233

Suddenness of onset, performance-influencing factors 110

System factors. See Organizational factors

System for predictive error analysis and reduction (SPEAR) described 207 210 qualitative human error analysis and 211



System for predictive error analysis and reduction (SPEAR) (Continued) system-induced error approach, performance optimization 20

System-induced error approach case study approach illustrating 17 data collection and 256 overview of 12 20 practical applications 19

System reliability assessment, human factors engineering/ergonomics 65

T Task analysis 161

action oriented techniques 162 decision/action flow diagram 169 hierarchical task analysis (HTA) 162 operational sequence diagram (OSD) 172 operator action event tree (OAET) 167 signal-flow graph analysis 176

applications of 161 cognitive techniques 179

critical action and decision evaluation technique (CADET) 180 influence modeling and assessment systems (IMAS) 183 overview of 179

evaluation of 187 offshore emergency blowdown operations, audit, case studies 340 purpose of 161 risk assessment, qualitative human error analysis 212

Task characteristics, performance-influencing factors 120

Task modeling, risk assessment, quantification process 224

Teamwork, performance-influencing factors 142

Technique for Human Error Rate Prediction (THERP) case study 229



Technique for Human Error Rate Prediction (THERP) (Continued) data collection systems 254 described 226 representation, risk assessment 219

Technology, human factors engineering/ergonomics, over reliance on 65

Temporal operational sequence diagram (OSD) 172

Testing, design process implementation guidelines 353

Thermal conditions, performance-influencing factors 112

Time dependency, performance-influencing factors 110

Total Quality Management (TQM) 253

Traditional safety engineering 47 data collection and 255 defined xix disadvantages of 49 disciplinary action 53 error prevention and 48 human error perspective of 44 overview of 47 safety campaigns 50 safety management system audits 54 training 55

Training data collection set-up 289 design process implementation guidelines 354 offshore emergency blowdown operations, audit, case study 336 performance-influencing factors

clarity of 126 task characteristics 128

traditional safety engineering 55

Tree of causes/variation diagram 270



TRIPOD approach performance-influencing factors and 105 109 sociotechnical systems 86 93

Type A and B personality, performance-influencing factors 141

U Unforgiving environment, described 19

United Kingdom Health & Safety Executive Research Program, sociotechnical systems 90 93

V Vagabonding, defined xix

Variation diagram, tree of causes/variation diagram 271

Verbal protocol analysis, defined xix

Violation error accident causation analysis 42 defined xix 43

Visual display unit design, case studies 325

W Warnings, performance-influencing factors 127

Withholding information technique, error prediction and reduction 160

Work analysis, human error analysis techniques 194

Workload distribution, performance-influencing factors 143

Work pattern, performance-influencing factors 112

Documents

Index terms Links A - UFUftp.feq.ufu.br/Luis_Claudio/Books/E-Books/Safety/Guidelines_Preventing... · solvent mischarge in batch plant described 307 standard operating procedure design