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Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
Dirty Dozen 2010 Client Presentation 97 03
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Dirty Dozen 2010 Client Presentation 97 03

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The Dirty Dozen Causes of Errors are factors that can be learned and addressed to prevent errors. I use this presentation in training sessions.

The Dirty Dozen Causes of Errors are factors that can be learned and addressed to prevent errors. I use this presentation in training sessions.

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  • Delete this slide before presenting
  • Say that The Dirty Dozen are easy to understand and are common ways to look at human factors in pipeline operations(or control room operations or pipeline maintenance operations). Tell the audience how many incidents the company had in 2009, and emphasize that 2010 needs to be a better year.
  • Feel free to change these objectives for your objectives.
  • Ask or tell the audience to do these things during the presentation, saying you will collect the written down goals.
  • Although there are complicated definitions, human factors is the interaction(s) of people with other people, with procedures(and other instructions), with machines like computers with SCADA systems and alarms, and with their environment in the control room or the facility or in an office or a vehicle.
  • Ask if the organization has a strategy, a culture, leaders, resources, budget, and communications to and from the employees. Ask if the job has tasks, workload, displays, etc. Ask if all the controllers(operators, technicians) are just alike. These three elements are connected, strongly linked.
  • Ask if any of these items cause problems. Ask if they have examples.
  • Ask if any of these exist in the control room or in the facility. Develop a list and address them soon.
  • Ask if any of these things ever affect them. Say that this presentation today is designed to help them see how these factors might affect them.
  • Pause and let the audience read the list, then challenge them to do these things during 2010.
  • Say these were originally developed for aviation mechanics, but have been adapted to the pipeline industry. Point out that anyone should be able to look at the list and understand The Dirty Dozen.
  • Ask if anyone experiences this situation – things to do and others calling, talking, yelling. Point out that stress requires a demand, and the reason stress may cause an error or an accident is when the demands exceed our abilities to cope. One stress that a pipeliner may face is due to shiftwork. Stress and fatigue are closely related, and one cure is good for both. Sleep is important for managing both stress and fatigue.
  • Ask if anyone has ever experienced any of these effects. The correct answer is that everyone has experienced at least one of these effects. The key part of this discussion is help people become aware of what they did as a healthy response to the stressor.
  • If you have a better example for your employees, insert it here.
  • If you have a better example for your employees, insert it here.
  • This graph illustrates that stress is a necessary part of life. The absence of stress is death. Each of us faces basic living stressors first – making sure we(and possibly others) are safe, secure, sheltered, fed, groomed, rested, satisfied, educated, healthy and the list goes on. Then our job presents some stressors. What stressors do you face in your job? How do you handle them? A desirable level of work stress is at the level of “go go stress.” That is when our performance is approaching high levels and our stress levels are still within our capacity to cope. What we, and our company, needs to avoid is getting into “no no stress” area. Note to presenter: If you have an example of when your capacity to cope was challenged, this is a good time to share it.
  • Ask what “safety valves” people use to handle stress. If your company provides materials or assistance, tell what those are.
  • Fatigue is a big issue in all modes of transportation. PHMSA has issued the final Control Room Management rule that states in the summary of the final rule: “Operators(pipeline company) must also implement methods to prevent controller fatigue.” That will prove impossible for shift workers. Fatigue is inherent, so what will we do? We will begin with education.
  • Ask which of these have affected people in the audience.
  • Ask for other examples.
  • The NTSB commissioned a study that examined a number of pipeline spills where controllers were involved. The study found that controllers MIGHT have been fatigued and that fatigue contributed to the accident. As a result, the NTSB recommended to Congress and PHMSA that regulations be developed. The NTSB has one “most wanted” for the pipeline industry: “Reduce accidents and incidents caused by human fatigue.” The objective is to “set working hour limits for pipeline controllers based on fatigue research, circadian rhythms, and sleep and rest requirements.”
  • If you get 8 hours of sleep in every 24 hour day, you will handle fatigue well. If not, you will have fatigue issues. Ask how many get 8 hours of sleep in every 24 hour day.
  • Complacency occurs when people are doing routine tasks over and over again, and they do not have any problems. Remember that the risks always exist, and do not be lulled into complacency.
  • Ask people if any of these effects might happen to them. Why?
  • Ask for examples from your company.
  • Discuss the slide content.
  • The five questions and STAR explanation are on the next slide. Independent verification means that one person asks another person to independently check his/her work or figures or positioning of equipment.
  • Provide an example. Perhaps a new task is being performed. 1. I am doing this task because a new pipeline segment has been installed with a new flow controller. 2. Although all the new equipment has been tested and I have been trained on the new procedure, the new flow controller may not work as smoothly as the previous one or I may be too cautious and I may block the line and cause an overpressure situation. 3. The probability of that happening is low, as long as I follow the procedure and monitor the pressure carefully. 4. If it does happen, I have the ability to address the abnormal situation and can get assistance from others. 5. I can do the new task carefully, based on the procedure and my experience as a controller. STAR can be a person’s good aid. Stop or pause before doing the task. Think about what you want to do and the expected result. Act by doing the task. Review and make sure you got the expected result. If not, make the necessary correction.
  • A control room is an environment with plenty of distractions. Some of the distractions may come from necessary equipment or people. Some are self-induced. We usually like the self-induced distractions and even seek them. We usually find the others irritating. Any or all can cause us to lose focus on the task.
  • Ask how interruptions might cause an error. State that multitasking is a myth, although many pipeline companies state that multitasking is a job requirement. What we do is switch between tasks. We can become better at switching tasks, but at a cost.
  • There is much attention being paid to the dangers of using phones and other devices while driving. Does your company have a policy about driving and using devices? It should, and the policy should forbid using devices while driving. What examples have occurred where you work?
  • What is done in your control room to minimize the effects of distractions?
  • These safety valves work, but people find them hard to do. What can the organization do to minimize distractions?
  • Ask what do people think the quote means. It likely means that pressure and stress are so commonplace that they affect us all the time, particularly in some “seasons.” Those seasons might be budget, when the line is shutdown, when there has been an accident, etc.
  • Pressure exists, and it is real. It may be self-imposed, and it is certainly imposed by company expectations, the cognitive tasks or the physical tasks in our jobs, and the environments in which we work, travel, and live. Watch for pressure when project deadlines are near!
  • This Department of Energy report documented the number of injuries and near misses in one type of operation. Ask when pressure has caused problems in your company, particularly in the control room. Some possible answers are on the next slide.
  • See if the examples given match any of these.
  • Ask what other safety valves might help with pressure.
  • Lack of awareness is when we do not notice or think about what is happening, what the risks are, and what could happen during the task or after the task or as a result of the task.
  • Ask if someone will explain or interpret what this means. A simple explanation is that 1. I have to be aware of what is going on in my work area, by using my senses and intuition. 2. I have to understand what the current task is going to involve with all those critical elements in my work area. 3. I need to predict accurately what is going to happen when the task is performed – what will happen, what will change, what is success, what is failure? And what I need to do if something fails.
  • Very, very common example because people cannot see the buried pipeline and they are paying more attention to the task.
  • What we see right in front of us, combined with what we are used to seeing in front of us in the past, has a more powerful effect on our situational awareness than an explanation that something is changed and the display is not accurate. It has always been accurate before. This error was “charged” to the SCADA technician who did not change the display and to the manager who approved this temporary workaround. The controller was set up to fail and did.
  • These safety valves should be easy to understand. A safety zone is created by knowing what is happening in front, behind, above, and below. A controller’s tasks and number of tasks can be complex and multi-stepped. In a complex task, it is difficult to maintain vigilance. Human performance principles include 1. people are fallible and even the best make mistakes; 2. Error-likely situations are predictable, manageable, and preventable; 3. Individual behavior is influenced by organizational and job factors; 4. People achieve good performance largely due to encouragement and reinforcement received from managers and co-workers; 5. Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events. I put these on the next slide. If you don’t want to get into these, deletd that safety valve.
  • I include these principles as part of lack of awareness, but they are overarching principles for error prevention and management.
  • Lack of assertiveness may not be a problem where you work. Is it? Think about the interactions between controllers and field personnel, controllers and controllers, controllers and schedulers, managers and employees, trainers and trainees. There is a need for every person to be assertive without becoming aggressive or angry. Ask the audience to tell the differences.
  • Discuss whether this occurs in your workplace. If it does occur, what harm might it do?
  • Ask for examples
  • I would hope the individual and work group and company values and beliefs match and that no one is ever pressured to compromise the standards, regulations, and operating procedures. The control room management rule requires that roles and responsibilities be defined. That task can serve as a great opportunity for all people to express their opinions and beliefs about the job.
  • Do you ever receive alarms and then someone calls and tells you they are false. What other examples of poor communication have you experienced?
  • Ask if they agree with these statements and what other ways lack of communication affects them.
  • Ask for more examples
  • 3-way communication means I tell you something, you repeat it back correctly, and I say “correct.” If you repeat it back incorrectly, I say “wrong” until you repeat it back correctly. All companies say they have a Management of Change process; all companies do not use their process for some changes that affect controllers and operators. The final control room management rule requires that companies “provide adequate information.”
  • Ask people to repeat after you. “I have the necessary knowledge to perform my job.” Ask why that is important. The person on the stretcher had been trained in high voltage maintenance procedures. Training is not knowledge.
  • Have any of these factors ever affected any of you?
  • Real examples, and there are more. What examples have occurred where you work?
  • These are basic safety valves for individuals. What does the organization do to ensure that people have adequate knowledge?
  • Ask, “What is the best way to learn from mistakes?” Why? Ask, “Why is it difficult for some people to learn from the mistakes of others?” One reason is that some people think they would never make that mistake. Remind them of the human performance principles.
  • This cartoon is about quality testing supplies? Ask what other resources are necessary. Be sure they remember that humans are a resource.
  • Discuss slide content.
  • Ask, “Do we have adequate resources to prevent fatigue, provide adequate information, maintain our training, and have adequate SCADA displays and alarm management? Ask, “Why do I ask that question?” It relates to the control room management rule.
  • What other safety valves are necessary when it comes to resources?
  • I don’t know if your company has teams or not, but a pipeline does require people in the same location and in other locations to do what a team is supposed to do. A team should have a shared purpose, such as transporting oil or gas safely from one point to another. A team should define roles and responsibilities, communicate with one another, assist one another, and build trust in order to achieve shared goals. There should be team rewards, recognition, and discipline.
  • Ask if anyone has ever been a member of a team that worked well or worked poorly. Discuss the differences.
  • Ask for other bad examples.
  • Ask for other good examples.
  • Ask the questions on the slide.
  • Discuss these safety valves.
  • Norms can be good or bad, and it is the bad norms that cause accidents and errors. Ask, “How many of agree with the man checking the gauge?” Also ask, “Do we do the job correctly, like checking a gauge, when it is 0430 and we are fatigued? What difference could it make by not getting up and reading one gauge on one shift?”
  • What are the norms at your work location? Are they the same at all work locations on the pipeline system? Why or why not?
  • Say that both these norms existed at one company. The first bullet example existed for many years. The second bullet example became the norm for one reason. What is the reason? The company had a major spill that caused significant environmental damage, massive fines, and a criminal conviction.
  • Look around your workplace for “clues” of norms. Check the housekeeping, the language with one another and with customers, the ways procedures are used or not used, and what behaviors get rewarded or punished.
  • Now we have looked at The Dirty Dozen. During 2010, we will emphasize one of these factors each month. A sheet for reading, discussion, and application will be provided.
  • Ask if people have met the goal. Encourage them to do so before leaving the meeting and give the written goal to you.
  • Review the objectives and achieve agreement that they have been accomplished.
  • Repeat that The Dirty Dozen are easy to understand and are common ways to look at human factors in pipeline operations(or control room operations or pipeline maintenance operations). Remind them of how many incidents the company had in 2009, and emphasize that 2010 needs to be a better year.
  • Not necessary to use this slide in presentation.
  • Not necessary to use this slide in presentation.
  • Not necessary to use this slide in presentation, but you could use it to tell the audience about where you got the calendars, presentation, and article.
  • Transcript

    • 1.  
    • 2. Suggested Instructions for Presenter
      • Use this presentation at a meeting or training session early in the year.
      • Ask each person to participate by thinking of examples when one of these causes affected them; ask them to write down the examples.
      • Ask each person to make learning and developing ways to avoid “The Dirty Dozen” a goal for 2010; ask for specific SMART goals.
    • 3. Suggested Instructions for Presenter(continued)
      • Tell them they will receive an article each month; hand out the article on “Stress” during the session.
        • Demonstrate how the article can be used for reading, discussions, and development.
      • Complete the presentation in one hour, OR
      • Present an overview early in the year, and use other parts in other meetings.
    • 4. Slide for Your Content
      • Your company has some goals, I hope, related to safety, operational excellence, quality assurance, error reduction, human factors.
      • Use these blank slides to link those goals, strategies, tactics, initiatives to The Dirty Dozen.
      • Delete the blank slides you do not use.
    • 5.  
    • 6. Presentation Objectives
      • Provide an introduction to human factors.
      • Present “The Dirty Dozen.”
      • Provide examples from pipelines.
      • Lead you to think of examples.
      • You provide examples and discuss.
      • Suggest some “Safety Valves.”
    • 7. Today’s Goal for You
      • Identify at least three of “The Dirty Dozen” that affect you.
      • Write down how you can address them, so they do not affect you.
      • Tell your manager about “The Dirty Dozen” and your goal.
      • Tell your manager the results in one month.
    • 8. Simple Definition of Human Factors
      • Interaction of:
        • People with people
        • People with procedures
        • People with machines
        • People with their environment
    • 9. Human Factors – Key Aspects!
      • ORGANIZATION
        • Strategy
        • Culture
        • Leadership
        • Resources
        • Work patterns
        • Communications
      What are people being asked to do and where?
      • JOB
      • Tasks
      • Environment
      • Workload
      • Displays & controls
      • Alarms
      • Procedures
      • INDIVIDUAL
        • Risk perception
        • Competence
        • Skills
        • Personality
        • Attitude
      Where are they working? Who is doing it?
    • 10. Organizational Factors
      • ORGANIZATION
        • Inadequate work planning, leading to high work pressure
        • Lack of safety systems and barriers
        • Inadequate responses to previous incidents
        • Inadequate leadership and management
        • Inadequate communication
        • Inadequate work standards
        • Poor management of health and safety
        • Poor safety culture
      Where are they working? What might cause problems?
    • 11. Job Factors
      • JOB
        • Poor design of equipment and instruments
        • Constant distractions and interruptions
        • Missing or unclear instructions
        • Poorly maintained equipment
        • Lack of parts and supplies
        • High workload
        • Noisy and unpleasant working conditions
      What are people being asked to do and where? What might cause problems?
    • 12. Individual Factors Who is doing it? What might cause problems?
      • INDIVIDUAL
        • Low skill and competence levels
        • Low physical or mental capabilities
        • Personal or family problems
        • Tired and stressed
        • Bored or discouraged
        • Medical problems
    • 13. What Can I Do?
      • I can learn my capabilities and limitations.
      • I can learn the ways I think, act, and behave.
      • I can learn and avoid “The Dirty Dozen.”
      • I can develop and use “Safety Valves.”
      • I can understand that organizational and job factors are major contributors to accidents and errors.
      • But I can take responsibility for my errors, and learn from any near misses and incidents.
    • 14. The Dirty Dozen
      • Stress
      • Fatigue
      • Complacency
      • Distractions
      • Pressure
      • Lack of Awareness
      • Lack of Assertiveness
      • Lack of Communication
      • Lack of Knowledge
      • Lack of Resources
      • Lack of Teamwork
      • Norms
    • 15.  
    • 16.
      • Anxiety, nervousness, jumpiness
      • Difficulty concentrating on task
      • Feeling overwhelmed
      • Fatigue
      • Health problems
      • Memory problems
      • Poor judgment
      Stress Effects
    • 17.
      • Pipeline controller who normally performed well.
      • Makes several errors where he forgot to do a task at the correct time.
      • Part of his “action plan” was to work with me on improving his work planning and ways to use reminders.
      • He told me(hadn’t told others) that:
        • He was having financial problems, and
        • His wife and children had left him, and
        • He was not sleeping much.
      Stress – Pipeline Example
    • 18.
      • Pipeline operator who normally performed well.
      • Was performing a valve inspection.
      • Closed a manual mainline valve and shut the line down.
      • Why?
      • Was not concentrating on task, because of a personal problem.
      • Mentally distracted.
      Stress – Pipeline Example
    • 19. Low Medium High STRESS PERFORMANCE High Basic Living Stressors Basic Job Stressors Capacity to Cope Caution Danger Distress Yerkes-Dodson Curve (1908) Adapted by G. Dupont Danger Go Go Stress So So Stress No No Stress Stress Curve Model
    • 20.
      • Be aware of the effects of stress on your work.
        • Does your company provide educational materials?
        • Materials are available.
      • Discuss what is happening with someone.
      • Ask a co-worker to check your work.
      • Take time off; take breaks regularly.
      • Turn off your devices, when not on duty.
      • Eat properly, rest adequately, exercise.
      • Plan an appropriate course of action, when stress is evident.
      Stress – Safety Valves
    • 21.  
    • 22. Fatigue Effects
      • Make more mistakes.
      • Delayed reactions.
      • Difficult to maintain attention and awareness.
      • Not able to handle much information.
      • Every task becomes more difficult to perform.
      • Doesn’t want to talk or interact with people
      • Irritable or bad mood.
      • Involuntary lapses into sleep may occur.
    • 23.
      • During a shutdown, a crew worked 34 hours installing a new piping system.
      • At hour 28, a laborer was trying to get two flanges aligned.
      • He stuck his hand in the wrong place.
      • Two fingers were cut and smashed.
      Fatigue – Pipeline Example
    • 24.
      • Pipeline controllers – a few NTSB reports
      • Either the controllers do not react quickly to abnormal operating conditions, OR
      • They do not react correctly.
      • People who work rotating shifts have the effects of fatigue.
        • Many examples from all over the world.
        • Fatigue in today’s world is a human problem, a socio-technical effect of the way we live.
      Fatigue – Pipeline Example
    • 25.
      • Get adequate amounts of sleep.
        • 8 hours each day/night for most people.
      • Educate self on causes and cures of fatigue.
        • Many resources on fatigue management.
      • Get a physical check-up annually.
        • Address any sleep disorders.
      • Eat properly and drink plenty of fluids.
        • Use caffeine strategically.
      • Exercise regularly.
      Fatigue – Safety Valves
    • 26.  
    • 27.
        • Letting your mind wander.
        • Taking shortcuts and omitting steps.
        • Fooling around or showing off.
        • Thinking that everything will work perfectly.
        • Working too long without a break.
        • Taking the attitude that safety is someone else’s job.
        • Performing a task without using the procedures or recommended personal protective equipment.
      Complacency Effects
    • 28.
      • Corrective Maintenance Performed On Wrong System
        • Familiarity and complacency with the work environment allowed workers to troubleshoot an electrical system that was not isolated.
      • Opened wrong valve
        • Person reported that he had performed task hundreds of times. Didn’t think about task.
      • Did not refer to procedure, and performed task incorrectly.
      Complacency – Pipeline Example
    • 29.
      • Understand the human factors involved:
        • We have a mental bias that allows our past experiences to guide present expectations.
        • We don’t use our brains fully in the situation since our present circumstances normally match our past circumstances
        • We devote our brains to more interesting parts of a task, or to a more interesting task.
      • Recognize that “It can’t happen to me” is a wrong belief.
      • Expect success, but be prepared for failure.
      Complacency – Safety Valves
    • 30.
      • Always practice risk assessment.
        • Use the 5 Questions
      • Use STAR with every task.
      • Practice independent verification.
      • Follow all policies and procedures.
      • Train continually and review often.
      • Create mental challenges for yourself.
      • Sustain a questioning attitude.
      Complacency – Safety Valves
    • 31.
      • Five Questions – Simple Risk Assessment
        • Why am I doing this task at all?
        • What could go wrong?
        • How likely is it to happen?
        • What effect could it have on me or others?
        • What can I do about it?
      • STAR
      Complacency – Safety Valves R EVIEW S TOP T HINK A CT
    • 32.  
    • 33.
      • Interruptions
        • How can interruptions cause an error?
      • “ Multitasking is counterproductive.” (CNN.com)
      • “ Multitasking makes us stupid.” (WSJ article)
        • There is a ‘time-cost’ to switching tasks.
        • There is a ‘switching-cost’.
        • One must change goals.
          • What do I want to do now?
        • One must change rules.
          • What rules apply to this task?
      Distractions
    • 34.
      • Driving and Doing Other Things
        • Vehicle accidents
        • Near misses
      • People talking on phones, surfing Internet, etc. and failing to notice that it is time to perform a task OR ignoring an alarm or other signal.
      • Technician was interrupted during a task and did not return pressure switch to service. Caused damage to equipment, and an abnormal operation.
      Distractions – Pipeline Examples
    • 35.
      • Televisions, radio, internet surfing.
      • Talking to others in the room or on the phone.
      • What else?
      • What do you do about distractions?
      Distractions – Control Rooms
    • 36.
      • Minimize or eliminate distractions.
      • Ask people to be quiet and leave your area.
      • Finish the task if possible.
      • Complete tasks step by step.
      • Flag or tag all uncompleted work.
      • Use STAR.
      • Use memory aids.
      • Focus by practicing mindful attention.
      Distractions – Safety Valves
    • 37.  
    • 38.
      • Demands are sometimes made for workers to:
        • Meet unrealistic deadlines.
        • Be multi-skilled.
        • Do many tasks in a workday, while multitasking.
        • Be as good or better than coworkers.
        • Perform all tasks safely and without error.
      • Over time or anytime, these pressures can cause performance problems.
      • Can cause accidents and injuries.
      Pressure
    • 39.
      • For instance, during the 36-month period from January 1, 2001 through December 31, 2003, 18 workers were injured and approximately 86 others were involved in near miss events.
        • Often pressure to “get the job done” results in actions that can permit disastrous consequences (i.e., personal injury and/or property damage).
        • This is from a DOE report.
      • Technicians were pressured by managers to work excessive hours to repair a pump. The repair took longer because the technicians, being fatigued, made some mistakes that caused rework.
      Pressure –Example
    • 40.
      • Perform tasks when a protective device is not working properly or a safety device is inhibited.
      • Take a shortcut in a procedure.
      • Do things that may compromise safety or quality, for the sake of profitability.
      • Work an extra shift or extra hours, when fatigued.
      • Do too many tasks at once, or in a short time period.
      • Stay at the console, when you need a break.
      • Work in a stressful environment, even when improvements can easily be made.
      Pressure in Control Rooms
    • 41.
      • Don’t overwhelm yourself or others.
      • Don’t be afraid to ask for help.
      • Communicate your concern to your manager and coworkers.
      • Don’t create a false sense of urgency.
      • Don’t take shortcuts; do the job right.
      • Say no to pressure.
      • Develop good planning and coping skills.
      Pressure – Safety Valves
    • 42.  
    • 43.
      • Perceive(see, hear, notice) the critical elements around you.
      • Understand what those critical elements mean, particularly as they relate to the current task.
      • Forecast what is going to happen in the near future.
      Situation Awareness
    • 44.
      • Excavation damage to pipelines
        • “ Didn’t know a pipeline was here.”
        • “ Thought the pipeline was a few feet over.”
        • “ Didn’t think I would damage the line by digging with the hoe.”
      Lack of Awareness - Pipeline Example
    • 45.
      • Controller has no change in display, but field equipment has changed.
        • Received brief explanation of change.
        • Is “aware” he cannot rely on display as “accurate.”
        • Relying on Controller to maintain “awareness of change” and make switch correctly.
        • Controller did not make switch correctly.
      Lack of Awareness - Pipeline Example
    • 46.
      • Learn the principles and practices of situation awareness.
      • Pay attention to your surroundings.
        • Create a “safety zone.”
      • Recognize that jobs and the requirements are complex.
      • Understand that vigilance can deteriorate while performing a task.
      • Learn and use human performance principles. (next slide lists them)
      Lack of Awareness Safety Valves
    • 47. Human Performance Principles
      • People are fallible and even the best make mistakes.
      • Error-likely situations are predictable, manageable, and preventable.
      • Individual behavior is influenced by organizational and job factors.
      • People achieve good performance largely due to encouragement and reinforcement received from managers and co-workers.
      • Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events.
    • 48.  
    • 49.
      • In group settings, some people are hesitant to express their opinions.
        • Affects work planning, hazard analysis, safety concerns.
      • New employees may not ask relevant questions, even when uncertain.
        • Can cause accidents, rework, quality issues.
      • Some employees will not contradict managers or experienced employees.
      Lack of Assertiveness
    • 50.
      • Younger employee knew more experienced employee was not following company requirements, BUT did not question … AND nothing happened for months, until a tank overflow.
      • Controller did not question temporary operating directions, which led to an abnormal operating condition.
      Lack of Assertiveness Example
    • 51.
      • Practice your values and beliefs.
      • Practice the company’s values and beliefs.
      • Refuse to compromise company and personal standards.
      • Ask for what you need.
      • Don’t be afraid to express your opinion and ideas.
      • Recognize your contributions matter.
      • Learn how to be assertive on the job.
      Lack of Assertiveness – Safety Valves
    • 52.  
    • 53.
      • Lack of communication affects performance:
        • Misunderstandings occur between workers.
        • Hurt feelings lead to petty disagreements.
        • Job doesn’t get done or is delayed.
        • Anger may affect individuals or groups.
        • Loss of trust and respect.
        • Near misses or incidents may result.
        • Performance of individuals and groups suffers.
      Lack of Communication
    • 54.
      • Field technician did not inform controller of a communication device failure, and the controller was not receiving accurate information. Abnormal event!
      • Scheduler did not properly inform operator of change and product was contaminated.
      • Many, many, many other examples.
      Lack of Communication Example
    • 55.
      • Practice 3-way communication.
      • Write down important information.
      • Always conduct briefings before, during, and after jobs.
      • Use the Management of Change process(even for small changes in the control room and elsewhere).
      • Provide the right information to the right people at the right time.
      • Don’t tell someone something when they are in the middle of doing something else.
      • Give people your full attention when listening.
      • Expect people’s full attention when talking.
      Lack of Communication – Safety Valves
    • 56.  
    • 57.
      • Factors contributing to lack of knowledge:
        • Inadequate training
        • New equipment
        • Procedures and regulations
        • New technology.
      • Provide adequate training and reference materials.
      • Use resources like the expertise of other people on shift, other people, and the manufacturer’s manual.
      • Teamwork and communication help to reduce the potential error due to the lack of knowledge.
      • Address all changes, including temporary ones.
      Lack of Knowledge
    • 58.
      • Technician did not know the procedure for maintenance on electrical equipment, BUT did the task AND was injured.
      • Operator did not know how to locate the pipeline and marked its location incorrectly, AND line got damaged.
      • Controller did not receive training, after a change in operating procedures, AND product was contaminated .
      Lack of Knowledge Example
    • 59.
      • Get the necessary training and practice.
      • Use procedures and manuals.
      • Don’t do a task if you do not know how to do it safely and correctly.
      • Ask someone who knows.
      • Don’t let pride get in the way.
      • Be a lifelong learner.
      • Learn from mistakes.
      Lack of Knowledge – Safety Valves
    • 60.  
    • 61.  
    • 62.
      • When supplies are not available, employees spend time trying to find substitutes.
      • When parts are not available, delays are necessary while a part is ordered, made, or retrofitted.
      • Employees are tempted to omit steps that require a missing resource.
      • Employees may “guess” at a solution, if the correct resource is not available.
      Lack of Resources
    • 63.
      • Most pipeline companies are operating with fewer employees than they had a few years ago.
        • The result is that employees are doing more tasks, driving more miles, working more overtime.
        • Causes stress, pressure, fatigue.
        • This can lead to errors, accidents, injuries.
      • Most pipeline companies are reducing expense budgets.
        • Fewer spare parts and supplies are available.
        • Fewer employees are available.
        • Fewer dollars are available for training.
      Lack of Resources Example
    • 64.
      • Have the correct people complement for the schedules required to operate the pipeline.
      • Assess needs for new parts before beginning a job.
      • Purchase and maintain critical parts inventory.
      • Don’t compromise standards if the correct resources are lacking.
      • Don’t use work arounds if you don’t have the proper parts or supplies.
      Lack of Resources – Safety Valves
    • 65.  
    • 66.
      • Roles and responsibilities, if not clear, cause confusion and frustration.
      • Teamwork problems lead to performance issues.
      • Decisions are made by one or two people in the group, without the team’s knowledge.
      • Problems and underlying issues may not be addressed.
      • Trust and respect are compromised.
      • Cynicism and sarcasm are present.
      Lack of Teamwork
    • 67. Lack of Teamwork Example
      • Tank Volume Record Keeping – Employee purposely recorded wrong volume to cover up his mistake. He got fired for lying.
    • 68. Good Teamwork Example
      • Tank Fire – When lightning caused a tank fire, the regular drills with employees and local fire departments proved that teamwork and preparation was worthwhile.
    • 69.
      • Is teamwork necessary?
        • On shift
        • Between shifts
        • With field operations
        • With support functions
        • With management
      • Does teamwork exist, in your control room?
      • What makes your team successful?
      What About Control Rooms?
    • 70.
      • Clarify the team goals.
      • Have an effective team plan.
      • Clearly define the roles.
      • Clear communication.
      • Reward good team behavior.
      • Punish poor team behavior.
      • Use well-defined decision procedures.
      • Balanced participation.
      • Establish ground rules.
      • Be aware of the group interactions.
      Lack of Teamwork – Safety Valves
    • 71.  
    • 72.
      • Norms can be positive or negative.
        • Use procedures or not.
        • Completing checklists or pencil whipping.
        • Naps encouraged or punished.
      • Norms exist for a reason
        • Restaurants have signs requiring employees to wash their hands. Why?
        • Sign in Nashville restaurant says “wash hands twice.” Why?
      • Norms are set by the employees
        • Pipeline example on next slide
      Norms
    • 73.
      • “ Do not shut the pipeline down for any reason.”
      • OR
      • “ Every employee has the authority to shut the pipeline down if he or she suspects a problem.”
        • Which one of those is closer to the norm for your company?
      Norms Example
    • 74.
      • Recognize norms where we work and live.
      • Work on removing bad habits and behaviors.
      • Accentuate the positive, eliminate the negative.
      • Don’t use shortcuts.
      • Abide by standards and requirements.
      • Be a good example for others.
      • Follow policies and procedures.
      • Keep in mind the “old way” may not be the correct way.
      Norms – Safety Valves
    • 75. The Dirty Dozen
      • Stress
      • Fatigue
      • Complacency
      • Distractions
      • Pressure
      • Lack of Awareness
      • Lack of Assertiveness
      • Lack of Communication
      • Lack of Knowledge
      • Lack of Resources
      • Lack of Teamwork
      • Norms
    • 76. Today’s Goal for You
      • Identify at least three of “The Dirty Dozen” that affect you.
      • Write down how you can address them, so they do not affect you.
      • Tell your manager about “The Dirty Dozen” and your goal.
      • Tell your manager the results in one month.
    • 77. Presentation Objectives
      • Suggest a goal for you.
      • Provide an introduction to human factors.
      • Present “The Dirty Dozen.”
      • Provide examples from pipelines.
      • Lead you to think of examples.
      • Suggest some “Safety Valves.”
    • 78.  
    • 79.  
    • 80.  
    • 81.  
    • 82.  
    • 83.  
    • 84.  
    • 85.  

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