Theres An Elephant In The Control Room V4


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Presentation from 2010 Control Room Forum. Open in notes view for more information

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  • An elephant is a big, hairy, loud beast that takes up lots of room. You may think there’s a whole herd of elephants in your control room – all the pieces of the CRM rule. Let me tell you a story.
  • There were these six blind men who were placed around an elephant. They felt what was in front of them, and thought there was a snake, a spear, a column, a fan, a wall, and a rope. None of them recognized this was an elephant. We do that, even though we can see. We see alarm management, change management, SCADA, fatigue management, training, shift change, and the pieces. And we mostly see the piece that most interests us. I hear much about alarms and SCADA because those are more technical aspects. A control room is a sociotechnical system, and we need to look at the whole elephant, not just the pieces.
  • These are the musts – time off and training; have you reduced the risks of fatigue? Yes, if controllers are sleeping eight hours at night or in the daytime and they receive adequate days off to recover from several shifts of night shift or day shift. Training is good, and a necessary part of fatigue management.
  • These are statements of interest, and we heard many others yesterday about sleep science.
  • If our blind men had been here yesterday, they would know that training, sleep opportunity, and maximum hours of service are important. I evaluated the online courses offered by SGA a few weeks ago, and think they are a simple way to complete the training requirements. But I believe in an educational program approach more than a single training course.
  • The real elephant in the room, which we don’t want to talk about, is those pesky people. And fatigue has immediate effects on performance and long term effects on our systems.
  • I was reading this mystery a few weeks ago. It is an accurate statement about people, I think. This is why we say, “I can’t control what the people do when they’re off. How do I know whether they sleep or not?”
  • Here’s the approach I think provides a more rigorous approach to fatigue management. If you have ever worked for a company that received attention from NTSB investigators, OPS taskforces, and other government agencies, you will never think about risk the same ways again.
  • I recommend to my clients that we use a risk-based approach to fatigue management. Today I am going to provide an overview of fatigue hazard analysis.
  • Theres An Elephant In The Control Room V4

    1. 1. There’s an Elephant in the Control Room<br />API Control Room Forum<br />
    2. 2. The Elephant and the Blind Men<br />
    3. 3. Specifics about Fatigue Mitigation<br />
    4. 4. Other Statements in Summary<br />PHMSA requires that operators implement methods to reduce the risks associated with fatigue.<br />PHMSA expects that operators will consider circadian effects, need for rest, and other factors highlighted by relevant research.<br />
    5. 5. Fatigue in Rule: What Do We See?<br />Training*<br />Training*<br />Maximum hours of service<br />Reduce risks<br />Consider<br />research<br />Sleep opportunity<br />*SGA Online Courses<br />
    6. 6. PEOPLE<br />Elephant in the Room is<br /><ul><li>Irritability
    7. 7. Cognitive impairment
    8. 8. Memory lapses or loss
    9. 9. Impaired moral judgment
    10. 10. Severe yawning
    11. 11. Hallucinations
    12. 12. Symptoms similarto ADHD
    13. 13. Increased heart rate variability
    14. 14. Risk of heart disease
    15. 15. Decreased reaction time and accuracy
    16. 16. Tremors
    17. 17. Aches
    18. 18. Impaired immune system</li></ul>Other:<br /><ul><li>Growth suppression
    19. 19. Risk of obesity
    20. 20. Decreased temperature
    21. 21. Risk of diabetes Type 2</li></li></ul><li>People are Unpredictable!<br />“<br />People are unpredictable creatures, they invent rules which they break incessantly and they follow impulses which they later cannot explain.<br />“<br />
    22. 22. Non-work-relatedFatigue<br />Work-related Fatigue<br />Hours of work<br />(Sleep Opportunity)<br />Job/Org.<br />Factors<br />Fatigue Modeling Software<br />Risk<br />Management<br />InterDynamics<br />Fatigue-risk Management<br />
    23. 23. Fatigue Risk Management System<br />Hours of Work Diagnostic<br />Fatigue Hazard Analysis<br />Scientific Research<br />Roster Design & Workforce Planning<br />Policies & Procedures<br />Training & Education<br />Contingency Planning<br />Compliance & Audit<br />
    24. 24. Risk Exposures & Safeguards<br />
    25. 25. Fatigue Scenario Hazard Analysis<br />
    26. 26. Modeling Fatigue Risk Exposure<br /> Based on the task an individual is performing, and following a rigorous risk management process, a tolerance is set at an acceptable indicative fatigue exposure level <br />InterDynamics<br />Fatigue-risk Management<br />
    27. 27. Don’t Ignore the Elephant in the Control Room<br />People are unpredictable, aren’t we?<br />Fatigue affects people in different ways.<br />Use a risk based approach with the group, the role of a controller, and the specific individuals.<br />Consider a Fatigue Risk Management System.<br />
    28. 28. There’s an Elephant in the Control Room<br />API Control Room Forum<br />