HumanSideofSafety ERTC Forum Bullemer 30nov10

Abnormal Situation Management and
the Human Side of Process Safety

Dr. Peter Bullemer
Human Centered Solutions
ERTC pbullemer@applyHCS.com
15th Annual Meeting
30 November 2010
Istanbul, Turkey Jason Laberge
Honeywell Advanced Technology
jason.laberge@honeywell.com
Paper presented on behalf of the Abnormal

ASM Situation Management® R&D Consortium
ASM® and Abnormal Situation Management® are registered trademarks of Honeywell International
ASM Key Message
• In recent years, many organizations have been
striving to improve process safety management
performance.
• One opportunity for improving process safety
performance is to reduce the probability of
human error through effective abnormal
situation management practices.
ERTC 15th Annual Meeting Dr. Peter Bullemer

30 November 2010 Page 2 Human Centered Solutions
Istanbul, Turkey pbullemer@applyHCS.com
ASM Abnormal Situation Management®
A Joint Research and Development Consortium
Founded in 1994
Challenges associated
with human side of Helping People Perform
process safety have been

a focus of the Abnormal
Situation Management®
(ASM) Consortium for the
past fifteen years.
www.asmconsortium.org
UCLA
ASM Abnormal Situation Management®
A Joint Research and Development Consortium
Founded in 1994
Enable operating teams
to proactively manage Helping People Perform
their plants to maximize

safety and minimize
environmental impact
while allowing the
processes to be pushed
to their optimal limits.
www.asmconsortium.org
UCLA
ASM Abnormal Situation Definition
 An industrial process is being disturbed and the

automated control system can not cope...
 Consequently, the operations team must
intervene to supplement the control system.
 Impacts profitability in multiple ways:
Loss of Life
Product Quality
Equipment Damage
Job Satisfaction Personal Injury

Product Thruput

ASM Relation to PSM
ASM Safety Pyramid Illustration
Process
Major Incidents
Safety Incidents above
Incidents threshold for Process
Safety Incident
Minor Incidents
Incidents below impact
Abnormal threshold for PS Incident
Situation
Near Miss
Incidents System Failures that
could lead to an incident
Effective
Operations Unsafe Behaviors
Practices Insufficient Operating Discipline
Illustration based on: CCPS Process Safety Leading and Lagging Metrics.
ASM Managing Abnormal Situations
Operational Modes and Critical Systems Perspective
Operational Critical Operational Plant

Modes: Plant States: Systems: Goals: Activities:
Disaster Area Emergency Response

System
Emergency Minimize Firefighting
Site Emergency Response Impact
Accident First Aid
System
Rescue
Physical and Mechanical Bring to
Containment System Safe State
Out of Evacuation
Control
Safety Shutdown,
Protective Systems,
Abnormal Hardwired Emergency Alarms
Return to Manual Control &
Normal Troubleshooting
Abnormal
DCS Alarm System
Decision Support System

Process Equipment,
Keep Normal Preventative
Normal Normal DCS, Automatic Controls Monitoring &
Plant Management Systems Testing

ASM Managing Abnormal Situations
Human Supervisory Control
Process Operator Mental & Physical Activities

State
Orienting Evaluating Acting

Inputs from Process (1) Sensing, (2) Analysis,
Physical and/or Outputs to Process
(sensors, analyzers, radios, Perception, Interpretation,
Verbal (SP, OP%, Manual
video, instructions, sounds & and/or and/or
Response adjustments)
smells) Discrimination (3) Projection
Situation Awareness (1
(1-3)
-3)
Internal Feedback
Assessing
External Feedback
• This model operationalizes the human processing

elements in the operator’s supervisory control
responsibilities for managing abnormal situations
Adaptation of Supervisory Control Activity models of Jens Rasmussen and David Woods - CMA.

ASM Sources of Abnormal Events
People:
Often Preventable Equipment • Fail to detect problems in
reams of data
40%
• Are required to make
hasty interventions
People • May be unable to make
Process 40% consistent responses
20% • May be unable to
communicate well
Mostly Preventable
Almost Always
Preventable
Established in literature ; confirmed by 18 plant studies - US, Canada, & Europe

ASM Making the Business Case
Unexpected Events Cost 3-8% of Capacity
30 0
25 0 3.2%
5.8%
Histo g ra m
~ $10 Billion annually in lost production !
5.8%
20 0
Frequency
15 0
10 0
50
0 Source: ASM Consortium Research

112
115
118
121
124
127
130
133
136
139
142
145
148
151
154
157
160
163
166
169
172
174
177
180
183
His tog ram
Pro du ct ion rat e
150 3
300
   
250
$24.2M
24.2M
200
Frequency
150
100
50
Plant Operating Target

457
463
468
474
480
486
492
497
503
509
515
520
526
532
538
543
549
555
561
567
572
578
584
590
595
Total Feed
Feed Ra te
18
16
14
38.5M
$38.5 M
12
# D ays
10
8
6
4
2
0
280
290
300
310
320
330
340
350
360
370
380
390
400
410
420
430
440
450
460
470
480
490
500
510
520
530
540
550
560
570
580
590
600
610
620
Total Feed
Rate
20
15
33.5M
$33.5 M
# D ays
10
Operational Constraints
280
290
300
310
320
330
340
350
360
370
380
390
400
410
420
430
440
450
460
470
480
490
500
510
520
530
540
550
560
570
580
590
600
610
620
Ra te
Summarized Production Data

Days per Year
Optimization efforts
Plant Incidents Plant Capacity Limit
< 60% 95% 100%

Daily Production Level
ASM Persistent Paradoxes
• Paradox of Automation
– Better automation leads to more sophisticated processes.
– More sophisticated processes leads to more opportunities for error.
– We tend to “fix” the increasing errors with still more automation.
• Paradox of Reliability
– Better equipment reliability leads to fewer operator interventions
– Fewer operator intervention leads to fewer opportunities to learn
from experience
– Less experiential knowledge and skill leads to more human errors
– We attempt to “fix” the increasing human error with equipment
reliability improvements
• Consequently, when things go wrong, people have difficulty

intervening to correct the problem.
• Need to better understand how to break the cycles and support
human intervention activities
ASM ASM Incident Analysis Study
Project Objectives
• Understand relation between ineffective
operations practices and process industry
incidents
–Systematically analyze incidents to determine
common operational practice failure modes
–Identify root causes of common operational
practice failure modes
–Why do failures occur ACROSS incidents
This research study was sponsored by the Abnormal Situation Management® (ASM®)
Consortium.
ASM ASM Incident Analysis Study
Common Operations Failures
# %
Top 10 Operations Failures
Hazard analysis/ communication 79 15%
• 32 incidents were
analyzed using TapRoot
First-line leadership 65 12% incident investigation
Continuous improvement 60 11% methodology
Safety culture 36 7%
Public Site Total
Initial and refresher training 30 6%
USA 14 7 21
Task communications 29 5%
Non
Comprehensive MOC 28 5% USA 6 5 11
Cross functional communication 23 4% Total 20 12 32
Compliance with procedures 15 3%
Design guidelines and standards 14 • Top 10 covered 70% of
3%
Other failure modes 160 30% identified operations
practice failures
TOTAL 539
Root Cause Analysis
ASM Impact by Practice Areas Study
Effective Operations % of • Based on a total of

Practice Area Failures 539 practice
Understanding Abnormal 4% failures across 32
Situations incident reports
Organization Roles, Resp. & 53%
Work Processes
Knowledge & Skill 7%
Development
Communications 17%
Procedures 8%
Work Environment 1%
Process Monitoring, Ctrl, & 10%
Support Applications

A Key to Success
ASM ASM Solution Framework
• Human reliability improvements require focus on more
than technology
• We need to identify the problems that have to be solved
and only then search for solutions:
– Culture,
– Organization, Organization Roles,
Responsibilities &
– Work place, Work Processes
Procedures
– Work process,
Process
– and Understanding
Monitoring, Control
Abnormal Situations Communications
– Technology & Support
Applications
Knowledge & Skill
Work Environment
Development

ASM Summary of Research Program
• 2009-10 Research Roadmap Analysis Findings vs. Past Research
Outcomes illustrates areas of emphasis
Research Opportunity X Research Outcomes Produced
Research Opportunity (Problems + Needs)
120
50
# Research Needs # Research Outcomes
Research Outcomes Produced

45 100
# Problems
40
35 80
30
31
29 60
25 27
20 21
19 19 40
15
10 20
7
10 12 10 13
5 8 8 5
0 0
n
l
t
ng
s
ill
tro
en
ns
io
re
Sk
at
i
io
m
on
u
nd
e/
iz
ed
at
on
C
ta
an
dg
c
oc
g/
vir
rs
ni
le
rg
rin
Pr
nu
e
En
ow
O
nd
ito
m
U
Kn
on
om
M
Highest Rank Importance Lowest

Understanding Abnormal Situations
ASM Vision
• Shared understanding of abnormal situation causes and
impacts, widely communicated across the site, in order
to efficiently and accurately inform continuous
improvement programs that mitigate and reduce
abnormal situations. Organizational Influences
Organizational
Influences
• Example project: Business Unsafe Supervision
Justification and Metrics System Supervisory
Influences Influences
Development
 Develop a conceptual cause and Preconditions for Unsafe
Acts Individual
effect framework for analysis of Influences
impact of operations practices on Unsafe Acts

operator and plant performance Human
Equipment &
Process
Performanc
Performance
e
Plant
Performanc
ERTC 15th Annual Meeting e Dr. Peter Bullemer
ASM Organization Roles, Responsibilities
& Work Processes Vision
• Management systems, work practices, organizational
structures, and a continuous improvement culture that
supports prevention and mitigation of abnormal
situations.
• Example project: Root Cause
Analysis of Industry Incident
Reports
 Develop understanding of operations
practice failures in 32 industry incident
reports
 Create plant manager’s audit checklist

ASM Knowledge & Skill Development Vision
• Knowledge and skill development establishes and
maintains the competencies needed for effective
abnormal situation response.
• Knowledge and skill development is a continuous
process that is supported by a performance evaluation
framework that identifies training opportunities and
enables sustainable operator performance over time.
• Example project: Use of Simulators

to Train ASM Competencies
 Demonstrate effective use of simulators
to train ASM competencies

Knowledge & Skill Development
ASM Research Roadmap
Predictive Training 2020+
Metrics 2018
2014
Competency 2020
Framework 2016
Knowledge
2010 Management
2012
Sustained Performance
Competency Driven, Sustainable,

Needs Based ASM Training

ASM Communications Vision
• Successful communication enables situation awareness
under normal, abnormal and emergency situations.
• Communications practices allow operational and
functional team members to efficiently perceive, orient,
evaluate and act on information in context to the current
team goals and constraints.
• Team members coordinate with respect to goals and
activities, through the use of effective information media
to ensure continuity in work conditions.
• Example project: Use of checklist to
improve shift handover
communications
 Assess impact of handover checklist with
structured electronic logbook
ASM Procedures Vision
• Procedure content (whether automated or manual) is up-
to-date and provides the guidance and instruction
needed to minimize, avoid and recover from deviations
in operating intent, including unexpected outcomes and
abnormal situations.
• A comprehensive usage policy and procedure
development, deployment, analysis, and lifecycle
management practices enable effective procedure use in
appropriate situations.
• Example project: Procedure Common Manifestations #
Inappropriate action 15
Execution Failure Modes during Fail to detect abnormal condition 12
Abnormal Situations Lack understanding of impact 8
Fail to detect abnormal situation 4
 Understand how and why failures occur Unaware of hazard 1
Total 40
 Identify solutions to mitigate failures

ASM Procedures Research Roadmap
Lifecycle Proactive
Management Procedures
Procedure Data
2020+
Models
Procedure Risk 2018
Assessment
Procedure 2014
Execution 2020
2016 Dynamic
Procedure Deviation Procedures
2010
2012
Procedure
Authoring
Automated
Procedures ‘Smart’, Robust, Context Sensitive,
Procedure Integrated Procedures
Integration

ASM Work Environment Vision
• The work environment enhances operations team
situation awareness within their scope of responsibility,
operator alertness, efficient work practices, collaborative
interactions (including with other disciplines) and
abnormal situation prevention and response.
• Example project: Vigilance High
Decrement on Alertness
Alertness
 Understand time course of Level
alertness loss with console
operations activity
Low
30 60 90 120 150
Time on Vigilance Task (min.)

ASM Process Monitoring, Control, &
Support Applications Vision
• A comprehensive and user-centered set of
applications and tools that enables a single point
of access to the information needed for
operations team situation awareness and effective
prevention and response to abnormal situations.
• Example project: Visual Thesaurus
 Develop feasible and effective
visualization techniques for console-
wide overview displays

ASM Process Monitoring, Control, &
Support Apps. Research Roadmap
Automation Design 2020+

‘
Proactive Monitoring 2018
2014
Interaction 2020
Requirements 2016
Adaptive Automation
Decision Support
2010 Integrated UI
2012
Operations ‘Cockpit’
User-Centered, Integrated,
Adaptive Applications

ASM ASM Guideline Documents
Available on www.createspace.com
• Recently published for use in process industries
• Emphasis on effective prevention and response to abnormal situations
• Based on observed effective practices in member production facilities
• Includes learning from research projects
ASM ASM Publications
• Understanding Abnormal Situations
– Bullemer, P.T. and Laberge, J.C. (2010). Common operations failure modes in the process
industries. Journal of Loss Prevention in the Process Industries. Elsevier. In press.
– Bullemer, P.T. (2009) Better metrics for improving human reliability in process safety. Paper
presented in the 11th Process Safety Symposium at the 5th Global Congress on Process
Safety, Tampa, FL.
• Organizational roles, responsibilities and processes
– Bloom, C. P., Barreth, R. & McLain, R. (2007). A rational methodology for conducting
operations staffing assessments. Proceedings of the NPRA 2007 Annual Meeting.
– Bullemer, P.T., Jiron, S. and Nimmo, I. (2004). Shaping the future role of the operator.
Chemical Engineering Progress. 100 (5), May 2004.
• Knowledge and Skill Development
– Bloom, C. P., Bullemer, P.T., Barreth, R. & Reising, D.C. (2010). Situation awareness for
refining and petrochemical process operators – Not by technology alone. Proceedings of the
2010 NPRA Annual Meeting, Phoenix, AZ.
– Laberge, J., Thiruvengada, H. & Thrananthan, A. (2010). Improving board operator
performance with simulator based training. Tech and More, Summer 2010, Issue 9.
– Bullemer, P.T., and Nimmo, I. (1996). A Training Perspective on Abnormal Situation
Management: Establishing an Enhanced Learning Environment. Proceedings of the 1996
AICHE conference on Process Plant Safety, Houston, TX.

• Communications
– Laberge, J. C., Bullemer, P.T. and Whitlow, S. D. (2008). Communication and coordination
failures in the process industries. Proceedings of the Human Factors and Ergonomics
Society 52nd Annual Meeting, New York, NY
– Bullemer, P.T., Cochran, E., Harp, S & Miller, C. (1999). Collaborative decision support for
operations personnel. Paper presented at the INTERKAMMA ISA Technical Conference,
Dusseldorf, Germany.
• Procedures
– Bullemer, P.T., Kiff, L. and Tharanathan, A. (2010). Common procedural execution failure
modes during abnormal situations. Presentation at Mary Kay O’Conner Process Safety
Center International Symposium. College Station, TX.
– Bullemer, P.T. and Hajdukiewicz, J. (2004). A study of effective procedural practices in
refining and chemical operations. Proceedings of the Human Factors and Ergonomics
Society's 48th Annual Meeting. New Orleans, La, September 20-24, 2004.
• Environment
– Bloom, C.P., Bullemer, P.T., and Reising, D.C. (2010). The interaction between large screen
technologies, overview displays & effective control room layout: A workshop. Paper
presented at the International Control Room Design Conference, Paris, FR.
– Bullemer, P.T., Cochran, E., & Millner, P. (1999). Effective control center design for a better
operating environment. Proceedings of NPRA Computer Conference, Kansas City, MO.

• Process Monitoring, Control & Support Applications
– Reising, D.C., Laberge, J. and Bullemer, P.T. (2010). Supporting operator situation
awareness with overview displays: A series of studies on information vs. visualization
requirements. Paper presented at the International Control Room Design Conference, Paris,
FR.
– Reising, D. C. & Montgomery, T. (2005). Achieving effective alarm system performance:
Results of ASM Consortium benchmarking against the EEMUA guide for alarm systems.
Proceedings of the 20th Annual CCPS international Conference, Atlanta, GA, April 11-13.
– Reising, D. C., Errington, J., Bullemer, P., DeMaere, T., & Harris, K. (2005). Establishing
operator performance improvements and economic benefit for an ASM® operator interface.
Paper presented at the NPRA Plant Automation & Decision Support conference, Grapevine,
TX, October 18-21.
– Errington, J., DeMaere, T., & Reising, D. (2004). After the alarm rationalization: Managing
the DCS alarm system. Paper presented at the AIChE 2004 Spring Meeting, New Orleans,
LA, April 25-29.
– Bell, M., Errington, J., Reising, D. & Mylaraswamy, D. (2003). Early event detection: A
prototype implementation. Paper presented at Honeywell Users Group 2003, June 9-13,
Phoenix, AZ.
– Soken, N., Bullemer, P.T., Ramanathan, P., and Reinhart, B. (1995). Human-computer
interaction requirements for managing abnormal situations in chemical process industries.
Proceedings of the ASME Symposium on Computers in Engineering, Houston, TX.

ASM Concluding Comment
• The ability of a plant to effectively prevent and
respond to abnormal situations is a key element to
reducing the impact of process safety incidents.
• Human reliability improvements require focus on more
than technology;
• Address the influence of
– Culture,
– Organization,
– Work place,
– Work process,
– and
– Technology

ASM Thank You!
Questions and/or Comments?
Dr. Peter Bullemer Jason Laberge
Human Centered Solutions Honeywell Advanced
Technology
pbullemer@applyHCS.com jason.laberge@honeywell.com
www.applyHCS.com www.honeywell.com
Visit www.ASMConsortium.org for

ASM more information including membership
Paper presented on behalf of the Abnormal

Situation Management® R&D Consortium

ASM Abstract
• In recent years, many organizations have been striving to improve process
safety management performance. One aspect of improving process safety
performance is to reduce the probability of human error.
• The challenges associated with human side of process safety have been a
focus of the Abnormal Situation Management® (ASM) Consortium for the past
fifteen years.
• The mission of the ASM Consortium, a group of 13 companies and universities
in the process control industry, is to enable operating teams to proactively
manage their plants to maximize safety and minimize environmental impact
while allowing the processes to be pushed to their optimal limits.
• This paper presents findings on sources of operational failures and a solution
framework developed to address the challenges to human reliability. The
solution framework consists of seven operation practice areas that influence
the effectiveness of abnormal situation management and the likelihood of
process safety incidents.
• The ability of a plant to effectively prevent and respond to abnormal situations
is a key element to reducing the impact of process safety incidents.
• Since 1994, the ASM Consortium has been striving to improve ASM practices
through their active Research & Development program.


HumanSideofSafety ERTC Forum Bullemer 30nov10

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

HumanSideofSafety ERTC Forum Bullemer 30nov10

Uploaded by

Copyright:

Available Formats

Abnormal Situation Management and

the Human Side of Process Safety

Paper presented on behalf of the Abnormal

ERTC 15th Annual Meeting Dr. Peter Bullemer

process safety have been

their plants to maximize

 An industrial process is being disturbed and the

Job Satisfaction Personal Injury

ERTC 15th Annual Meeting Dr. Peter Bullemer

Operational Critical Operational Plant

Disaster Area Emergency Response

Decision Support System

ERTC 15th Annual Meeting Dr. Peter Bullemer

Process Operator Mental & Physical Activities

Orienting Evaluating Acting

• This model operationalizes the human processing

ERTC 15th Annual Meeting Dr. Peter Bullemer

Established in literature ; confirmed by 18 plant studies - US, Canada, & Europe

ERTC 15th Annual Meeting Dr. Peter Bullemer

0 Source: ASM Consortium Research

Plant Operating Target

Summarized Production Data

Plant Incidents Plant Capacity Limit

< 60% 95% 100%

• Consequently, when things go wrong, people have difficulty

Effective Operations % of • Based on a total of

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

Research Outcomes Produced

Highest Rank Importance Lowest

ERTC 15th Annual Meeting Dr. Peter Bullemer

impact of operations practices on Unsafe Acts

ERTC 15th Annual Meeting Dr. Peter Bullemer

• Example project: Use of Simulators

ERTC 15th Annual Meeting Dr. Peter Bullemer

Competency Driven, Sustainable,

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

Automation Design 2020+

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

Visit www.ASMConsortium.org for

Paper presented on behalf of the Abnormal

ERTC 15th Annual Meeting Dr. Peter Bullemer

ERTC 15th Annual Meeting Dr. Peter Bullemer

You might also like