Human Factors Handbook For Process Plant Operations Improving Process Safety and System Performance 1St Edition Ccps Center For Chemical Process Safety Full Chapter

Human Factors Handbook for Process
Plant Operations: Improving Process

Safety and System Performance 1st
Edition Ccps (Center For Chemical
Process Safety)
Visit to download the full and correct content document:
https://ebookmass.com/product/human-factors-handbook-for-process-plant-operation
s-improving-process-safety-and-system-performance-1st-edition-ccps-center-for-che
mical-process-safety/
HUMAN FACTORS HANDBOOK
FOR PROCESS PLANT OPERATIONS
HUMAN FACTORS HANDBOOK
FOR PROCESS PLANT OPERATIONS
Improving Process Safety and

System Performance
CENTER FOR CHEMICAL PROCESS SAFETY

AMERICAN INSTITUTE OF CHEMICAL ENGINEERS
New York, NY
This edition first published 2022
© 2022 the American Institute of Chemical Engineers
A Joint Publication of the American Institute of Chemical Engineers and John Wiley &
Sons, Inc.
All rights reserved. No part of this publication may be reproduced, stored in a

retrieval system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording or otherwise, except as permitted_by law. Advice on how to
obtain permission to reuse material from this title is available at http://www.wiley.com/
go/permissions.
The rights of CCPS to be identified as the author of the editorial material in this work
have been asserted in accordance with law.
Registered Office
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
Editorial Office
111 River Street, Hoboken, NJ 07030, USA
For details of our global editorial offices, customer services, and more information
about Wiley products visit us at www.wiley.com.
Wiley also publishes its books in a variety of electronic formats and by print-on-demand.
Some content that appears in standard print versions of this book may not be available
in other formats.
Limit of Liability/Disclaimer of Warranty

In view of ongoing research, equipment modifications, changes in governmental
regulations, and the constant flow of information relating to the use of experimental
reagents, equipment, and devices, the reader is urged to review and evaluate the
information provided in the package insert or instructions for each chemical, piece of
equipment, reagent, or device for, among other things, any changes in the instructions
or indication of usage and for added warnings and precautions. While the publisher and
authors have used their best efforts in preparing this work, they make no representations
or warranties with respect to the accuracy or completeness of the contents of this
work and specifically disclaim all warranties, including without limitation any implied
warranties of merchantability or fitness for a particular purpose. No warranty may be
created or extended by sales representatives, written sales materials or promotional
statements for this work. The fact that an organization, website, or product is referred to
in this work as a citation and/or potential source of further information does not mean
that the publisher and authors endorse the information or services the organization,
website, or product may provide or recommendations it may make. This work is sold with
the understanding that the publisher is not engaged in rendering professional services.
The advice and strategies contained herein may not be suitable for your situation. You
should consult with a specialist where appropriate. Further, readers should be aware
that websites listed in this work may have changed or disappeared between when this
work was written and when it is read. Neither the publisher nor authors shall be liable
for any loss of profit or any other commercial damages, including but not limited to
special, incidental, consequential, or other damages.
Library of Congress Cataloging-in-Publication Data Applied for
Cover Design: Wiley

Cover Image: Pand P Studio/Shutterstock, manine99/ Shutterstock, agsandrew/Shutterstock
10 9 8 7 6 5 4 3 2 1
This book is one in a series of process safety guidelines and concept books
published by the Center for Chemical Process Safety (CCPS). Refer to
www.wiley.com/go/ccps for full list of titles in this series.
It is sincerely hoped that the information presented in this document will lead to
a better safety record for the entire industry; however, neither the American
Institute of Chemical Engineers, its consultants, CCPS Technical Steering
Committee and Subcommittee members, their employers, their employers'
officers and directors, nor Greenstreet Berman, Ltd., and its employees and
subcontractors warrant or represent, expressly or by implication, the correctness
or accuracy of the content of the information presented in this document. As
between (1) American Institute of Chemical Engineers, its consultants, CCPS
Technical Steering Committee and Subcommittee members, their employers, their
employers' officers and directors, and Greenstreet Berman, Ltd., and its
employees and subcontractors, and (2) the user of this document, the user accepts
any legal liability or responsibility whatsoever for the consequence of its use or
misuse.
Human Factors Handbook for Process Plant Operations
is dedicated to
Jack L. McCavit
Jack is passionate about process safety, especially in the areas of culture and
human factors. His work, both in his career at Celanese, and after his retirement,
has concentrated on educating workers and industry leaders on the importance
of process safety, the payback of sustaining a great program, and most
importantly, the impact of not making process safety a top priority. Jack had first-
hand experience with the latter when he witnessed a butane vapor cloud explosion
at the Celanese site in Pampa, Texas, in 1987, resulting in three fatalities and
dozens of injuries. Based on his significant and relevant expertise, Jack was
selected as the technical manager for the prominent Baker Panel investigation of
the BP Texas City Explosion in 2005.
Jack is a CCPS Fellow, an AIChE Fellow, and is rumored to be the fifth most famous
Texan in history. He was the committee chair for the CCPS flagship book,
Guidelines for Risk Based Process Safety, and a driving force behind CCPS’s Vision
20/20.
It is both an honor and a privilege to see Jack in action!
Louisa A. Nara, CCPSC

CCPS Global Technical Director
Table of Contents
Table of Contents .............................................................................................. ix

Glossary .......................................................................................................... xxiii
Acronyms ......................................................................................................... xxv
Acknowledgements ...................................................................................... xxvii
Foreword ........................................................................................................ xxix
Part 1: Concepts, principles, and foundational knowledge .......................... 1

1 Introduction.................................................................................................. 3
1.1 What is “Human Factors”? .............................................................. 3
1.2 Purpose of this handbook .............................................................. 4
1.3 Why Human Factors? ...................................................................... 7
1.4 The structure of this handbook ..................................................... 9
2 Human performance and error ............................................................... 11
2.1 Learning objectives of this Chapter ............................................ 11
2.2 An example of successful human performance........................ 11
2.3 An example of unsuccessful human performance ................... 13
2.4 Key learning points from this Chapter........................................ 17
3 Options for supporting human performance........................................ 19
3.1 Learning objective of this Chapter .............................................. 19
3.2 Types of human performance ..................................................... 19
3.3 Types of human performance, errors and mistakes ................ 21
3.4 Selecting options for supporting human performance............ 30
4 Supporting human capabilities................................................................ 35
4.2 Attention ......................................................................................... 35
4.3 Vigilance .......................................................................................... 36
4.4 Memory ........................................................................................... 37
4.5 Cognitive capacity .......................................................................... 38
4.6 Cognitive heuristics/biases ........................................................... 39
x Human Factors Handbook
Part 2: Procedures and job aids .................................................................... 43

5 Human performance and job aids .......................................................... 45
5.2 An example of a major accident .................................................. 45
5.3 The role of job aids in supporting human performance .......... 46
5.4 Approach to developing effective job aids ................................. 48
6 Selecting a type of job aid ........................................................................ 53
6.2 Stage 1: Determining the need for a job aid .............................. 53
6.3 Stage 2: Selecting the type of job aid .......................................... 62
6.4 Electronic job aids.......................................................................... 67
7 Developing content of a job aid............................................................... 69
7.2 Outputs from task analysis .......................................................... 69
7.3 Outputs from Hazard Identification and Risk Analysis ............. 72
7.4 User involvement........................................................................... 72
7.5 Validation of job aids ..................................................................... 74
7.6 Keeping job aids up to date ......................................................... 75
8 Format and design of job aids ................................................................. 77
8.2 Structure and layout...................................................................... 77
8.3 Navigation ....................................................................................... 82
8.4 Instructional Language ................................................................. 84
8.5 Pictorial information ..................................................................... 87
8.6 Icons ................................................................................................ 88
Part 3: Equipment............................................................................................ 91
9 Human Factors in equipment design ..................................................... 93
9.2 Definitions ...................................................................................... 93
9.3 Major accident example ............................................................... 94
Table of Contents xi
9.4 Error traps ...................................................................................... 96

9.5 How might poor equipment Human Factors cause error? ...... 98
9.6 Example of poor equipment Human Factors ......................... 101
9.7 Supporting human performance by good equipment
design ........................................................................................... 103
9.8 Mitigating poor design ............................................................... 111
9.9 Key learning points from this Chapter..................................... 113
Part 4: Operational competence ................................................................. 115

10 Human performance and operational competency .......................... 117
10.1 Learning objectives of this Chapter ......................................... 117
10.2 What is competency? ................................................................. 117
10.3 Competency Management ........................................................ 118
10.4 An example of effective Process Safety Competency
Management ............................................................................... 121
10.5 An example of gaps in operational competency .................... 122
10.6 Competency influencing factors ............................................... 124
11 Determining operational competency requirements........................ 127
11.2 Identify and define safety critical competency: overview ..... 127
11.3 Step 1: Identify safety critical tasks .......................................... 128
11.4 Step 2: Identify required competency ..................................... 130
11.5 Step 3: Define performance standards ................................... 132
12 Identifying learning requirements ....................................................... 137
12.2 Competency gap analysis .......................................................... 137
12.3 Training Needs Analysis ............................................................. 138
13 Operational competency development ............................................... 143
13.2 Good practice in learning .......................................................... 143
xii Human Factors Handbook
14 Operational competency assessment ................................................. 151

14.2 Reasons for competency assessment ..................................... 151
14.3 How to conduct assessment of competency .......................... 151
14.4 Reassessment ............................................................................. 157
14.5 Managing competency gaps ..................................................... 158
14.6 Competency and learning records ........................................... 160
Part 5: Task support ...................................................................................... 161

15 Fatigue and staffing levels ..................................................................... 163
15.2 A fatigue-related accident ......................................................... 163
15.3 Managing fatigue risk ................................................................. 168
16 Task planning and error assessment................................................... 179
16.2 Incident example ........................................................................ 179
16.3 Human Factors and task planning ........................................... 180
16.4 Error assessment within task planning ................................... 182
17 Error management in task planning, preparation and control ........ 189
17.2 Overview ...................................................................................... 189
17.3 Preventing optimism bias in task planning: scheduling ........ 190
17.4 Assigning safety critical tasks .................................................... 194
17.5 Distractions and interruptions.................................................. 195
17.6 Long and low demand tasks ..................................................... 199
17.7 The Human Factors of control of work packages .................. 202
17.8 Team briefings ............................................................................ 204
17.9 Human Factors of system isolation.......................................... 205
17.10 Human Factors of managing interlocks and automatic trips 210
18 Capturing, challenging and correcting operational error ................. 215
18.2 Failing to spot, challenge, and recover from errors ............... 215
Table of Contents xiii
18.3 Why do we fail to capture, challenge, and correct errors? ... 217
18.4 Coaching people to recognize risk of making errors ............. 218
18.5 Error Management Training ...................................................... 220
18.6 Enabling challenge of task performance ................................. 224
19 Communicating information and instructions ................................... 233
19.2 Incident example ........................................................................ 233
19.3 Causes of poor communication ............................................... 234
19.4 Human Factors of communications ......................................... 235
19.5 Avoiding communication overload .......................................... 237
19.6 Human Factors in shift handover ............................................. 241
Part 6: Non-technical skills ........................................................................... 247

20 Situation awareness and agile thinking ............................................... 249
20.2 What are situation awareness and agile thinking? ................ 249
20.3 Accidents from poor situation awareness and rigid
thinking ........................................................................................ 252
20.4 Causes of poor situation awareness and rigid thinking ........ 253
21 Fostering situation awareness and agile thinking.............................. 257
21.2 Training in situation awareness skills ...................................... 257
21.3 Practical situation awareness tools and tactics ...................... 262
21.4 Recognizing loss of situation awareness ................................. 268
21.5 Fostering agile decision-making ............................................... 270
22 Human Factors in emergencies ............................................................ 277
22.2 An example accident .................................................................. 277
22.3 Supporting human performance in emergencies .................. 281
22.4 Non-technical skills for emergency response ......................... 284
xiv Human Factors Handbook
Part 7: Working with contractors and managing change......................... 299

23 Working with contractors ...................................................................... 301
23.2 An accident involving contractors ............................................ 301
23.3 Human Factors tactics for supporting contractors ................ 304
24 Human Factors of operational level change ....................................... 309
24.2 What do we mean by operational level change?.................... 309
24.3 Operational level change and major accidents ...................... 310
24.4 Recognizing operational level changes that impact human
performance................................................................................ 311
24.5 Managing Human Factors of changes ..................................... 314
Part 8: Recognizing and learning from performance ............................... 319

25 Indicators of human performance ....................................................... 321
25.2 What are performance indicators? .......................................... 321
25.3 Identifying human performance indicators ............................ 323
25.4 Examples of human performance indicators ......................... 324
25.5 Sharing and acting on human performance indicators ........ 332
26 Learning from error and human performance .................................. 335
26.2 The importance of understanding error ................................. 336
26.3 Examples of poor learning ........................................................ 338
26.4 Learning in high performing teams ......................................... 340
26.5 Human Factors of investigating process ................................. 341
26.6 Selecting preventive Human Factors actions .......................... 356
26.7 Learning ....................................................................................... 359
Table of Contents xv
APPENDICES
A Human error concepts .................................................................... 373

B Major accident case studies ........................................................... 383
C Human Factors Competency Matrix ............................................. 397
D Competency performance standards ........................................... 415
E Learning methods and performance ............................................ 420
F Situation awareness and behavioral markers ............................. 425
G Human Factors change checklist ................................................... 431
Index................................................................................................................ 437
List of Figures
Figure 1-1: Human Factors science, concepts and principles .................................... 3

Figure 1-2: Overview of the handbook, by chapter................................................... 10
Figure 2-1: “Miracle on the Hudson” ........................................................................... 12
Figure 2-2: Performance Influencing Factors............................................................. 16
Figure 3-1: The Skill-Rule-Knowledge Performance Model ...................................... 20
Figure 3-2: Human performance modes, errors and mistakes ............................... 23
Figure 3-3: Strategies for knowledge and rule-based human performance.......... 31
Figure 3-4: Supporting skill-based performance ....................................................... 33
Figure 4-1: Typical vigilance decrement ..................................................................... 36
Figure 5-1: Overview of Human Factors aspects of developing a job aid .............. 51
Figure 6-1: Selecting a type of job aid for operational use ...................................... 56
Figure 6-2: Using HIRA risk matrix results to assess task safety criticality ............. 57
Figure 6-3: Example of a formal safety critical task assessment ............................. 58
Figure 6-4: Task safety criticality rating ...................................................................... 60
Figure 6-5: Mapping of type of job aid to type of task performance ...................... 63
Figure 7-1: Example of a graphical task description ................................................. 70
Figure 7-2: Example of HIRA results............................................................................ 72
Figure 7-3: Task walk-through process ....................................................................... 74
Figure 8-1: Good practice SOP example ..................................................................... 79
Figure 8-2: An example grab card ............................................................................... 81
Figure 8-3: An example decision flow chart for unresponsive casualties .............. 82
Figure 8-4: An example of icon and color coding ...................................................... 83
Figure 8-5: Examples poor and good practice of instructional language............... 86
Figure 8-6: An annotated diagram .............................................................................. 88
Figure 8-7: An example of icon and color coding ...................................................... 89
Figure 9-1: The Buncefield fuel storage facility before and after ............................ 94
Figure 9-2: A Human Factors solution to selecting the right control ...................... 96
Figure 9-3: A common error trap ................................................................................ 97
Figure 9-4: Control and instrumentation panel....................................................... 102
Figure 9-5: User- centered design ............................................................................. 103
Figure 9-6: Examples of good and poor natural mapping for a stove .................. 108
Figure 9-7: Example of good practice in natural mapping ..................................... 109
Figure 9-8: Principles of good alarm design ............................................................ 112
Figure 10-1: Competency Management ................................................................... 120
Figure 11-1: SCTA and Level of Training ................................................................... 129
Figure 13-1: Example of competency development through training .................. 144
Figure 13-2: The Learning Pyramid ........................................................................... 147
Figure 14-1: Learning assessments........................................................................... 157
Figure 15-1: Example of rapid rise in fatigue scores from a 16-hour day ............ 166
Figure 15-2: Working without rest breaks ................................................................ 167
Figure 15-3: Working nights ....................................................................................... 168
Figure 15-4: Typical scope of fatigue risk policy ...................................................... 169
xviii Human Factors Handbook
Figure 15-5: Guidelines on shift design .................................................................... 171

Figure 15-6: Signs and symptoms of fatigue ........................................................... 173
Figure 15-7: Signs of under staffing .......................................................................... 175
Figure 15-8: Managing workloads ............................................................................. 176
Figure 15-9: A simple task timeline ........................................................................... 177
Figure 16-1: Examples of error-likely situations ...................................................... 184
Figure 17-1: Overview of HF task planning, preparation and control................... 190
Figure 17-2: Open language for inviting questions and opinions ......................... 191
Figure 17-3: Barrier ownership prevented wrong valve line up ............................ 195
Figure 17-4: Tactics for minimizing distraction and interruptions ........................ 197
Figure 17-5: Schematic of some factors influencing attention span .................... 200
Figure 17-6: Features of a good Tool Box Talk or task briefing. ............................ 205
Figure 18-1: Draining pumps ..................................................................................... 215
Figure 18-2: Categories of cognitive error................................................................ 217
Figure 18-3: Factors contributing to error................................................................ 218
Figure 18-4: Error contributing factors ..................................................................... 221
Figure 18-5: Cognitive skills required for error self-management ........................ 223
Figure 18-6: Factors building psychological safety.................................................. 226
Figure 18-7: Challenging skills ................................................................................... 229
Figure 19-1: Repeating back....................................................................................... 240
Figure 20-1: Stages of situation awareness ............................................................. 250
Figure 21-1: Behavioral Markers for “Actively seeks relevant information” ......... 259
Figure 21-2: Causes of failed Situation Awareness ................................................. 268
Figure 22-1: Error recognition and management process ..................................... 279
Figure 22-2: Human Errors – categories ................................................................... 280
Figure 22-3: Refinery explosion, Philadelphia Energy Solutions ........................... 282
Figure 22-4: Stress management – training strategies ........................................... 288
Figure 22-5: Decision-making in emergency situations.......................................... 290
Figure 24-1: Types of change and impact ................................................................ 311
Figure 24-2: Sample Management of Change process ........................................... 314
Figure 25-1: Design of human performance indicators ......................................... 323
Figure 25-2: Gathering and reviewing feedback ..................................................... 326
Figure 25-3: Stress in the workplace and performance ......................................... 328
Figure 25-4: Signs of mindfulness ............................................................................. 331
Figure 25-5: Lessons learned – knowledge sharing ................................................ 332
Figure 26-1: Steps of effective learning – learning process ................................... 338
Figure 26-2: The consequences of blame culture ................................................... 343
Figure 26-3: “New” Just Culture Process ................................................................... 348
Figure 26-4: Error – causal factors and conditions.................................................. 350
Figure 26-5: Matching improvements to type of error ........................................... 358
Figure 26-6: Goals of Restorative Just Culture ......................................................... 359
List of Figures xix
Figure A-1 Energy Institute human performance principles.................................. 377

Figure A-2 What are the causes of incidents? .......................................................... 378
Figure B-1 Texas City Refinery Explosion ................................................................. 383
Figure B-2 Bayer Crop Science plant damage ......................................................... 385
Figure B-3 Longford Esso Gas Plant explosion ........................................................ 387
Figure B-4 The explosion and fires at Milford Haven ............................................. 389
Figure B-5 Interaction of the key valves and vessels .............................................. 392
Figure B-6 The polyvinyl fluoride process ................................................................ 393
Figure B-7 Deepwater Horizon Oil Spill – Macondo blowout................................. 395
List of Tables
Table 3-1: SRK types of human performance ............................................................ 22

Table 3-2: Case study example of a knowledge-based mistake .............................. 24
Table 3-3: Example of a rule-based mistake .............................................................. 27
Table 3-4: Example of skill-based human error in a major accident ...................... 29
Table 6-1: Guidelines for rating task complexity ....................................................... 61
Table 6-2: Guidelines for rating task frequency ........................................................ 61
Table 6-3: Time available to complete a task ............................................................. 62
Table 6-4: Definition of types of operational job aids .............................................. 64
Table 6-5: Pros and cons of electronic job aids ......................................................... 68
Table 7-1: Example task analysis as a table ............................................................... 71
Table 8-1: Typical structure of procedures ................................................................ 77
Table 8-2: Checklist for layout of job aids .................................................................. 78
Table 8-3: Checklist for instructional language ......................................................... 84
Table 8-4: When to use different presentation options ........................................... 87
Table 9-1: Examples of poor design for hard-wired interfaces – physical panels . 98
Table 10-1: Key features of effective process safety Competency Management 125
Table 11-1: An example industry standard .............................................................. 133
Table 11-2: Generic example of a competency standards matrix ........................ 134
Table 11-3: Petrochemical example of a competency standards matrix ............. 135
Table 12-1: Competency Gap Analysis and Training Needs Analysis template ... 140
Table 13-1: Learning methods for developing individuals ..................................... 145
Table 13-2: Team learning methods ......................................................................... 148
Table 14-1: Suitability of and differences between competency assessments ... 153
Table 15-1: Principles of shift design ........................................................................ 170
Table 16-1: Example of locks removed on wrong blinds........................................ 180
Table 16-2: Task planning tactics for potential high-risk situations ...................... 185
Table 16-3: Task planning tactics for different task errors .................................... 186
Table 17-1: Scheduling ............................................................................................... 193
Table 17-2: Barrier ownership to prevent commissioning loss of containment . 194
Table 17-3: Example tactics for enabling attention................................................. 201
Table 17-4: An isolation incident: relying on experience ....................................... 207
Table 17-5: Human Factors of isolation.................................................................... 208
Table 17-6: Example of defeating an interlocked valve .......................................... 212
Table 17-7: Human Factors good practice for interlocks and trips ....................... 213
Table 18-1: Draining pumps leads to product release ........................................... 216
Table 18-2: Error management training and coaching ........................................... 219
Table 18-3: High-risk observable behaviors............................................................. 220
Table 18-4: Error detection techniques .................................................................... 227
Table 18-5: Examples of error recovery techniques ............................................... 230
Table 18-6: Types of task verification ....................................................................... 231
Table 19-1: Verbal and communication techniques ............................................... 236
Table 19-2: Shift handover contributed to a massive explosion ........................... 241
xxii Human Factors Handbook
Table 19-3: Shift handover risk factors ..................................................................... 242

Table 19-4: Elements of effective handover ............................................................ 244
Table 20-1: Cognitive biases ...................................................................................... 254
Table 21-1: Situation awareness – Assessment record .......................................... 261
Table 21-2: Human performance tools – examples ................................................ 263
Table 21-3: Clues for recognizing impaired Situation Awareness ......................... 269
Table 21-4: Group-think – behaviors (symptoms) ................................................... 273
Table 21-5: Confirmation bias – observable behavior ............................................ 274
Table 22-1: Non-technical skills and error prevention ........................................... 285
Table 22-2: Stress indicators in emergency situations ........................................... 286
Table 22-3: Shared situation awareness requirements ......................................... 289
Table 22-4: Emergency decision-making aids.......................................................... 291
Table 22-5: Leadership in emergency situations .................................................... 295
Table 22-6: Delegating and communicating in emergency situations.................. 296
Table 24-1: Tips on recognizing change ................................................................... 313
Table 25-1: Leading and lagging indicators ............................................................. 322
Table 25-2: Specifying a human performance indicator ........................................ 324
Table 26-1: High performing teams and self-learning from error ........................ 341
Table 26-2: Investigation biases and mitigating strategies .................................... 345
Table 26-3: Human Factors investigation tools ....................................................... 352
Table 26-4: Effective learning tips ............................................................................. 361
Table A-1 ‘Hearts and Minds’ definitions for non-compliance............................... 375

Table C-1 Human Factors Competency Matrix ........................................................ 397
Table D-1 Competency standards template – Skill-based task ............................. 415
Table D-2 Competency standards template – Procedure/Rule-based task ......... 417
Table D-3 Competency standards template – Knowledge-based task ................. 418
Table E-1 Application of learning methods to type of performance .................... 420
Table F-1 Situation awareness – behavioral markers for oil and gas industry .... 425
Table G-1 Human Factors Change Checklist ............................................................ 431
Glossary
Accident: An event that can cause (or has caused) significant harm to workers, the
environment, property, and the surrounding community.
Anthropometrics: The science of measuring the size and proportions of the
human body (called anthropometry), especially as applied to the design of
furniture and machines.
Behavioral marker: Non-technical behaviors that can be observed and described.
They refer to a prescribed set of behaviors and are indicative of specific types of
non-technical skills performance (e.g., effective decision-making in emergencies)
within a work environment.
Cognitive overload: A mental state where an individual is unable to process all
the information provided by the system.
Cognitive underload: A mental state when an individual is under-stimulated due
to insufficient workload. This mental state leads to lack of attention.
Competency Assessment: System which allows measuring and documenting
personnel competency. The goal of competency assessment is to identify
problems with employee performance, and to correct these issues before they
affect performance.
Competency: Set of skills and knowledge which enables a person to perform tasks
efficiently, reliably and safely to a defined standard.
Competency Gap: Difference between the current competency level and the
required competency level of an employee.
Competency Management: Method of categorizing and tracking the
development of individual employee competency, allowing an organization to
track progress, and identify future training needs.
Fatigue: Fatigue is a decline in physical and/or mental performance.
Hold Points: Point where change cannot happen until there has been verification
that the prerequisites have been achieved.
Human Error: Intended or unintended human action or inaction that produces an
unintended result. This includes, but is not limited to, actions by designers,
operators, planners/schedulers, maintainers, engineers or managers that may
contribute to or result in accidents [1].
Human Factors: Discipline concerned with designing machines, operations, and
work environments so they match human capabilities, limitations, and needs. This
includes any technical work (engineering, procedure writing, worker training,
worker selection, operations, maintenance, etc.) related to the human interface in
human-machine systems [1].
Human Performance: Measure of an individual’s ability to execute a task
effectively.
Incident: Event, or series of events, resulting in one or more undesirable
consequences, such as harm to people, damage to the environment, or
asset/business losses.
xxiv Human Factors Handbook
Job aid: Specific information or material intended to help workers execute a task
more effectively.
Learning: Acquisition of knowledge or skills through study, experience, or being
taught.
Major accident: Major accident means an occurrence such as a major emission,
fire, or explosion resulting from uncontrolled developments in the course of the
operation of any establishment, and leading to serious danger to human health or
the environment (whether immediate or delayed) inside or outside the
establishment, and involving one or more dangerous substances [2].
Mistake: A decision or judgement that is misguided.
Non-technical skills: The cognitive, social, and personal resource skills that
complement technical skills and contribute to safe and efficient task execution [3].
Performance Influencing Factors (PIFs): Characteristics of the job, the individual
and the organization that influence human performance [4].
Performance standards: Description of how the job is a description of what
(actions/tasks) needs to be taken/executed, how the job must be done
(behaviors/methods) and outcomes/results that will define satisfactory or
acceptable performance.
Psychological safety: The outcome of an open workplace culture where people
are willing to express an opinion, or admit mistakes or unsafe behaviors, without
fear of being embarrassed, rejected, or punished.
Root cause: Fundamental, underlying, system-related reason why an incident
occurred that identifies a correctable failure(s) in management systems. There is
typically more than one root cause for every process safety incident.
Rota: A period of work taken in rotation with other workers (an abbreviation of
rotation).
Rotation: A period of work taken in rotation with other workers.
Shift working (shifts): Work which takes place on a schedule outside traditional
day work hours. It can involve evening or night shifts, early morning shifts, and
rotating shifts.
Training: “Practical instruction in job and task requirements and methods.
Training may be provided in a classroom or at the workplace, and its objectives are
to enable workers to meet some minimum initial performance standards
(minimum required competency level), maintain their proficiency, or to qualify
them for promotion to a more demanding position” [5].
Vigilance decrement: Decline in “the ability to sustain attention and remain alert
to a particular stimulus over a prolonged period of time” [6].
Acronyms
Acronym Meaning
ANP Agência Nacional do Petróleo (Brazil Petroleum Regulator)
BP British Petroleum
CCPS Center for Chemical Process Safety
CK Checklist
CSB Chemical Safety Board
CRM Crew Resource Management
DCS Distributed Control System
DFC Diagnostic Flow Charts
DIF Difficulty, Importance and Frequency Analysis
DOE Department of Energy
DT Decision Tree or Diagnostic Tree
EEMUA Engineering Equipment and Materials Users Association
FCCU Fluidized catalytic cracking unit
GC Grab Card
GUI Graphical User Interface
HIRA Hazard Identification and Risk Analysis
ICAO International Civil Aviation Organization
IChemE Institute of Chemical Engineers
IOGP International Association of Oil and Gas Producers
ISO International Standards Institute
ISOM Isomerization
LEL Lower Explosive Level
LFL Lower Flammability Level
LOPA Layers of Protection Analysis
MDMT Minimum design metal temperature
MEB Material and Energy Balance
MOC Management of Change
NATO North Atlantic Treaty Organization
xxvi Human Factors Handbook
Acronym Meaning
OIM Offshore Installation Manager
OSHA Occupational Safety and Health Agency
PFD Process Flow Diagram
P&ID Piping and Instrumentation Diagrams
PSB Plant Status Boards
PSI Process Safety Information
PSV Pressure Safety Valve
PTW Permit to Work
RBPS Risk Based Process Safety
SCTA Safety Critical Task Analysis
SH Shift Handover
SOP Standard Operating Procedure
SRK Skills, Rule and Knowledge
STAR Stop Think Act and Review
QRA Quantitative Risk Analysis
WI Work Instruction
UK United Kingdom
U.S. United States
Acknowledgements
The American Institute of Chemical Engineers (AIChE) and the Center for Chemical
Process Safety (CCPS) express their gratitude to all the members of the Human
Factors Handbook for Plant Operations Project Team and their member
companies for their generous efforts and technical contributions. The committee
structure for this concept book differs from other CCPS books in that this was a
project done in collaboration with the Energy Institute (EI) and the generous efforts
and technical contributions of the EI Technical Partner and Technical Company
members is also gratefully acknowledged.
The writers from the Human Factors consultancy Greenstreet Berman Ltd are
also acknowledged, especially the principal writers Michael Wright and Dr. Ludmila
Musalova, with additional inputs from David Pennie, Rebecca Canham and
Ninoslava Shah.
Project Team Members

Chris Aiken Cargill, Chair
Eric Freiburger Linde, Vice Chair
Stuart King Energy Institute (EI), Co-Chair
Charles Cowley CCPS Staff Consultant, Project Manager
Sandra Adkins BP
Lee Allford Energy Institute (EI)
Mayara Carbono Ex Ecolab
Carlos Carvalho Petrobras
Erin Collins Jensen Hughes
Ruskin Damani Reliance
Gretel D'Amico Pluspetrol
Joseph Deeb Exxon Mobil (retired)
Alexandre Glitz CCPS Emeritus
Cheryl Grounds CCPS Emeritus
Jeff Hazle Marathon
Gregg Kiihne BASF
Ajay Shah Chevron
Caroline Morais ANP
Andrew Moulder Inter Pipeline
Meg Reese OxyChem
Rob Saunders Shell
Scott Wallace Olin (retired)
xxviii Human Factors Handbook
Gabriela Dutra (ex Braskem), Sahika Korkmaz (ex Chevron) and Josué Eduardo
Maia França (Petrobras) also contributed to certain stages of the project.
Before publication, all CCPS and EI books are subjected to a thorough peer
review process. CCPS and EI gratefully acknowledge the thoughtful comments and
suggestions of the peer reviewers. Their work enhanced the accuracy and clarity
of this concept book. The peer reviewers have provided many constructive
comments and suggestions. They were not asked to endorse this book and were
not shown the final manuscript before its release.
Peer Reviewers
Linda Bellamy White Queen BV
Michelle Brown FMC
Denise Chastain-Knight Exida
Palani Chidambaram DSS
Ed Corbett UK Health and Safety Executive
David Cummings DuPont
Rhona Flin Aberdeen University
Jerry Forest Celanese
Jeff Fox CCPS Emeritus, ex Dow
Osvaldo Fuente Dow
SP Garg GAIL
Zsuzsanna Gynes The Institution of Chemical Engineers
John Herber CCPS Emeritus
Alison Knight 3M
Susan Lee Marathon
Maria Chiara Leva TU Dublin
Keith Mayer Kraton Polymers
Rob Miles Hu-Tech
Chelsea Miller Chevron
Raphael Moura ANP
Cathy Pincus ExxonMobil
Tim Thompson Braskem
Elliot Wolf Chemours
Neal Yeomans Advansix
The affiliations of writers, project team members and peer reviewers were
correct at the time of publication.
Foreword
Humans are resourceful, resilient, innovative, smart creatures. They can also be
error-prone – forgetting to complete a step in a sequence, misunderstanding
instructions, making mistakes in task execution. Disentangling these strengths and
limitations, determining how and why human performance can be both resilient
and fragile is the science of human factors.
The military and aviation sectors were the first to appreciate that the design of
equipment and task environments had to take into account the psychological,
anatomical and physiological capabilities of the human operators. The influential
role of the organizational culture and its component systems on both managers
and workers also became apparent. As the hybrid blend of engineers,
psychologists, designers and other human factors specialists began to coalesce in
the late 1940s, professional human factors and ergonomics societies were formed,
helping to systematize an established body of evidence relating to human factors
science, with a range of accepted methods for investigation and intervention. But
it has taken some time for the value of this approach for the management of
workplace operations to be recognized across industrial sectors.
In the early 1990s, I was working on research projects examining psychological

aspects of offshore safety in the oil and gas industry. These were influenced by
Lord Cullen’s Inquiry reports on the Piper Alpha disaster and included studies of
safety climate, managerial behaviors, emergency response decisions, supervisors’
leadership. It was evident that there was very limited knowledge in this sector of
the factors influencing human performance. So, my colleague Georgina Slaven and
I decided we would edit a book on this subject and submitted a proposal to
PennWell Books. They liked our proposal, but not our title, ’Human Factors in the
Offshore Oil Industry’ as one of their reviewers, an industry expert, had told them
that no-one would know what this meant. Our book was published in 1996 with a
different title that did not use the mysterious term ‘Human Factors’.
More than two decades later, at the time of this book’s publication, awareness
and understanding of the factors influencing human performance in the process
industries has become more active. This volume, one of a series directed by the
Center for Chemical Process Safety, reflects the increased activity in the process
industries. It provides an essential handbook for people on the frontline of plant
operations, helping them apply good human factors principles and knowledge
with practical techniques.
It has been written especially with operations and maintenance supervisors in

mind, since such technical specialists have not traditionally been educated on the
factors influencing human performance during their basic training, and there is
now a vital need to address that pervasive knowledge gap.
xxx Human Factors Handbook
Engineers, process safety practitioners and regulators who wish to gain an

understanding of Human Factors concepts and methods will find much of
immediate practical value.
This book has been written by a combined panel of plant operations

professionals with in-depth knowledge of a wide range of process plants together
with very experienced Human Factors experts. It has then been widely peer-
reviewed, resulting in a comprehensive handbook that is easy to follow. Each of
the 26 chapters contains essential knowledge, presented in a straightforward,
accessible manner and supported by numerous examples to show why the
concepts are relevant in processing industries. A notable feature is the analysis of
major accidents from this sector that reveal where human factors contributed to
failure or recovery during the event.
Practical tools and techniques are provided for each topic area with guidance
for application and more experienced practitioners will discover new ideas for
their portfolio of Human Factors methods.
This valuable handbook is definitely recommended reading for those striving

to improve the safety and efficiency of process plant operations.
Rhona Flin
Professor of Industrial Psychology
Aberdeen Business School
Robert Gordon University
Human Factors Handbook For Process Plant Operations: Improving Process Safety and System
Performance CCPS.
© 2022 CCPS. Published 2022 The American Institute of Chemical Engineers.
Part 1: Concepts, principles, and foundational knowledge

Performance CCPS.
1 Introduction
1.1 What is “Human Factors”?
As illustrated in Figure 1-1, like engineering, Human Factors is a combination of

science, concepts, and principles. Human Factors draws on several scientific
disciplines. These include psychology, ergonomics, anthropometrics, and
physiology. The Human Factors approach uses these disciplines to help people
understand how and why they behave and perform as they do, and how best to
support them to perform tasks. The science adds to the knowledge gained from
operational experience.
Figure 1-1: Human Factors science, concepts and principles

4 Human Factors Handbook
Human Factors also provides a set of principles and concepts that can be used
to guide day-to-day decisions. The decisions focus on how best to support
successful human performance. This approach helps people to understand tasks
from the perspective of the person doing the work and provides ideas on how to
support people to perform better. It advocates an orientation (a way of thinking)
towards making improvements that support human performance and the
prevention of error. It recognizes people’s capabilities and commitment, and it
aims to maximize people’s roles in safe and productive operations, and to build
their ability to cope mentally and emotionally with stressful and demanding tasks,
i.e., psychological resilience.
A short video that presents a Human Factors view for successfully

addressing human performance, titled Being Human, is available as a resource
for “understanding and accepting why, as people, we do what we do, why we
do it, and the way we do it.” [7]
Human Factors covers a very wide range of topics including, training, work
planning, and fatigue. Many of these topics come under existing management
systems, such as the operation of rotating shift schedule systems, and training
systems. Human Factors provides knowledge, tools, and insights that can be
integrated into an organization’s existing systems of work and operational
management, safety assessments, incident investigations, and day-to-day
operational decision-making. In this book, the terms ‘incident’ and ‘accident’ will be
used interchangeably.
1.2 Purpose of this handbook
1.2.1 Purpose and scope
This handbook provides practical advice

and examples of good practice that can be
applied to design, process operations, start-
ups and shut-downs, maintenance, and
emergency response. It is a comprehensive
but simple to understand handbook aimed
at people responsible for the process
operations.
The handbook:
• Provides examples of practical

application, principles, and tools. It
also provides an understanding of
the fundamentals of Human
Factors, so the reader can develop
their own approach.
1. Introduction 5
• Provides an explanation of how people think and behave, why people

make mistakes, and how to help people perform process operational
tasks successfully. This includes how to support human performance
through procedures and job aids, training and learning, effective task
planning, high reliability communications, fatigue risk management,
development of error management skills, and preparing people to
perform emergency response tasks.
• Briefly covers the Human Factors of change management and managing
contractors. It also offers help on how to learn from errors, and how to
use indicators of human performance to improve support to people.
1.2.2 Other guidance
How does this handbook fit with

other guidance documents?
Safety culture, leadership, and

process safety management are
covered in other CCPS publications,
as shown by the book front covers.
Most chemical process businesses
have a set of process safety
management systems in place
already. The advice in this handbook
can be integrated into these process
safety management systems.
Human Factors methods, such as

error analysis and Human Reliability
Assessment, typically applied during
a “Hazard Identification and Risk
Analysis”, are not covered in this
handbook. CCPS books on “Bow Ties
in Risk Management” and “Guidelines
for Integrating Process Safety into
Engineering Projects” are available if
further information is needed. This
handbook does outline forms of
error assessment that can be used by
everyone involved in task planning
and task management.
This handbook can be read in conjunction with other CCPS guidance on safety
culture and process safety management, including:
• Essential Practices for Creating, Strengthening, and Sustaining Process

Safety Culture [8].
• Process Safety Leadership from the Boardroom to the Frontline [9].
• Guidelines for Risk Based Process Safety [5] [10].
• Recognizing and Responding to Normalization of Deviance [11].
• Human Factors Methods for Improving Performance in the Process
Industries [12].
• Investigating Process Safety Incidents [13].
Some of the elements within “Guidelines for Risk Based Process Safety” are
relevant to this handbook. Therefore, they have been referenced at various points
throughout the handbook as additional information where this would be helpful
to the reader.
1.2.3 Who should read this handbook?
This handbook is intended for everyone involved with defining, planning,

instructing, and managing process operations, maintenance, and emergency
response. This includes:
• Frontline supervisors.
• Designers.
• Operations and maintenance managers.
• Plant superintendents.
• Process engineers.
• Project managers.
• Construction managers.
• Process safety and health and safety personnel with the role of coaching
higher-level managers on Human Factors aspects.
The handbook is intended for people who understand process operations and
have some process safety management experience.
1.2.4 A note on language and terminology
The explanation of some topics has been intentionally simplified and phrased in
normal everyday language, rather than in scientific terms. This has been done in
order to make the document more accessible, readable and more usable in the
practical domain, and also with the aim of making it more understandable for an
international audience.
1. Introduction 7
For example, the term ‘mistake’ is used in this book to refer to both mistakes
and other kinds of error, even though human factors specialists commonly
understand the term ‘mistake’ to mean a specific kind of error that is to do with
judgement and decision-making, as distinct from other kinds of error such as ‘slips
and lapses’. The term 'mistake' is used generally in the book, but where specific
types of error are being discussed then the specific appropriate terms are used
where that aids clarity.
A more complete explanation of the traditional terminology of ‘human error’

commonly used by Human Factors specialists is given in Appendix 0.
1.3 Why Human Factors?
1.3.1 Major accidents associated with human performance
Human performance is a factor in

BP's Texas City 2005 refinery almost every major process
explosion: 15 fatalities, 170 injured. accident. The costs of major
The compensation totalled billions of process accidents are well known:
US dollars. Repairs and lost profits major injury, destruction of
cost over US $1billion. facilities, environmental damage,
See section B.1 immense costs, reputational loss,
closure.
In those cases where obvious signs of poor Human Factors were found,
stakeholder confidence in the company was greatly reduced and employee morale
was destroyed.
The United States Chemical Safety and Hazard Investigation Board (CSB)
investigation of the Texas City accident cited that previous accidents have shown
that Human Factors plays a role in industrial accidents [14]. The Texas City event
includes several examples of Human Factors. People had worked without rest for
many weeks or worked excessively long days. In some cases, it was known that
process instrumentation was unreliable or that critical information such as Piping
and Instrumentation Diagrams were out of date, and that training on new control
systems had not been provided.
This kind of evidence greatly undermines stakeholder trust in an organization

and can cause loss of the “license to operate”.
1.3.2 It is more than common sense
Human Factors is more than common sense. People may make mistakes for many
reasons. Many factors influence how people perform. Process operations can be
complex and involve many difficult tasks. Technology is constantly changing.
People who plan work and develop

operating procedures should not be remote
“Work as done”
from the actual task. They need to understand
versus
how the tasks are carried out in the field.
“Work as imagined”
Authors should have a complete knowledge of
the surrounding environment or operational
requirements.
Time constraints and attention demands impact frontline managers and

supervisors. These demands can prevent frontline managers and supervisors from
spending time to understand how people are performing, and what is influencing
their performance. Issues should not be overlooked or considered in a superficial
way.
Businesses must prioritize and balance production, operations, maintenance,

and budget. Human Factors appreciation can direct focus to human performance
support. It can also aid in prioritizing schedule, and managing fatigue and
workloads.
In a dynamic process environment, with many complex tasks and safety critical
operations in flux, a high level of human performance needs to be achieved
systematically. Process safety does not depend on a single person’s view of what
is “common sense”. Recognized and implemented good practice and guidance is
necessary to achieve a high standard of human performance.
Human Factors adds scientific knowledge to help workers achieve high

standards of performance in safety critical process operations. It provides an
insight into how the mind and the body work. It also offers lessons learned from
decades of worldwide experience. Adopting a Human Performance mindset
enables people to understand the context of the work as well as monitor the gap
between ‘work as planned’ versus ‘work as performed’.
1.3.3 The benefit of high performing teams
People diagnose unfamiliar faults. They As a leader, it is

innovate solutions to novel problems. They important to get the
handle unforeseen process upsets. A process best from people and
cannot be designed, operated or maintained be responsible for
without people. A common business mantra is how they do their
"People are the solution, not the problem." work more robustly.
Workers are incredibly adaptable and at the same
time fallible, thus we must ensure systems are error
tolerant to avoid single points of failure where human error can lead to significant
events.
Stakeholders must have confidence that an organization can achieve high

standards of process safety and operational productivity. Human Factors helps to
achieve high performing and reliable teams.
1. Introduction 9
1.4 The structure of this handbook
An overview of the handbook is given in Figure 1-2. The handbook is loosely split
into eight parts. Each Chapter can be read by itself. It is, however, useful to read
Chapters 2 to 4 first.
Part 1 includes Chapters 1, 2, 3, and 4 which provide overarching Human

Factors concepts and knowledge.
The other Chapters can be grouped into Parts around a set of core topics, such
as Part 2 job aids, Part 3 equipment design, Part 4 competence, Part 5 task support,
Part 6 non-technical skills and Part 7 covering working with contractors and
managing change.
Part 8 comprises Chapter 25, which discusses the use of indicators in

recognizing human performance issues, and Chapter 26 covers learning from
error and performance.
Appendix C provides a tabulation of Human Factors skills and knowledge for

operational and frontline supervisors/managers.
Figure 1-2: Overview of the handbook, by chapter
Concepts, principles, and foundational knowledge

2. Human performance and error 3. Options for supporting human performance 4. Supporting human capabilities
Non-technical skills
Procedures and job aids Operational competence Task support
20. Situation awareness and
5. Human performance 10. Human performance and 15. Fatigue and staffing levels
agile thinking
and job aids operational competency 16. Task planning and error
21. Fostering situation
6. Selecting a type of job 11. Determining operational assessment
awareness and agile
aid competency requirements 17. Error management in task
thinking
7. Developing content of 12. Identifying learning planning, preparation, and
22. Human Factors in
a job aid requirements control
emergencies
8. Format and design of 13. Operational competency 18. Capturing, challenging,
job aids development and correcting operational
14. Operational competency error
assessment 19. Communicating
information and
instructions
9. Human Factors in
Equipment design
Recognizing and learning from performance

25. Indicators of human performance 26. Learning from error and human performance
Performance CCPS.
2 Human performance and error
2.1 Learning objectives of this Chapter
Understanding human performance is important to support people to successfully

complete tasks. Understanding human performance will also help people reduce
the likelihood of errors and mistakes. Learning from errors and mistakes is part of
the journey to high performance.
This chapter provides some Human Factors principles that will help people to
reduce the likelihood of errors and mistakes. By the end of this chapter, the reader
should be able to:
• Understand how to proactively and methodically support human

performance,
• Understand the many factors affecting human performance, and
• Understand solutions used to help improve human performance.
These principles will be addressed again in later Chapters.
2.2 An example of successful human performance
2.2.1 What happened?
The “Miracle on the Hudson” happened on January 15, 2009, when a bird strike
occurred shortly after US Airways flight 1549 took off from New York’s LaGuardia
airport [15]. The Airbus struck a flock of Canada geese while on the climb from the
airport. The Captain, Chesley Sullenberger, and First Officer Jeff Skiles decided to
ditch (emergency water landing) the aircraft in the Hudson River, saving all on
board. This famous event was portrayed in a 2016 film (Sully) starring Tom Hanks
as Chesley “Sully” Sullenberger. The successful ditching of an unpowered
passenger airline onto the Hudson River, within six minutes of the bird strike, when
both engines had failed, is an example of skilled and knowledgeable human
performance.
Following the bird strike, a very short period of time was available for the pilots
to determine what had happened, enact a Mayday, determine they could not
return to the airport, decide they had to glide around and find an alternative
landing site (the Hudson River), and identify a new course. They achieved this and
ditched on the Hudson River, after which the 150 passengers and five crew were
rescued by nearby boats and ferries.
The normal procedure for dual engine failure was to attempt to return to the
airport. This turn back to the airport was not possible at the plane’s low altitude. It
was also not possible to complete a “dual engine failure” checklist due to the
limited time available prior to ditching. Simulator training did not cover ditching.
Figure 2-1: “Miracle on the Hudson”
(credit: Greg Lam Pak Ng)
The Captain and First Officer needed to make decisions quickly based on their
knowledge and judgment.
2.2.2 How did they perform successfully?
Despite the popular title of “Miracle on the Hudson”, the successful unpowered
ditching did not happen by luck.
First, airline pilots receive a high level of training in piloting, annual simulator-
based training in handling emergencies, and training in Crew Resource
Management (CRM). CRM provides training in understanding human performance,
interpersonal skills, communications, leadership and decision-making. This
includes maintaining situation awareness and making decisions in high stress
emergencies. The National Transportation Safety Board investigation report
(NTSB, 2010) [15] stated:
“The captain credited the US Airways CRM training for providing him and the
first officer with the skills and tools that they needed to build a team quickly and
open lines of communication, share common goals, and work together.” (p61)
Second, the plane’s “fly by wire” design meant that after the pilot changed
course, the computers adjusted the flight control to maintain plane stability. This
allowed the crew to focus on emergency decision-making. The system design
reduced the crew workload.
Third, having two pilots also allowed them to multi-task as a team and to check
each other’s judgments and actions.
2. Human performance and error 13
2.2.3 The human performance perspective
Directors, managers and supervisors should

High standards of human
create the right environment for successful task
performance are developed
performance. This is sometimes called the
by identifying the demands
“systems” approach to Human Factors. This
of a task and the support
means it is vital to ensure that the system of
that people need.
training, the system of supervision, the rotating
shift schedule system, the system of
communication are all designed to positively support successful task performance.
The “Miracle on the Hudson” shows that with training and experience, people
are able to carry out complex tasks reliably and accurately. With education on how
a system works, people can use their knowledge and experience to quickly come
up with ways to handle new situations. Training in decision-making helps people
make better judgments and decisions, and to act quickly. While the application of
a Human Factors approach can prevent many errors and mistakes, it should
greatly improve human performance and reduce the potential for unrecoverable
errors.
2.3 An example of unsuccessful human performance
2.3.1 Texas City refinery explosion, 2005
In 2005, a major explosion occurred at the BP refinery in Texas City, United States
of America. A summary of the accident is given in B.1 (page 383) and the ‘The B.P.
U.S. Refineries Independent Safety Review Panel’ provides a very detailed report
of this accident [16].
The CSB [14] 2007 investigation report stated people were “set up to fail”. Some
points from the CSB investigation which highlight Human Factors issues include:
• Leadership Decision – The process unit was started despite previously

reported malfunctions of the tower level indicator, level sight glass, and a
pressure control valve.
• Competence – “The hazards of unit start-up, including tower overfill
scenarios, were not adequately covered in operator training…” ([14],
p.91).
• Procedures – “The ISOM raffinate section start-up procedure lacked
sufficient instructions for the Board Operator to safely and successfully
start-up the unit…” ( [14], p.75).
• Interfaces – the readings showing how much liquid raffinate was entering
the ISOM unit and how much was leaving the ISOM unit were on different
screens. This made it harder to spot an imbalance between the input and
output readings (i.e., more input than output), which would have indicated
over-filling.
• Fatigue – “…the CSB concludes that fatigue of the operations personnel

contributed to overfilling the tower” ( [14]
p.289). Several key operational staff had “…numerous latent
worked between 29 and 37 12-hour shifts conditions and safety
in a row. system deficiencies at
• Not enough staff – “…operator staffing the refinery influenced
levels below the numbers required for their (operator) actions
‘safe staffing’. This involves the day-to-day and contributed to the
operation of units with less than the accident…”
minimum numbers of operators
(CSB, 2007, [14] p.69)
required…” ( [14], p.285).
• Supervision – while the start-up shift
started with two supervisors, the experienced supervisor left due to a
family matter, leaving an inexperienced supervisor alone. The remaining
supervisor was busy with several tasks.
• Alarm flood – ISOM operators faced hundreds of alarms going off in a
short time frame. They were not able to assess the situation or warn
others.
There were many factors influencing the operational decisions and actions.
Deficiencies in each of these factors combined to exacerbate operational
problems.
2.3.2 Contributing Human Factors
“You cannot change the human condition, but you can change the conditions in
which people work.” Professor James Reason (Chapter 7, page 96) [17].
A Human Factors principle is that errors and Human error and

mistakes happen because of a combination of mistakes are not the root
problems in the working environment and due to cause of incidents.
the support, or lack of it, offered by the
organization.
It is important to provide a working environment (or set of conditions) that set

people up to succeed throughout the lifespan of an operating facility. Establishing
this working environment / set of conditions should begin in the design of each
new facility. Design should include proper Human Factors design in the layout of
systems and equipment, and process hazard analyses and risk assessments must
include consideration for Human Factors.
A Human Factors principle is that it is vital to ask how and why errors occur.
This includes asking:
• How an individual’s performance is influenced by the conditions they

work in;
• Whether the information and equipment they have been given are
suitable and sufficient;
• Whether the training they have been given is sufficient; and
• How an individual’s performance is influenced by the prevailing culture.
An understanding of human errors and mistakes makes it possible to identify
how to reduce the possibility they occur. Consequently, it enables the
improvement of human performance.
2.3.3 Performance influencing factors and human error
Many factors contribute to an individual or a team making a mistake. These include

the operator’s level of experience, the complexity of a task, the clarity of operating
instructions, the duration of working hours, organizational culture, as well as many
others. These factors are sometimes called Performance Influencing Factors
(PIFs). Some common PIFs are illustrated in Figure 2-2.
Directors, managers and

supervisors should identify which of “Performance Influencing Factors (PIFs)
these factors influence the are the characteristics of the job, the
performance of a particular task. It is individual and the organization that
then possible to create conditions to influence human performance.”
successfully carry out tasks. Later UK Health and Safety Executive [4]
Chapters in this handbook provide
advice on creating these conditions.
Figure 2-2: Performance Influencing Factors
Environment-
related
• Temperature,
humidity,
ventilation
• Noise
Person-related • Lighting Equipment-
• Attitudes & • Space related
behaviors
• Layout
• Training &
• Fit for purpose
experience
• Accessibility
• Capabilities
• Complexity
• Relationships
Performance
influencing factors
Information-
related
Job-related
• Clarity
• Fatigue
• Information
overload • Organizational
Task-related stressors
• Accuracy
• Situational stressors • Workload
• Completeness
• Availability • Distractions
• Multi-tasking
• Complexity
• Time available
• Task frequency/
duration
• Workload
2.4 Key learning points from this Chapter
Key learning points include:
• Errors and mistakes are caused by:

o The environment in which people work; and
o The level or type of support offered to people.
• High standards of human performance are achieved by identifying the
demands of tasks and providing the support needed.
• Understanding diverse performance influencing factors is important to
improving human performance.
• Understanding human errors and mistakes helps to identify how to
reduce likelihood of occurrence, thereby supporting successful human
performance.
Performance CCPS.
3 Options for supporting human performance
3.1 Learning objective of this Chapter
By the end of this chapter, the reader should be able to understand:
• The types of human performance; and

• The concept of matching solutions to the types of performance.
This Chapter provides some key principles for identifying options to support
human performance. The later Chapters provide advice on these options.
In order to support human performance and reduce the potential for errors
and mistakes, it is important to understand the nature of the tasks, the type of
human performance required, and the causes of possible error and mistakes.
A general understanding of human performance can be used when designing

training programs, setting staffing levels, selecting a type of job aid and many other
Human Factors matters.
3.2 Types of human performance
The Skill, Rule and Knowledge-based model (SRK) is a commonly used way of
thinking about how people perform. The idea is that people perform differently
according to the type of task they are doing and their familiarity with the task. The
SRK performance model is shown in Figure 3-1.
This model has been used since the 1980’s to help identify ways to support
people in performing process operations tasks. It was originally proposed by
Professor Jens Rasmussen [18] and further developed by other researchers such
as Professor James Reason [19].
Knowledge based tasks involve a person using their “general knowledge” to

work out what to do. This would be diagnosing a rare fault in a car engine that is
not explained in a manual. Knowledge-based behavior is often necessitated by
uncertainty or novelty in the circumstances at hand. It involves higher cognitive
activities and is fundamentally what most people mean by “thinking”.
Rule based tasks tend to require following a procedure, assessing the situation
(situation awareness), decision-making, and experience related to carrying out the
procedure. An example is identifying a fault in a car engine that is explained in a
manual.
Figure 3-1: The Skill-Rule-Knowledge Performance Model
(adapted from [18])
The words “rule” and “procedure” are not meant to be used literally. A written
procedure may not exist. These words are used to mean the right set of actions
are known in advance of performing a task and it has been determined when these
actions should be performed.
Skill-based performance means people can reliably and quickly perform tasks
with a low level of conscious mental effort, as the actions are so well practiced they
do not require much thought. Steering a car is a typical example. This may also
include being able to gather and understand information very quickly, such as
reading process instrumentation.
A task may involve a combination of these types of performance. For example:
• A control room operator may recognize a high-level alarm in a storage

tank and then check the status of inlet and outlet valves and pumps. This
involves knowledge of the meaning of high-level alarms and the possible
causes of what activated them.
• After identifying the cause of a high-level alarm, the operator may apply
“rules” in the form of a shut-down procedure for inlet valves and pumps.
3. Options for supporting human performance 21
• Quickly carrying out control actions, without using much thought, such as
operating the controls, would use a skill-based performance.
Different tasks will require different levels of each type of performance ability.
Table 3-1 provides definitions and examples.
3.3 Types of human performance, errors and mistakes
3.3.1 Types of human performance and types of errors and mistakes
Different types of errors or mistakes are linked to the three types of human
performance discussed in 3.2.
By identifying the type of errors or mistakes most likely to be made at different

stages of a task or activity, it is possible to put in place support and controls to
prevent or mitigate them. Without this understanding, any interventions made are
less likely to succeed. This is shown in Figure 3-2. The definitions for slips, lapses
and mistake are:
Slips and lapses Mistakes

Slips occur when a person intends to carry Mistakes are judgment and
out the right action, but accidentally does decision-making failures.
it wrong. For example, accidentally They often occur when people do
pressing the wrong button or misreading something wrong, while believing
a number. they have done something right.
Lapses of attention occur when a person This may happen when someone
loses their place in a series of actions (for incorrectly interprets what is
example, steps in a procedure), skipping a happening or selects a wrong
step due to a distraction or a gap in course of action.
memory. The intention is correct and the
knowledge may be right, but one or more
steps are missed.
Table 3-1: SRK types of human performance
Type of human
Definition Examples
performance
Knowledge- When a task is new or complicated, a person will need to • Diagnosing a process upset
based task pay a lot of attention to what they are doing and decide • Working out how to perform a rare
performance what to do based on general knowledge and experience. maintenance task
When the “rules” (actions, decisions and judgments) for a

• Choosing the right maintenance procedure
task are well known, for example, written into a procedure
Rule-based task to fix a faulty pump
or manual.
performance • Remembering the sequence of work for an
Task performance involves remembering and applying
these rules. operations team to follow
When a person can perform a task to a high level of • Pressing an accelerator pedal to maintain
Skill-based
accuracy and reliability with a low level of attention, the steady speed of a chemical road tanker
performance
performance is based on skill. • Applying the right amount of torque to a bolt
Another random document with
no related content on Scribd:
stay with it till it quits. If yu’ happen to wish to
speak to me about that pistol or bears, yu’
come around to Smith’s Palace—that’s the
boss hotel here, ain’t it?—and if yu’ don’t come
too late I’ll not be gone to bed. By this time of
night I’m liable to get sleepy. Tell your friends
good-bye for me, and be good to yourself. I’ve
appreciated your company.”
Mr. McLean entered Smith’s Palace, and,
engaging a room with two beds in it, did a
little delicate lying by means of the truth. “It’s
a lost boy—a runaway,” he told the clerk.
“He’ll not be extra clean, I expect, if he does come. Maybe he’ll give
me the slip, and I’ll have a job cut out to-morrow. I’ll thank yu’ to put
my money in your safe.”
The clerk placed himself at the disposal of
the secret service, and Lin walked up and
down, looking at the railroad photographs for
some ten minutes, when Master Billy peered
in from the street.
“Hello!” said Mr. McLean, casually, and
returned to a fine picture of Pike’s Peak.
Billy observed him for a space, and,
receiving no further attention, came stepping
along. “I’m not a-going back to Laramie,” he
stated, warningly.
“I wouldn’t,” said Lin. “It ain’t half the town
Denver is. Well, good-night. Sorry yu’ couldn’t call sooner—I’m dead
sleepy.”
“O-h!” Billy stood blank. “I wish I’d shook the darned old show.
Say, lemme black your boots in the morning?”
“Not sure my train don’t go too early.”
“I’m up! I’m up! I get around to all of ’em.”
“Where do yu’ sleep?”
“Sleeping with the engine-man now. Why can’t you put that on me
to-night?”
“Goin’ up-stairs. This gentleman wouldn’t
let yu’ go up-stairs.”
But the earnestly petitioned clerk
consented, and Billy was the first to hasten
into the room. He stood rapturous while Lin
buckled the belt round his scanty stomach,
and ingeniously buttoned the suspenders
outside the accoutrement to retard its
immediate descent to earth.
“Did it ever kill a man?” asked Billy,
touching the six-shooter.
“No. It ’ain’t never
had to do that, but I
expect maybe it’s stopped some killin’ me.”
“Oh, leave me wear it just a minute! Do you
collect arrow-heads? I think they’re bully.
There’s the finest one you ever seen.” He
brought out the relic, tightly wrapped in
paper, several pieces. “I foun’ it myself,
camping with father. It was sticking in a crack
right on top of a rock, but nobody’d seen it till
I came along. Ain’t it fine?”
Mr. McLean pronounced it a gem.
“Father an’ me found a lot, an’ they made mother mad lying
around, an’ she throwed ’em out. She takes stuff from Kelley’s.”
“Who’s Kelley?”
“He keeps the drug-store at Laramie. Mother gets awful funny.
That’s how she was when I came home. For I told Mr. Perkins he
lied, an’ I ran then. An’ I knowed well enough she’d lick me when she
got through her spell—an’ father can’t stop her, an’ I—ah, I was sick
of it! She’s lamed me up twice beating me—an’ Perkins wanting me
to say ‘God bless my mother!’ a-getting up and a-going to bed—he’s a
flubdub! An’ so I cleared out. But I’d just as leaves said for God to
bless father—an’ you. I’ll do it now if you say it’s any sense.”
Mr. McLean sat down in a chair. “Don’t yu’ do it now,” said he.
“You wouldn’t like mother,” Billy continued. “You can keep that.”
He came to Lin and placed the arrow-head in his hands, standing
beside him. “Do you
like birds’ eggs? I
collect them. I got
twenty-five kinds—
sage-hen, an’ blue
grouse, an’ willow-
grouse, an’ lots more
kinds harder—but I
couldn’t bring all them
from Laramie. I
brought the magpie’s,
though. D’you care to
see a magpie egg? Well,
you stay to-morrow an’ I’ll show you that an’ some other things I got
the engine-man lets me keep there, for there’s boys that would steal
an egg. An’ I could take you where we could fire that pistol. Bet you
don’t know what that is!”
He brought out a small tin box shaped like a thimble, in which
were things that rattled.
Mr. McLean gave it up.
“That’s kinni-kinnic seed. You can have that, for I got some more
with the engine-man.”
Lin received this
second token also, and
thanked the giver for it.
His first feeling had
been to prevent the
boy’s parting with his
treasures, but
something that came
not from the polish of
manners and
experience made him
know that he should
take them. Billy talked away, laying bare his little soul; the street boy
that was not quite come made place for the child that was not quite
gone, and unimportant words and confidences dropped from him
disjointed as he climbed to the knee of Mr. McLean, and
inadvertently took that cow-puncher for some sort of parent he had
not hitherto met. It lasted but a short while, however, for he went to
sleep in the middle of a sentence, with his head upon Lin’s breast.
The man held him perfectly still, because he had not the faintest
notion that Billy would be impossible to disturb. At length he spoke
to him, suggesting that bed might prove more comfortable; and,
finding how it was, rose and undressed the boy and laid him between
the sheets. The arms and legs seemed aware of the moves required of
them, and stirred conveniently; and directly the head was upon the
pillow the whole small frame burrowed down, without the opening of
an eye or a change in the breathing. Lin stood some time by the
bedside, with his eyes on the long, curling lashes and the curly hair.
Then he glanced craftily at the door of the room, and at himself in
the looking-glass. He stooped and kissed Billy on the forehead, and,
rising from that, gave himself a hangdog stare in the mirror, and
soon in his own bed was sleeping the sound sleep of health.
V
Santa Claus Lin
He was faintly roused by the churchbells,

and lay still, lingering with his sleep, his eyes
closed and his thoughts unshaped. As he
became slowly aware of the morning, the
ringing and the light reached him, and he
waked wholly, and, still lying quiet,
considered the strange room filled with the
bells and the sun of the winter’s day. “Where
have I struck now?” he inquired; and as last
night returned abruptly upon his mind, he
raised himself on his arm.
There sat Responsibility in a chair, washed clean and dressed,
watching him.
“You’re awful late,” said Responsibility.
“But I weren’t a-going without telling you
good-bye.”
“Go?” exclaimed Lin. “Go where? Yu’ surely
ain’t leavin’ me to eat breakfast alone?” The
cow-puncher made his voice very plaintive.
Set Responsibility free after all his trouble to
catch him? This was more than he could do!
“I’ve got to go. If I’d thought you’d want for
me to stay—why, you said you was a-going by
the early train.”
“But the durned thing’s got away on me,”
said Lin, smiling sweetly from the bed.
“If I hadn’t a-promised them—”
“Who?”
“Sidney Ellis and Pete Goode. Why, you know them; you grubbed
with them.”
“Shucks!”
“We’re a-going to have fun to-day.”
“Oh!”
“For it’s Christmas, an’ we’ve bought some
good cigars, an’ Pete says he’ll learn me sure.
O’ course I’ve smoked some, you know. But I’d
just as leaves stayed with you if I’d only
knowed sooner. I wish you lived here. Did you
smoke whole big cigars when you was
beginning?”
“Do yu’ like flapjacks and maple syrup?”
inquired the artful McLean. “That’s what I’m
figuring on inside twenty minutes.”
“Twenty minutes! If they’d wait—”
“See here, Bill. They’ve quit expectin’ yu’, don’t yu’ think? I’d ought
to waked, yu’ see, but I slep’ and slep’, and kep’ yu’ from meetin’ your
engagements, yu’ see—for you couldn’t go, of course. A man couldn’t
treat a man that way now, could he?”
“Course he couldn’t,” said Billy,
brightening.
“And they wouldn’t wait, yu’ see. They
wouldn’t fool away Christmas, that only comes
onced a year, kickin’ their heels, and sayin’
‘Where’s Billy?’ They’d say, ‘Bill has sure made
other arrangements, which he’ll explain to us
at his leesyure.’ And they’d skip with the
cigars.”
The advocate paused, effectively, and from
his bolster regarded Billy with a convincing
eye.
“That’s so,” said Billy.
“And where would yu’ be then, Bill? In the street, out of friends,
out of Christmas, and left both ways, no tobacker and no flapjacks.
Now, Bill, what do yu’ say to us puttin’ up a Christmas deal together?
Just you and me?”
“I’d like that,” said Billy. “Is it all day?”
“I was thinkin’ of all day,’ said Lin. “I’ll not
make yu’ do anything yu’d rather not.”
“Ah, they can smoke without me,” said Billy,
with sudden acrimony. “I’ll see ’em to-
morro’.”
“That’s yu’!” cried Mr. McLean. “Now, Bill,
you hustle down and tell them to keep a table
for us. I’ll get my clothes on and follow yu’.”
The boy went, and
Mr. McLean procured
hot water and dressed
himself, tying his scarf with great care.
“Wished I’d a clean shirt,” said he. “But I don’t
look very bad. Shavin’ yesterday afternoon
was a good move.” He picked up the arrow-
head and the kinni-kinnic, and was particular
to store them in his safest pocket. “I ain’t sure
whether you’re crazy or not,” said he to the
man in the looking-glass. “I ’ain’t never been
sure.” And he slammed the door and went
down-stairs.
He found young Bill on guard over a table for four, with all the
chairs tilted against it as a warning to strangers. No one sat at any
other table or came into the room, for it was late, and the place quite
emptied of breakfasters, and the several entertained waiters had
gathered behind Billy’s important-looking back. Lin provided a
thorough meal, and Billy pronounced the flannel cakes superior to
flapjacks, which were not upon the bill of fare.
“I’d like to see you often,” said he. “I’ll come and see you if you
don’t live too far.”
“That’s the trouble,” said the cow-puncher. “I do. Awful far.” He
stared out of the window.
“Well, I might come some time. I wish you’d write me a letter. Can
you write?”
“What’s that? Can I write? Oh yes.”
“I can write, an’ I can read, too. I’ve been to
school in Sidney, Nebraska, an’ Magaw,
Kansas, an’ Salt Lake—that’s the finest town
except Denver.”
Billy fell into that cheerful strain of
comment which, unreplied to, yet goes on
content and self-sustaining, while Mr. McLean
gave amiable signs of assent, but chiefly
looked out of the window; and when the now
interested waiter said, respectfully, that he
desired to close the room, they went out to the
office, where the money was got out of the safe
and the bill paid.
The streets were full of the bright sun, and
seemingly at Denver’s gates stood the
mountains; an air crisp and pleasant wafted
from their peaks; no smoke hung among the
roofs, and the sky spread wide over the city
without a stain; it was holiday up among the
chimneys and tall buildings, and down among
the quiet ground-stories below as well; and
presently from their scattered pinnacles
through the town the bells broke out against
the jocund silence of the morning.
“Don’t you like music?” inquired Billy.
“Yes,” said Lin.
Ladies with their husbands and children were passing and
meeting, orderly yet gayer than if it were only Sunday, and the
salutations of Christmas came now and again to the cow-puncher’s
ears; but to-day, possessor of his own share in this, Lin looked at
every one with a sort of friendly challenge, and young Billy talked
along beside him.
“Don’t you think we could go in here?” Billy asked. A church door
was open, and the rich organ sounded through to the pavement.
“They’ve good music here, an’ they keep it up without much talking
between. I’ve been in lots of times.”
They went in and sat
to hear the music.
Better than the organ,
it seemed to them, were
the harmonious voices
raised from somewhere
outside, like
unexpected visitants;
and the pair sat in their
back seat, too deep in
listening to the
processional hymn to
think of rising in decent imitation of those around them. The crystal
melody of the refrain especially reached their understandings, and
when for the fourth time “Shout the glad tidings, exultingly sing,”
pealed forth and ceased, both the delighted faces fell.
“Don’t you wish there was more?” Billy whispered.
“Wish there was a hundred verses,” answered Lin.
But canticles and responses followed, with so little talking between
them they were held spellbound, seldom thinking to rise or kneel.
Lin’s eyes roved over the church, dwelling upon the pillars in their
evergreen, the flowers and leafy wreaths, the texts of white and gold.
“‘Peace, good-will towards men,’” he read. “That’s so. Peace and
good-will. Yes, that’s so. I expect they got that somewheres in the
Bible. It’s awful good, and you’d never think of it yourself.”
There was a touch on his arm, and a woman
handed a book to him. “This is the hymn we
have now,” she whispered, gently; and Lin,
blushing scarlet, took it passively without a
word. He and Billy stood up and held the book
together, dutifully reading the words:
“It came upon the midnight clear,
That glorious song of old,
From angels bending near the earth
To touch their harps of gold;
Peace on the earth—”
This tune was more beautiful than all, and Lin lost himself in it, until
he found Billy recalling him with a finger upon the words, the
concluding ones:
“And the whole world sent back the song

Which now the angels sing.”
The music rose and descended to its lovely and simple end; and, for a
second time in Denver, Lin brushed a hand across his eyes. He
turned his face from his neighbor, frowning crossly; and since the
heart has reasons which Reason does not know, he seemed to himself
a fool; but when the service was over and he came out, he repeated
again, “‘Peace and good-will.’ When I run on to the Bishop of
Wyoming I’ll tell him if he’ll preach on them words I’ll be there.”
“Couldn’t we shoot your pistol now?” asked Billy.
“Sure, boy. Ain’t yu’ hungry, though?”
“No. I wish we were away off up there. Don’t you?”
“The mountains? They look pretty—so white! A heap better ’n
houses. Why, we’ll go there! There’s trains to Golden. We’ll shoot
around among the foot-hills.”
To Golden they immediately went, and, after a meal there,
wandered in the open country until the cartridges were gone, the sun
was low, and Billy was walked off his young heels—a truth he learned
complete in one horrid moment and battled to
conceal.
“Lame!” he echoed, angrily. “I ain’t.”
“Shucks!” said Lin, after the next ten steps.
“You are, and both feet.”
“Tell you, there’s stones here, an’ I’m just a-
skipping them.”
Lin, briefly, took the
boy in his arms and
carried him to Golden.
“I’m played out
myself,” he said, sitting
in the hotel and looking lugubriously at Billy
on a bed. “And I ain’t fit to have charge of a
hog.” He came and put his hand on the boy’s
head.
“I’m not sick,” said the cripple. “I tell you
I’m bully. You wait an’ see me eat dinner.”
But Lin had hot water and cold water and
salt, and was an hour upon his knees bathing the hot feet. And then
Billy could not eat dinner.
There was a doctor in Golden; but in spite of his light prescription
and most reasonable observations, Mr. McLean passed a foolish
night of vigil, while Billy slept, quite well at first, and, as the hours
passed, better and better. In the morning he was entirely brisk,
though stiff.
“I couldn’t work quick to-day,” he said. “But I guess one day won’t
lose me my trade.”
“How d’ yu’ mean?” asked Lin.
“Why, I’ve got regulars, you know. Sidney Ellis an’ Pete Goode has
theirs, an’ we don’t cut each other. I’ve got Mr. Daniels an’ Mr. Fisher
an’ lots, an’ if you lived in Denver I’d shine your boots every day for
nothing. I wished you lived in Denver.”
“Shine my boots? Yu’ll never! And yu’ don’t black Daniels or
Fisher, or any of the outfit.”
“Why, I’m doing first-rate,” said Billy,
surprised at the swearing into which Mr.
McLean now burst. “An’ I ain’t big enough to
get to make money at any other job.
“I want to see that
engine-man,” muttered
Lin. “I don’t like your
smokin’ friend.”
“Pete Goode? Why,
he’s awful smart. Don’t
you think he’s smart?”
“Smart’s nothin’,” observed Mr. McLean.
“Pete has learned me and Sidney a lot,”
pursued Billy, engagingly.
“I’ll bet he has!” growled the cow-puncher;
and again Billy was taken aback at his
language.
“‘This is Mister Billy Lusk’”

It was not so simple, this case. To the
perturbed mind of Mr. McLean it grew less
simple during that day at Golden, while Billy
recovered, and talked, and ate his innocent
meals. The cow-puncher was far too wise to
think for a single moment of restoring the
runaway to his debauched and shiftless
parents. Possessed of some imagination, he
went through a scene in which he appeared at
the Lusk threshold with Billy and forgiveness,
and intruded upon a conjugal assault and
battery. “Shucks!” said he. “The kid would be
off again inside a week. And I don’t want him there, anyway.”
Denver, upon the following day, saw the little bootblack again at
his corner, with his trade not lost; but near him stood a tall, singular
man, with hazel eyes and a sulky expression. And citizens during that
week noticed, as a new sight in the streets, the tall man and the little
boy walking together. Sometimes they would be in shops. The boy
seemed as happy as possible, talking constantly, while the man
seldom said a word, and his face was serious.
Upon New Year’s Eve Governor Barker was

overtaken by Mr. McLean riding a horse up
Hill Street, Cheyenne.
“Hello!” said Barker, staring humorously
through his glasses. “Have a good drunk?”
“Changed my mind,” said Lin, grinning.
“Proves I’ve got one. Struck Christmas all
right, though.”
“Who’s your friend?” inquired his
Excellency.
“This is Mister Billy Lusk. Him and me have agreed that towns
ain’t nice to live in. If Judge Henry’s foreman and his wife won’t
board him at Sunk Creek—why, I’ll fix it somehow.”
The cow-puncher and his Responsibility rode on together towards
the open plain.
“Suffering Moses!” remarked his
Excellency.
THE END
TRANSCRIBER’S NOTES
1. Silently corrected obvious typographical errors and
variations in spelling.
2. Retained archaic, non-standard, and uncertain spellings
as printed.
*** END OF THE PROJECT GUTENBERG EBOOK A JOURNEY IN
SEARCH OF CHRISTMAS ***
Updated editions will replace the previous one—the old editions

will be renamed.
Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright
in these works, so the Foundation (and you!) can copy and
distribute it in the United States without permission and without
paying copyright royalties. Special rules, set forth in the General
Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.
START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
To protect the Project Gutenberg™ mission of promoting the

free distribution of electronic works, by using or distributing this
work (or any other work associated in any way with the phrase
“Project Gutenberg”), you agree to comply with all the terms of
the Full Project Gutenberg™ License available with this file or
online at www.gutenberg.org/license.
Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand,
agree to and accept all the terms of this license and intellectual
property (trademark/copyright) agreement. If you do not agree to
abide by all the terms of this agreement, you must cease using
and return or destroy all copies of Project Gutenberg™
electronic works in your possession. If you paid a fee for
obtaining a copy of or access to a Project Gutenberg™
electronic work and you do not agree to be bound by the terms
of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.
1.B. “Project Gutenberg” is a registered trademark. It may only

be used on or associated in any way with an electronic work by
people who agree to be bound by the terms of this agreement.
There are a few things that you can do with most Project
Gutenberg™ electronic works even without complying with the
full terms of this agreement. See paragraph 1.C below. There
are a lot of things you can do with Project Gutenberg™
electronic works if you follow the terms of this agreement and
help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright
law in the United States and you are located in the United
States, we do not claim a right to prevent you from copying,
distributing, performing, displaying or creating derivative works
based on the work as long as all references to Project
Gutenberg are removed. Of course, we hope that you will
support the Project Gutenberg™ mission of promoting free
access to electronic works by freely sharing Project
Gutenberg™ works in compliance with the terms of this
agreement for keeping the Project Gutenberg™ name
associated with the work. You can easily comply with the terms
of this agreement by keeping this work in the same format with
its attached full Project Gutenberg™ License when you share it
without charge with others.
1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.
1.E. Unless you have removed all references to Project

Gutenberg:
1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project
Gutenberg™ work (any work on which the phrase “Project
Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed,
viewed, copied or distributed:
This eBook is for the use of anyone anywhere in the United

States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it
away or re-use it under the terms of the Project Gutenberg
License included with this eBook or online at
www.gutenberg.org. If you are not located in the United
States, you will have to check the laws of the country where
you are located before using this eBook.
1.E.2. If an individual Project Gutenberg™ electronic work is

derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to
anyone in the United States without paying any fees or charges.
If you are redistributing or providing access to a work with the
phrase “Project Gutenberg” associated with or appearing on the
work, you must comply either with the requirements of
paragraphs 1.E.1 through 1.E.7 or obtain permission for the use
of the work and the Project Gutenberg™ trademark as set forth
in paragraphs 1.E.8 or 1.E.9.
1.E.3. If an individual Project Gutenberg™ electronic work is

posted with the permission of the copyright holder, your use and
distribution must comply with both paragraphs 1.E.1 through
1.E.7 and any additional terms imposed by the copyright holder.
Additional terms will be linked to the Project Gutenberg™
License for all works posted with the permission of the copyright
holder found at the beginning of this work.
1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files
containing a part of this work or any other work associated with
Project Gutenberg™.

Human Factors Handbook For Process Plant Operations Improving Process Safety and System Performance 1St Edition Ccps Center For Chemical Process Safety Full Chapter

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

Human Factors Handbook For Process Plant Operations Improving Process Safety and System Performance 1St Edition Ccps Center For Chemical Process Safety Full Chapter

Uploaded by

Copyright:

Available Formats

Human Factors Handbook for Process

Plant Operations: Improving Process

Improving Process Safety and

CENTER FOR CHEMICAL PROCESS SAFETY

All rights reserved. No part of this publication may be reproduced, stored in a

Limit of Liability/Disclaimer of Warranty

Library of Congress Cataloging-in-Publication Data Applied for

Cover Design: Wiley

It is both an honor and a privilege to see Jack in action!

Louisa A. Nara, CCPSC

Table of Contents .............................................................................................. ix

Part 1: Concepts, principles, and foundational knowledge .......................... 1

Part 2: Procedures and job aids .................................................................... 43

9.4 Error traps ...................................................................................... 96

Part 4: Operational competence ................................................................. 115

14 Operational competency assessment ................................................. 151

Part 5: Task support ...................................................................................... 161

Part 6: Non-technical skills ........................................................................... 247

Part 7: Working with contractors and managing change......................... 299

Part 8: Recognizing and learning from performance ............................... 319

A Human error concepts .................................................................... 373

Figure 1-1: Human Factors science, concepts and principles .................................... 3

Figure 15-5: Guidelines on shift design .................................................................... 171

Figure A-1 Energy Institute human performance principles.................................. 377

Table 3-1: SRK types of human performance ............................................................ 22

Table 19-3: Shift handover risk factors ..................................................................... 242

Table A-1 ‘Hearts and Minds’ definitions for non-compliance............................... 375

Project Team Members

In the early 1990s, I was working on research projects examining psychological

It has been written especially with operations and maintenance supervisors in

Engineers, process safety practitioners and regulators who wish to gain an

This book has been written by a combined panel of plant operations

This valuable handbook is definitely recommended reading for those striving

Part 1: Concepts, principles, and foundational knowledge

1.1 What is “Human Factors”?

As illustrated in Figure 1-1, like engineering, Human Factors is a combination of

Figure 1-1: Human Factors science, concepts and principles

A short video that presents a Human Factors view for successfully

1.2 Purpose of this handbook

1.2.1 Purpose and scope

This handbook provides practical advice

• Provides examples of practical

• Provides an explanation of how people think and behave, why people

1.2.2 Other guidance

How does this handbook fit with

Safety culture, leadership, and

Human Factors methods, such as

• Essential Practices for Creating, Strengthening, and Sustaining Process

1.2.3 Who should read this handbook?

This handbook is intended for everyone involved with defining, planning,

1.2.4 A note on language and terminology

A more complete explanation of the traditional terminology of ‘human error’

1.3 Why Human Factors?

1.3.1 Major accidents associated with human performance

Human performance is a factor in

This kind of evidence greatly undermines stakeholder trust in an organization

1.3.2 It is more than common sense

People who plan work and develop

Time constraints and attention demands impact frontline managers and

Businesses must prioritize and balance production, operations, maintenance,

Human Factors adds scientific knowledge to help workers achieve high

1.3.3 The benefit of high performing teams

People diagnose unfamiliar faults. They As a leader, it is