Dirty Dozen 2010 Client Presentation 97 03

Suggested Instructions for Presenter

• Use this presentation at a meeting or training session early in the year.

• Ask each person to participate by thinking of examples when one of these causes affected them; ask them to write down the examples.

• Ask each person to make learning and developing ways to avoid “The Dirty Dozen” a goal for 2010; ask for specific SMART goals.

Suggested Instructions for Presenter(continued)

• Tell them they will receive an article each month; hand out the article on “Stress” during the session. – Demonstrate how the article can be used for

reading, discussions, and development.

• Complete the presentation in one hour, OR

• Present an overview early in the year, and use other parts in other meetings.

Slide for Your Content

• Your company has some goals, I hope, related to safety, operational excellence, quality assurance, error reduction, human factors.

• Use these blank slides to link those goals, strategies, tactics, initiatives to The Dirty Dozen.

• Delete the blank slides you do not use.

Presentation Objectives

• Provide an introduction to human factors.

• Present “The Dirty Dozen.”

• Provide examples from pipelines.

• Lead you to think of examples.

• You provide examples and discuss.

• Suggest some “Safety Valves.”

Today’s Goal for You

• Identify at least three of “The Dirty Dozen” that affect you.

• Write down how you can address them, so they do not affect you.

• Tell your manager about “The Dirty Dozen” and your goal.

• Tell your manager the results in one month.

Simple Definition of Human Factors

• Interaction of:–People with people

–People with procedures

–People with machines

–People with their environment

Human Factors – Key Aspects!ORGANIZATION

• Strategy• Culture• Leadership• Resources• Work patterns• Communications

What are people being asked to do and where? JOB

• Tasks• Environment• Workload• Displays & controls• Alarms• Procedures

INDIVIDUAL• Risk

perception• Competence• Skills• Personality• Attitude

Where are they working?

Who is doing it?

Organizational Factors

ORGANIZATION• Inadequate work planning,

leading to high work pressure• Lack of safety systems

and barriers• Inadequate responses to

previous incidents• Inadequate leadership

and management• Inadequate communication• Inadequate work standards• Poor management of health

and safety• Poor safety culture

Where are they working? What might cause problems?

JOB• Poor design of equipment and

instruments• Constant distractions and

interruptions• Missing or unclear

instructions• Poorly maintained equipment• Lack of parts and supplies• High workload• Noisy and unpleasant working

conditions

Job Factors What are people being asked to do and where?

What might cause problems?

Individual FactorsWho is doing it? What might cause problems?

INDIVIDUAL• Low skill and

competence levels• Low physical or mental

capabilities• Personal or family

problems• Tired and stressed• Bored or discouraged• Medical problems

What Can I Do?

• I can learn my capabilities and limitations.

• I can learn the ways I think, act, and behave.

• I can learn and avoid “The Dirty Dozen.”

• I can develop and use “Safety Valves.”

• I can understand that organizational and job factors are major contributors to accidents and errors.

• But I can take responsibility for my errors, and learn from any near misses and incidents.

The Dirty Dozen

• Stress • Fatigue• Complacency• Distractions• Pressure• Lack of Awareness

• Lack of Assertiveness• Lack of

Communication • Lack of Knowledge• Lack of Resources• Lack of Teamwork• Norms

• Anxiety, nervousness, jumpiness

• Difficulty concentrating on task

• Feeling overwhelmed

• Fatigue

• Health problems

• Memory problems

• Poor judgment

Stress Effects

• Pipeline controller who normally performed well.• Makes several errors where he forgot to do a

task at the correct time.• Part of his “action plan” was to work with me on

improving his work planning and ways to use reminders.

• He told me(hadn’t told others) that:– He was having financial problems, and– His wife and children had left him, and– He was not sleeping much.

Stress – Pipeline Example

• Pipeline operator who normally performed well.• Was performing a valve inspection.• Closed a manual mainline valve and shut the

line down.• Why?• Was not concentrating on task, because of a

personal problem. • Mentally distracted.

Stress – Pipeline Example

Low Medium High

STRESS

PERF

ORM

ANCE

High

BasicLivingStressors

BasicJobStressors

Capacityto Cope

CautionDangerDistress

Yerkes-Dodson Curve (1908)Adapted by G. Dupont

Danger

Go Go Stress So So Stress

No No Stress

Stress Curve Model

• Be aware of the effects of stress on your work.– Does your company provide educational

materials?– Materials are available.

• Discuss what is happening with someone.• Ask a co-worker to check your work.• Take time off; take breaks regularly.• Turn off your devices, when not on duty.• Eat properly, rest adequately, exercise.• Plan an appropriate course of action, when stress is

evident.

Stress – Safety Valves

• Make more mistakes.

• Delayed reactions.

• Difficult to maintain attention and awareness.

• Not able to handle much information.

• Every task becomes more difficult to perform.

• Doesn’t want to talk or interact with people

• Irritable or bad mood.

• Involuntary lapses into sleep may occur.

Fatigue Effects

• During a shutdown, a crew worked 34 hours installing a new piping system.

• At hour 28, a laborer was trying to get two flanges aligned.

• He stuck his hand in the wrong place.

• Two fingers were cut and smashed.

Fatigue – Pipeline Example

• Pipeline controllers – a few NTSB reports

• Either the controllers do not react quickly to abnormal operating conditions, OR

• They do not react correctly.

• People who work rotating shifts have the effects of fatigue. – Many examples from all over the world.– Fatigue in today’s world is a human problem,

a socio-technical effect of the way we live.

Fatigue – Pipeline Example

• Get adequate amounts of sleep.– 8 hours each day/night for most people.

• Educate self on causes and cures of fatigue.– Many resources on fatigue management.

• Get a physical check-up annually.– Address any sleep disorders.

• Eat properly and drink plenty of fluids.– Use caffeine strategically.

• Exercise regularly.

Fatigue – Safety Valves

• Letting your mind wander.• Taking shortcuts and omitting steps.• Fooling around or showing off. • Thinking that everything will work perfectly.• Working too long without a break.• Taking the attitude that safety is someone

else’s job.• Performing a task without using the

procedures or recommended personal protective equipment.

Complacency Effects

• Corrective Maintenance Performed On Wrong System– Familiarity and complacency with the work

environment allowed workers to troubleshoot an electrical system that was not isolated.

• Opened wrong valve– Person reported that he had performed task

hundreds of times. Didn’t think about task.• Did not refer to procedure, and performed task

incorrectly.

Complacency – Pipeline Example

• Understand the human factors involved:– We have a mental bias that allows our past

experiences to guide present expectations.– We don’t use our brains fully in the situation since our

present circumstances normally match our past circumstances

– We devote our brains to more interesting parts of a task, or to a more interesting task.

• Recognize that “It can’t happen to me” is a wrong belief.

• Expect success, but be prepared for failure.

Complacency – Safety Valves

• Always practice risk assessment.– Use the 5 Questions

• Use STAR with every task.

• Practice independent verification.

• Follow all policies and procedures.

• Train continually and review often.

• Create mental challenges for yourself.

• Sustain a questioning attitude.


• Five Questions – Simple Risk Assessment1. Why am I doing this task at all?2. What could go wrong?3. How likely is it to happen?4. What effect could it have on me or others?5. What can I do about it?

• STAR


REVIEWSTOP THINK ACT

• Interruptions– How can interruptions cause an error?

• “Multitasking is counterproductive.” (CNN.com)• “Multitasking makes us stupid.” (WSJ article)

– There is a ‘time-cost’ to switching tasks.

– There is a ‘switching-cost’.

– One must change goals.• What do I want to do now?

– One must change rules.• What rules apply to this task?

Distractions

• Driving and Doing Other Things– Vehicle accidents– Near misses

• People talking on phones, surfing Internet, etc. and failing to notice that it is time to perform a task OR ignoring an alarm or other signal.

• Technician was interrupted during a task and did not return pressure switch to service. Caused damage to equipment, and an abnormal operation.

Distractions – Pipeline Examples

• Televisions, radio, internet surfing.• Talking to others in the room or on the

phone.• What else?

• What do you do about distractions?

Distractions – Control Rooms

• Minimize or eliminate distractions.

• Ask people to be quiet and leave your area.

• Finish the task if possible.

• Complete tasks step by step.

• Flag or tag all uncompleted work.

• Use STAR.

• Use memory aids.

• Focus by practicing mindful attention.

Distractions – Safety Valves

• Demands are sometimes made for workers to:– Meet unrealistic deadlines.

– Be multi-skilled.

– Do many tasks in a workday, while multitasking.

– Be as good or better than coworkers.

– Perform all tasks safely and without error.

• Over time or anytime, these pressures can cause performance problems.

• Can cause accidents and injuries.

Pressure

• For instance, during the 36-month period from January 1, 2001 through December 31, 2003, 18 workers were injured and approximately 86 others were involved in near miss events.– Often pressure to “get the job done” results in

actions that can permit disastrous consequences (i.e., personal injury and/or property damage).

– This is from a DOE report.• Technicians were pressured by managers to

work excessive hours to repair a pump. The repair took longer because the technicians, being fatigued, made some mistakes that caused rework.

Pressure –Example

• Perform tasks when a protective device is not working properly or a safety device is inhibited.

• Take a shortcut in a procedure.• Do things that may compromise safety or

quality, for the sake of profitability.• Work an extra shift or extra hours, when

fatigued.• Do too many tasks at once, or in a short time

period.• Stay at the console, when you need a break.• Work in a stressful environment, even when

improvements can easily be made.

Pressure in Control Rooms

• Don’t overwhelm yourself or others.

• Don’t be afraid to ask for help.

• Communicate your concern to your manager and coworkers.

• Don’t create a false sense of urgency.

• Don’t take shortcuts; do the job right.

• Say no to pressure.

• Develop good planning and coping skills.

Pressure – Safety Valves

1. Perceive(see, hear, notice) the critical elements around you.

2. Understand what those critical elements mean, particularly as they relate to the current task.

3. Forecast what is going to happen in the near future.

Situation Awareness

• Excavation damage to pipelines

–“Didn’t know a pipeline was here.”

–“Thought the pipeline was a few feet over.”

–“Didn’t think I would damage the line by digging with the hoe.”

Lack of Awareness - Pipeline Example

• Controller has no change in display, but field equipment has changed.– Received brief explanation of change.– Is “aware” he cannot rely on display as

“accurate.”– Relying on Controller to maintain “awareness

of change” and make switch correctly.– Controller did not make switch correctly.

Lack of Awareness - Pipeline Example

• Learn the principles and practices of situation awareness.

• Pay attention to your surroundings.– Create a “safety zone.”

• Recognize that jobs and the requirements are complex.

• Understand that vigilance can deteriorate while performing a task.

• Learn and use human performance principles. (next slide lists them)

Lack of Awareness Safety Valves

Human Performance Principles

1. People are fallible and even the best make mistakes.

2. Error-likely situations are predictable, manageable, and preventable.

3. Individual behavior is influenced by organizational and job factors.

4. People achieve good performance largely due to encouragement and reinforcement received from managers and co-workers.

5. Events can be avoided through an understanding of the reasons mistakes occur and application of the lessons learned from past events.

• In group settings, some people are hesitant to express their opinions.– Affects work planning, hazard analysis, safety

concerns.

• New employees may not ask relevant questions, even when uncertain.– Can cause accidents, rework, quality issues.

• Some employees will not contradict managers or experienced employees.

Lack of Assertiveness

• Younger employee knew more experienced employee was not following company requirements, BUT did not question …AND nothing happened for months, until a tank overflow.

• Controller did not question temporary operating directions, which led to an abnormal operating condition.

Lack of Assertiveness Example

• Practice your values and beliefs.

• Practice the company’s values and beliefs.

• Refuse to compromise company and personal standards.

• Ask for what you need.

• Don’t be afraid to express your opinion and ideas.

• Recognize your contributions matter.

• Learn how to be assertive on the job.

Lack of Assertiveness – Safety Valves

• Lack of communication affects performance:– Misunderstandings occur between workers.– Hurt feelings lead to petty disagreements.– Job doesn’t get done or is delayed.– Anger may affect individuals or groups.– Loss of trust and respect.– Near misses or incidents may result.– Performance of individuals and groups suffers.

Lack of Communication

• Field technician did not inform controller of a communication device failure, and the controller was not receiving accurate information. Abnormal event!

• Scheduler did not properly inform operator of change and product was contaminated.

• Many, many, many other examples.

Lack of Communication Example

• Practice 3-way communication.• Write down important information.• Always conduct briefings before, during, and after jobs.• Use the Management of Change process(even for small

changes in the control room and elsewhere).• Provide the right information to the right people at the

right time.• Don’t tell someone something when they are in the

middle of doing something else.• Give people your full attention when listening.• Expect people’s full attention when talking.

Lack of Communication – Safety Valves

• Factors contributing to lack of knowledge:– Inadequate training– New equipment– Procedures and regulations– New technology.

• Provide adequate training and reference materials. • Use resources like the expertise of other people on shift,

other people, and the manufacturer’s manual.• Teamwork and communication help to reduce the

potential error due to the lack of knowledge.• Address all changes, including temporary ones.

Lack of Knowledge

• Technician did not know the procedure for maintenance on electrical equipment, BUT did the task AND was injured.

• Operator did not know how to locate the pipeline and marked its location incorrectly, AND line got damaged.

• Controller did not receive training, after a change in operating procedures, AND product was contaminated.

Lack of Knowledge Example

• Get the necessary training and practice.• Use procedures and manuals.• Don’t do a task if you do not know how to

do it safely and correctly.• Ask someone who knows.• Don’t let pride get in the way.• Be a lifelong learner.• Learn from mistakes.

Lack of Knowledge – Safety Valves

• When supplies are not available, employees spend time trying to find substitutes.

• When parts are not available, delays are necessary while a part is ordered, made, or retrofitted.

• Employees are tempted to omit steps that require a missing resource.

• Employees may “guess” at a solution, if the correct resource is not available.

Lack of Resources

• Most pipeline companies are operating with fewer employees than they had a few years ago.– The result is that employees are doing more tasks,

driving more miles, working more overtime.– Causes stress, pressure, fatigue.– This can lead to errors, accidents, injuries.

• Most pipeline companies are reducing expense budgets.– Fewer spare parts and supplies are available.– Fewer employees are available.– Fewer dollars are available for training.

Lack of Resources Example

• Have the correct people complement for the schedules required to operate the pipeline.

• Assess needs for new parts before beginning a job.

• Purchase and maintain critical parts inventory.• Don’t compromise standards if the correct

resources are lacking.• Don’t use work arounds if you don’t have the

proper parts or supplies.

Lack of Resources – Safety Valves

• Roles and responsibilities, if not clear, cause confusion and frustration.

• Teamwork problems lead to performance issues.

• Decisions are made by one or two people in the group, without the team’s knowledge.

• Problems and underlying issues may not be addressed.

• Trust and respect are compromised.• Cynicism and sarcasm are present.

Lack of Teamwork

Lack of Teamwork Example

• Tank Volume Record Keeping – Employee purposely recorded wrong volume to cover up his mistake. He got fired for lying.

Good Teamwork Example

• Tank Fire – When lightning caused a tank fire, the regular drills with employees and local fire departments proved that teamwork and preparation was worthwhile.

• Is teamwork necessary?– On shift– Between shifts– With field operations– With support functions– With management

• Does teamwork exist, in your control room?• What makes your team successful?

What About Control Rooms?

• Clarify the team goals.• Have an effective team plan. • Clearly define the roles.• Clear communication.• Reward good team behavior. • Punish poor team behavior.• Use well-defined decision procedures.• Balanced participation.• Establish ground rules. • Be aware of the group interactions.

Lack of Teamwork – Safety Valves

• Norms can be positive or negative.– Use procedures or not.– Completing checklists or pencil whipping.– Naps encouraged or punished.

• Norms exist for a reason– Restaurants have signs requiring employees to

wash their hands. Why?– Sign in Nashville restaurant says “wash hands

twice.” Why?• Norms are set by the employees

– Pipeline example on next slide

Norms

• “Do not shut the pipeline down for any reason.”

OR• “Every employee has the authority to shut

the pipeline down if he or she suspects a problem.”

– Which one of those is closer to the norm for your company?

Norms Example

• Recognize norms where we work and live.• Work on removing bad habits and behaviors.• Accentuate the positive, eliminate the

negative.• Don’t use shortcuts.• Abide by standards and requirements.• Be a good example for others.• Follow policies and procedures.• Keep in mind the “old way” may not be

the correct way.

Norms – Safety Valves

The Dirty Dozen

• Stress • Fatigue• Complacency• Distractions• Pressure• Lack of Awareness

• Lack of Assertiveness

• Lack of Communication

• Lack of Knowledge• Lack of Resources• Lack of Teamwork• Norms

Today’s Goal for You

• Identify at least three of “The Dirty Dozen” that affect you.

• Write down how you can address them, so they do not affect you.

• Tell your manager about “The Dirty Dozen” and your goal.

• Tell your manager the results in one month.

Presentation Objectives

• Suggest a goal for you.

• Provide an introduction to human factors.

• Present “The Dirty Dozen.”

• Provide examples from pipelines.

• Lead you to think of examples.

• Suggest some “Safety Valves.”

Dirty Dozen 2010 Client Presentation 97 03

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Transcript of Dirty Dozen 2010 Client Presentation 97 03