Presentation Objectives
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Present “The Dirty Dozen.”
Provide examples from pipelines.
Lead you to think of examples.
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 for addressing the three.
• Tell your manager the results in one month.
Stress Effects
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Anxiety, nervousness, jumpiness
Difficulty concentrating on task
Feeling overwhelmed
Fatigue
Health problems
Memory problems
Poor judgment
Stress – Pipeline Example
• 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 Curve Model
High
PERFORMANCE
Go Go Stress
So So Stress
No No Stress
Danger
Caution
Basic
Living
Stressors
Low
Yerkes-Dodson Curve (1908)
Adapted by G. Dupont
Basic
Job
Stressors
Capacity
to Cope
Medium
STRESS
Danger
Distress
High
Stress – Safety Valves
• 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.
Fatigue Effects
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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 – Pipeline Example
• 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 – Safety Valves
• 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.
Complacency Effects
• 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
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else’s job.
Performing a task without using the
procedures or recommended personal
protective equipment.
Complacency – Pipeline Example
• 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 – Safety Valves
• 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
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Use STAR with every task.
Practice independent verification.
Follow all policies and procedures.
Train continually and review often.
Create mental challenges for yourself.
Sustain a questioning attitude.
Complacency – Safety Valves
• Five Questions – Simple Risk Assessment
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5.
Why am I doing this task at all?
What could go wrong?
How likely is it to happen?
What effect could it have on me or others?
What can I do about it?
• STAR
STOP
THINK
ACT
REVIEW
Distractions
• 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 – Pipeline Examples
• 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 – Control Rooms
• Televisions, radio, internet surfing.
• Talking to others in the room or on the
phone.
• What else?
• What do you do about distractions?
Distractions – Safety Valves
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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.
Pressure
• Demands are sometimes made for workers to:
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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 –Example
• 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 in Control Rooms
• 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 – Safety Valves
• 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.
Situation Awareness
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.
Lack of Awareness - Pipeline Example
• 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.
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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 Safety Valves
• 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)
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.
Lack of Assertiveness
• 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 Example
• 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 – Safety Valves
• 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 Communication
• 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 Example
• 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 – Safety Valves
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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 Knowledge
• 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 Example
• 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 – Safety Valves
• 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 Resources
• 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 Example
• 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 – Safety Valves
• 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 Teamwork
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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 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.
What About Control Rooms?
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Is teamwork necessary?
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On shift
Between shifts
With field operations
With support functions
With management
Does teamwork exist, in your control room?
What makes your team successful?
Lack of Teamwork – Safety Valves
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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.
Norms
• 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 Example
• “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 – Safety Valves
• 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.
The Dirty Dozen
Stress
Fatigue
Complacency
Distractions
Pressure
Lack of Awareness
The Dirty Dozen
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
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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.”