- Oil & Gas
- South Asia
REDUCING THE POTENTIAL FOR HUMAN FAILURE
Humans are creatures of habit. If an operator has worked at a plant for, say, 10 years, he or she has may have a vested interest in the status quo. They understand the set up, how things function, from every button to lever to read-out dial. Consolidating a number of small, field-based control rooms into one large single centralized control room dominated by computer screens digitized control systems may be in the best interest of the company for reasons of efficiency and technological advancements. But to some operators new technologies and changes to the interactions and processes may undermine the familiarity, skills, and access to the necessary knowledge and competencies needed to manage the plant safely in times past. The key concern is the potential for human failure that may increase the risk of a major accident. Weaknesses in the system as a result of or during the transition need to be examined for all operational scenarios. Abnormal situations, such as plant upsets, are typically where these weaknesses come to light. It is a time of high workload and high reliance on safety critical communications, team work and competency to bring the plant back under control. Unfortunately, there are several examples where poor organizational change management have played a part on major accidents, including the Challenger space shuttle disaster (1986), Bhopal Methyl Isocyanate leak (1984), and Nimrod aircraft refueling disaster (2006), to name but a few.
As well as the risk of human failure, there is another aspect of the change that needs to be carefully managed. Emotional upheaval and resistance are is a common reaction to change and the emotional response has been likened to a grief response. Of course this is individual and some operators and managers may welcome the change if their vested interest in the existing situation is low. However, it can also reflect as group resistance which is often influenced by their historical experience of organizational changes. Uncertainty, ambiguity and outright chaos are distinctly possible and in fact many change projects fail as a result of not properly assessing and understanding the ‘human’ aspects of change. Low morale or complete rejection of new processes and technology can result, which can severely compromise efficiency and safety. Averting these potentialities is what OCM is all about. Another way of putting it that OCM applies scientific methods and metrics to reduce the potential for human failure during transition. Managing transition practically and well is as important as the decision to embrace new technologies in the first place.
ASSESSING THE CHANGE
In a control room consolidation or a move to a new plant, new processes are always typically introduced, the following questions must be asked as part of risk assessment:
- What are the changes, and how do they impact people?
- What are the new changes to roles and responsibilities?
- Is there a reduction or addition to staff and how will they coordinate?
- Has the chain of command changed and will supervisory roles be eroded?
- Are operators doing more tasks (or fewer) than before? Both can have a negative influence on performance
- Are they being asked to step into roles for which they lack skill, experience or competency?
- Is training being provided systematically for any technology that has been introduced, with sufficient time for practice and familiarization in a range of operational scenarios?
- Have any new tasks been clearly documented and communicated?
- If new supervisors or management personnel are being introduced, do they have experience at that plant or a similar plant, and if so, to what degree? Is it enough?
In March of 2005, the Texas City Refinery explosion occurred, killing 15 workers and injuring more than 170 other plant personnel. The cause was a hydrocarbon vapor cloud explosion at the isomerization (ISOM ) process. But looked at from another angle, this tragedy was caused in part by lack of soundly implemented organizational change management. The plant had, prior to the explosion, undergone the following changes:
- A 25% reduction in workforce across the board, including plant operators. Where originally two board operators were responsible for startup, personnel cuts meant that one operator was left to oversee three complex process units and manage the startup of the ISOM tower, an extremely heavy workload by any estimation.
- Preventative maintenance personnel was programs were also reduced by 25%. Cuts to maintenance meant that a lot of instruments were incorrectly calibrated, and some level indicators and high level alarms failed as well, effectively blinding the operator to crucial pressure, flow and safety information relating to the level of raffinate in the ISOM tower.
- High turnover at the position of refinery plant managers across several sites causing a loss of continuity of leadership, and motivation towards plant safety.
- Where originally two operators were responsible for startup, personnel cuts also meant that one operator was left to oversee three process units and manage the startup of the ISOM tower, an extremely heavy workload by any estimation.
- Cuts to maintenance meant that a lot of instruments were not calibrated, and some level indicators failed as well, effectively blinding the operator to crucial pressure, flow and safety information.
In a report issued by the Chemical Safety Board, the horrendous accident was determined to be in part the result of this poorly managed change and budget cuts that massively increased the risk of a catastrophic event. The findings were the driving force for the establishment of Human Factors Engineering recommendations as a dedicated, necessary component of mission-critical industries, and generally put process safety, and organizational change management, and other issues such as fatigue management on the map.
TRANSITION TO CHANGE
Consolidation in control rooms has been happening for decades. Ever-evolving advances in technology are the norm. The Industrial Internet of Things will pose yet more new challenges to existing paradigms. Modern control rooms seem to be proving the 5th century BC maxim from Heraclitis: “Nothing endures but change.”
Often the organizational impact of that change is not properly assessed. Operators are often unprepared for the increased workload that generally results from a consolidation. New technologies may provide an overwhelming amount of information, and the hierarchies of importance may be obscured. Extra time, resources and supervision are needed to help people get used to new equipment. Processes need to be defined. Management and other stakeholders may be in a rush to simply implement the change, but the transition demands focus if it is to be done correctly. If it’s rushed things go wrong.
During transition operator involvement is crucial, yet often there is enormous resistance to change. We overcome that by engaging with the operators and inviting input at every turn. This engagement may take the following forms:
- Inviting people to talk with us directly about their work situation, demands and apprehensions about the new processes.
- Soliciting anonymous comments so that people are free to speak their mind without fear of repercussion.
- Workshops with the operators, management and us, the facilitators, wherein all are actively engaged. Critical design decisions are discussed, and a consensus is reached with input from all sides.
Solid organizational change management during transition and new process implementation is an investment in morale and safety that mission-critical industries cannot afford to ignore. Learn more about why BAW Architecture is the leader in 24/7 mission-critical control building design, or contact us to start a conversation.