2014 software global client conference -...

2014 Software Global Client Conference

SS S&T - 03 B

The impact of

the operator

on plant safety

Gregor Fernholz

DYNSIM Product Manager


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Agenda

1. Motivation

2. The Operator’s Perspective – “Human Error”

3. Case Studies

4. Outlook

5. Summary


1. MOTIVATION


“Abnormal” Situation – Root Causes “Industry studies of the 170 largest property-

damage losses over the last 30 years in the

hydrocarbon processing industry have shown

that 28% are due to operational error or

process upsets.”

“...about 40% of abnormal operations

were caused by human errors.”


Does this mean that operators are a threat to plant safety?

Operators have a significant impact on plant safety.

Operators will make mistakes sometimes...

... but how can we prevent them?

Operators can save the plant from an accident...

...so what’s making those successful?


2. OPERATOR‘S PERSPECTIVE:

“HUMAN ERROR“


Classification of “human errors” – The operator’s perspective Mistakes

• “I didn’t know what to do!”

• “I thought I did the right thing.”

Violation or noncompliance • Convenience – it’s easier/faster this way.

• For good reasons – instruction might be wrong.


Mismatches • Beyond my ability.

• Beyond everybody’s ability.

Slips/lapses of attention • Confusion

• Lack of information

• Routine

• Miscommunication

Classification of “human errors” – The operator’s perspective, cont’d


Requirements Operator education

• Fundamentals of the process & operation.

• Understanding why accidents happen.

• Prevent accidents in the future.

Validating and improving rules and procedures

• Identify and train best-practice.

• Violated rules: “Change or adopt.”

• Analyze new procedures on plant safety impact.

Improving communication skills

Improve critical situation readiness

Sustain improvements!


Consequences

1. Training is key to enhance the operator’s impact

on plant safety.

2. Use training means matching all requirements:

Operator Training Simulator (OTS)

3. Embed the use of OTS in design, operation and

corporate training practice


Why Operator Training Simulators? Understand the process fundamentals.

Understand why accidents happen.

Prevent accidents.

Identify Best Practices & roll-out.

Adopt of rules and procedures.

Analyze lack of information vs. information overkill.

Test changes using the simulator on safety impact.

Improve communication skills.

Critical situation readiness.

Avoid routine by re-training.

Don’t forget the lessons-learned.

TRB

P. Safety Mgmt.

Incident Investigation

Emergency Response

Mitigation

Anaylsis

Hazards

Operations and Management

Processes

Equipment

Properties of Hydrocarbons

Company Policy

The Competency Pyramid & OTS

Pyramid Copyright: John M Campbell and Company

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Examples of applying OTS in the different training levels


3. CASE STUDIES


Brunner Mond Chemical Plant, UK

Situation in 2001

Safe and Unsafe Acts (Susa) Training Initiative

• Training of Trainers

• Training of Observers (25% of the workforce)

• Training of all employees and of contractors

Result

• 0 LTI in 1 million hours (1st in 10 years)

• Top safety records in the UK chemical industries

My lessons-learnt

• Accidents aren’t fate.

• Training needs to be safety-centric.

• Active participation increases adoption. Higher than average accident rate.

• Statistics: 1 LTI per employee during working life


Chevron Richmond Refinery 2012 Handling of emergency situations The accident

• Pipe failure due to corrosion.

• Release of vapour which eventually ignited.

• Root cause: Corrosion and lack of maintenance.

Some investigation results (Cal/OSHA and CSB)

• “Chevron failed to implement its own emergency procedures to shut down the

No. 4 Crude Unit ...”

• “...strong indicator that workers aren’t properly trained for emergency situation.”

My lessons-learned

• Procedures might not be followed.

• Team readiness for emergency situations?

• Identify gaps in the operator’s competency!


BP Texas City Refinery, 2005 The accident (a simplified version)

• Operator overfilled and overheated the column.

• Intervention steps: late, inadequate & wrong.

• Supervisory staff didn’t verify the correct procedures were used or followed.

• Right procedures would have prevented the accident

Some investigation results in the root causes

• “BP has not ... ensured that ... refinery personnel … have sufficient process

safety knowledge and competence.”

• “...process safety education and training needs to be more rigorous,

comprehensive and integrated.”

• “Develop an implement a system to ensure … safety knowledge and

expertise.”


Engro fertilizer plant, Pakistan 2007 Sequence of events August 2007

• Shift found issue with the synthesis gas compressor.

• Operators tripped the compressor after analysis.

• Compressor repaired & restarted.

• Compressor still showed abnormal behaviour.

• Full shut-down, inspection and rotor replacement.

• Re-start after 10 days.

Analysis by the plant engineers and management

• Well-trained shift identified the problems correctly.

• Operators took the right decision.

• Prevention of an accident or long shutdown.

My lessons-learned

• Trained & empowered operators take right decisions.

• If you train them, you’ll trust them.


4. OUTLOOK


Demographics Less opportunity for on-the-job training due to increased

plant automation.

Changing job environments The experienced operators will retire.

High training demand for new operators!


New regulations and technologies • OTS is mandatory for nuclear power plants.

• Introduction of new (voluntary) standards, e.g. ANSI Z490.1 for best HSE practices.

• Industry leaders including OTS as a standard in their training concepts. A key driver

is process safety.

• New technologies enable new concepts for operator-centric safety training.

3D virtual reality environments

integrated with OTS for field and

control room operator training.


5. SUMMARY


Summary 1. “Human error” is still a significant source for accidents.

2. Operators have a significant impact on plant safety.

3. Training for operators needs to be safety centric covering all safety

relevant aspects.

4. Operator Training Simulators are currently the best technology for

delivering operator-centric safety training.

5. Training needs to be embedded in a long-term, sustainable training

concept and strategy.

6. Case studies clearly show that the mission is not accomplished, yet.

7. Demographics, changing job requirements and regulations will increase

training demand and requirements.


Your Partner Excellence in project delivery

• Global delivery team

• More than 250 engineers

• More than 100 projects per year

• Expertise in all process industries

• Global customer base

• Side-wide programs

• Corporate-wide programs

Cutting- edge

software technology

• DYNSIM for dynamic simulation

• EYESIM for immersive 3D training

• System intergration for DCSs

• System integration for PLCs

• Wonderware for HMI

• Cloud-based systems

Scalable Solutions

• DCS/HMI familiarization

• Generic OTS

• High Fidelity OTS

• Corporate OTS

• Consultancy services for training

• Software as a Service

• Training as a Service

27 Confidential Property of Schneider Electric

Related Support, Services, Training & Expo Demos

> SimSci software support

Support

Training

> DYNSIM Training Course

> Instructor Training

> OTS Maintenance Training

> OTS Projects

> OTS Consulting

> Developing training programs

> Customer First for OTS

Services

Expo Demos

> Dynamic Simulation and SimSci APC 2014

(booth #20)

> Power Plant Operator Training Simulator (booth

#21)

> Immersive Operator Training System (booth #22)

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