Management system errors

SETTING UP AN ERROR MANAGEMENT SYSTEM IN AN EXISTING PLANT... 

Development of programs to create an appropriate culture to support the error management system... 

Setting Up the Proactive Error Management System This system will include the following topics ... 

The book begins with a discussion of the theories of error causation and then goes on to describe the various ways in which data can be collected, analyzed, and used to reduce the potential for error. Case studies are used to teach the methodology of error reduction in specific industry operations. Finally, the book concludes with a plan for a plant error reduction program and a discussion of how human factors principles impact on the process safety management system. 

As discussed earlier in this chapter, the main requirements to ensure an appropriate safety culture are similar to those which are advocated in quality management systems. These include active participation by the workforce in error and safety management initiatives, a blame-free culture which fosters the free flow of information, and an explicit policy which ensures that safety considerations will always be primary. In addition both operations and management staff need feedback which indicates that participation in error reduction programs has a real impact on the way in which the plant is operated and systems are designed. 

Error free operation and maintenance can only occur within an effective management system. At the level of the task itself, this is provided by operating instructions. However, at a more global level, separate tasks have to be organized in a systematic manner, particularly if hazardous operations are involved, and where several individuals need to coordinate to achieve an overall objective. This section illustrates some accidents due to poor organization of work or failure to carry out checks. 

Implementing an Integrated Error and Process Safety Management System at the Plant... 

The purpose of this chapter is to set out in concrete terms the ways in which the techniques described in the previous sections can be implemented in the chemical process plant environment. The integration of error and process safety management systems is also described. 

Accountability is the obligation to answer for one s performance with respect to expectations, goals, and objectives. It is an important element of an effective process safety management system. To improve safety, the risk associated with human errors must be reduced. The work situation is the predominant cause of human errors and management has control over the work situation. 

The final element in management s communication of a desire to reduce human error is the identification and elimination of error-likely situations. Every task is an opportunity for a human error, but some situahons represent greater risks than others. Identifying these high-risk situations is not easy and an expertise in applying human factors principles to the workplace is an essential prerequisite for this identification. Eliminating these hazardous situations is often relatively simple once they have been identified. In some cases it may be appropriate to provide error-tolerant systems, which are those that facilitate identification of and recovery from the errors. 

The various elements of the error management program such as the development of high quality procedures and training and effective feedback and communications systems need to be supported by policies and standards to implement these policies. The development of these policies is an important strategic aspect of the implementation process. 

This book was written by Dr. David Embrey of Human Reliability Associates, with the assistance of the CCPS Human Reliability Subcommittee. Section 8.2, Managing Human Error by Design, which deals with the application of human factors principles in the process safety management system, was written by the Human Reliability Subcommittee. 

Validation of the data management system is typically done in two rounds. First, correctly completed data forms are entered to ensure that the system is not flagging any good data. In the second round, completed data forms with intentional data errors are entered. All errors must be identified by the system. 

Although the providers of proficiency testing schemes should have a quality management system in place, on occasions problems can arise which will affect the quality of the data evaluation being carried out. These can include transcription errors during data entry, mistakes in the report, software problems and inappropriate criteria for evaluation being used. Such problems should be remedied by the provider once the problem has been identified. 

Latent component failures, human errors, and related imsafe acts and errors are all results of weaknesses in our management systems. This is why the terms root cause and management system weaknesses are used interchangeably. The term latent failure or latent error is still used in some academic settings. 

---