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Baseefa Ltd

Enhancing human performance by better decision support systems

22 July 2013

At a typical process plant a major accident may only occur occasionally leading to a significant impact such as loss of life, injury, major material release to the environment or significant equipment damage.  However, non-reportable and less impact incidents occur more frequently resulting in off-specification production and increased costs. 

The ASM Consortium (ASMC) has been recording industrial incidents occurring globally on their public website ( since 2008 and in general, incidents are reported in the media every 2-3 days. 

The cost of major incidents can be significant. The Macondo well incident cost BP and its operating partners billions of dollars. Early ASM Consortium work estimates the cost of incidents to equal 3-8% of production. Apart from this cost, there are other direct and indirect costs associated with an incident as per the OSHA study which is summarised here:

Incident Cost (Source: OSHA) - “The ratio of indirect to direct cost of an incident varies from 20:1 to 1:1.”

Direct Cost: Workers' compensation payments, medical expenses, and costs for legal services. Indirect Cost: Cost of training and replacement employees, accident investigation and implementation of corrective measures, lost productivity, repair of damaged equipment and property and costs associated with lower employee morale and absenteeism.

Human Performance and Process Safety

An important aspect of understanding the management of abnormal situations is the interrelationships between root causes and interventions by plant systems and plant personnel. An abnormal situation occurs when normal controls are unable to keep the process within its normal operating envelope and the operations team must intervene to return the plant to safe, on-specification operation. The operations team comprises console operators, lead operators, supervisors and field operators, with various support functions such as laboratory, maintenance and engineering. 

Reports from the ASM Consortium indicate that  “People and work context factors account for 42% of incidents and these factors are almost always preventable” (see Figure 1, below).

Additionally, it has been reported that on an average, 70-80% of equipment problems are due to incorrect operation of equipment. Further, the UK Health and Safety Executive hs reported that human performance impacts 70-80% of abnormal situations.  In summary, recognizing that human performance is integral to reducing the impact of abnormal situations, the ASM Consortium focuses on understanding the implications of human performance in process operations. This is effectively summarized by the Energy Institute as shown here:

Human Factors characteristics (Source: Energy Institute. UK)

Job: Nature of the task, workload, design of control and displays, procedures, environment Organisation: Culture, leadership, communication, resources - Individual or human: Risk perception, attitude, skills, competence, personality

Structured Shift Handover – A Decision Support System to Enhance Human Performance

A poorly documented relief valve status resulted in miscommunication between the shifts which led to the fatal Piper Alpha offshore platform incident of 1988.  In 2002, a pipefitter exposed to toxic chemical at an undisclosed facility due to poorly documented tank maintenance status. Effective communication between shift operators during shift handovers is an important aspect which if overlooked can prove fatal and is heavily influenced by human performance.  It has been found that approximately 80% of industrial operations lack a structured approach to shift handovers.  

Shift logs are an important part of the shift handover process and is the mechanism by which activities are coordinated and situation awareness is maintained across shifts.  A shift handover which lacks a structured approach increases likelihood of miscommunication of critical information like equipment statuses, alarm limits, ongoing safety work permits and so on. 

A process plant operator has to communicate the shift critical information to the next shift personnel at the end of a shift.  At the end of the shift, the operator is often stressed and is ready to call it a day.  In addition, the critical shift information of the 8-10hrs long shift has to be communicated in a short time of shift overlap period.  This short time reduces the scope of two way communication between the shift operators and increases the chances of incomplete and inaccurate critical information communication during the shift handover.  A structured shift handover with scientifically designed shift logs acts as a decision support system which enhances effective communication between operators during shift handover.

Figure 1 -  Responsibility for incidents. Source ASM Consortium. Established in literature; confirmed by 18 plant studies in US, Canada & Europe
Figure 1 - Responsibility for incidents. Source ASM Consortium. Established in literature; confirmed by 18 plant studies in US, Canada & Europe

The ASM Consortium sponsored a research programme to demonstrate the value of structured shift handovers in the form of structured logs, checklists and displays.  The research was jointly conducted by Honeywell (Jason Laberge & Tom Plocher) along with Nanyang Technical University (Shanqing Yin), Singapore at one of the leading petrochemical company refinery units in Durban, South Africa. The research compared the quality of shift handovers using a structured checklist-integrated logbook to a traditional, less structured logging approach. The checklist-integrated shift log provided sub-categories of information, which prompted operators to acknowledge each detail.  

The research results were exciting.  It showed remarkable improvements in the situation awareness of the operators at the refinery.  

– Checklist-integrated logbook generated higher-quality log entries compared to model logbook entries generated by operations experts (+18.6%)

– Second shift operators were able to provide more accurate and comprehensive account of the unit situation (+9%)

– Operators were better at answering questions without the need to consult supervisors and team members (8%)

– Structured handovers took only a minute or so longer than those conducted in less structured way (+16%)

 Best Practices for Structured Shift Handover 

The ASM Consortium research demonstrated that structured approach to shift handover has clear benefits over the traditional shift logging methods.  Shift handovers are more effective when supported by a structured shift log based on a checklist of important categories of plant information.  The structured approach reduces the risk of critical information not being communicated during a shift change and therefore, helps to maintain an accurate and consistent understanding of plant situation across shifts. This new structured approach will need the following best practices to be adapted by the process industry to realize the benefits of improved situation awareness during shift handovers.

* Use structured shift logs clearly indicating what should be reported in the handover presentation

*Structure shift logs around vital categories and subdivisions of information needed by incoming second shift operator

* Set clear expectations for complete and accurate shift handovers and for individual responsibility

* Require outgoing first shift operators to acknowledge every key category of information in the logbook during shift handover, even if no new events have occurred during his or her shift

* Plan ahead for sufficient time to conduct a complete shift handover

* Train operators in the skill of conducting effective shift handovers and in effective two-way communication

* Emphasize to both outgoing and incoming shift operators that they have a joint responsibility for effective communication of the situation

The ASM Consortium – Enhancing Human Performance

Abnormal Situation Management is a challenging and expensive problem to solve.  Operators must deal with abnormal situations in real-time, in highly complex, dynamic environments.  Operators need to be competent and supported by decision support systems like structured shift log books that are easy to deploy, improves their situation awareness and which can empower them to manage abnormal situations safely and effectively.  The ASM Consortium has experience in human factors and process safety, and offers a unique membership model allowing for collaboration across companies.  The ASM Consortium members participate directly in defining and reviewing the research they fund, and they enjoy early access to reports, whitepapers and case studies.  

The Abnormal Situation Management (ASM) Consortium has been diligently working on a challenging mission, for more than 15 years, that operating teams should be empowered and enabled to proactively manage their plants to maximize safety and minimize environmental impact while allowing the processes to be pushed to their optimal limits.  The Consortium believes that the goal of avoiding or mitigating abnormal situations through enhancing human performance and situation awareness at work is the key to safer plant operations.  

The gravity of this mission is exemplified by the following UK Health and Safety Executive (HSE) statement, “It is estimated that up to 80% of accidents may be attributed, at least in part, to the actions or omissions of people.” The ASM Consortium sustains this mission by helping its operating members minimize human errors and failures that impact profitability.  To successfully achieve its mission, the Consortium focuses on seven practice areas.

The ASM Consortium Practice Areas

Understanding: Focuses on measuring, reporting, analyzing, and communicating the causes and effects associated with abnormal situations.

Organisational: Focuses on management practices that influence the organizational culture, work processes, staff roles and responsibilities, and valued behaviors as they relate to abnormal situations.  

Knowledge: Focuses on development and maintenance of a competent work force through training and the creation of a continuous learning environment so that personnel can effectively respond and cope with abnormal situations.  

Communications: Focuses on daily communication and situational dialog among plant personnel and explores opportunities to use information technology that improves site-wide collaboration in all situations.  

Procedures: Focuses on all aspects of procedure use such as accessibility, accuracy, clarity, and policy compliance so that personnel can accomplish important tasks at an industrial site, particularly start-up and shut-down.  

Environment: Focuses on work place design factors that impact performance of personnel during abnormal situations.  

Monitoring: Focuses on effective design, deployment, and maintenance of hardware and software platforms that support process monitoring, control and support for effective operations.

The ASM Consortium provides value to its members and companies that choose to implement ASM solutions and best practices – fewer incidents, safer operations and more satisfied employees leading to higher profits.  For more information on the ASM Consortium visit


Subhankar Dey, Senior Marketing Specialist, Honeywell

Anand Tharanathan, Principal Research Scientist, Honeywell

Peggy Hewitt, Marketing Director, Honeywell

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