{"operation":"document","citation":"PHMSA Guidance, Liquid Operator RM Guide","title":"Liquid Operator RM Guide","source_type":"guidance","agency":"Pipeline and Hazardous Materials Safety Administration","status":"guidance","official":true,"published_on":null,"effective_on":null,"summary":"Liquid Operator RM Guide Document Liquid-Operator-RM-Guide-Final-Nov2008.pdf (1.55 MB) First-generation \"Liquid Pipeline Operator’s Control Room Human Factors Risk Assessment and Management Guide,\" resulting in a comprehensive methodology that could be applied by pipeline operators to assess and manage human factors risks in their operations. Effective Date: Thursday, July 12, 2012","machine_formats":{"json":"https://regulus.evalyn.ai/document/phmsa-guidance-liquid-operator-rm-guide-e06a34e9.json","markdown":"https://regulus.evalyn.ai/document/phmsa-guidance-liquid-operator-rm-guide-e06a34e9.md"},"app_url":"https://regulus.evalyn.ai/document/phmsa-guidance-liquid-operator-rm-guide-e06a34e9","source_url":"https://www.phmsa.dot.gov/regulatory-compliance/phmsa-guidance/liquid-operator-rm-guide","body":"Liquid Operator RM Guide\n\nDocument\n\n Liquid-Operator-RM-Guide-Final-Nov2008.pdf (1.55 MB)\n\n        First-generation \"Liquid Pipeline Operator’s Control Room Human Factors Risk Assessment and Management Guide,\" resulting in a comprehensive methodology that could be applied by pipeline operators to assess and manage human factors risks in their operations.\n\n          Effective Date: Thursday, July 12, 2012\n\n<<<PAGE 1>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page i\nLIQUID PIPELINE OPERATOR’S\nCONTROL ROOM HUMAN FACTORS\nRISK ASSESSMENT AND\nMANAGEMENT GUIDE\nPrepared by:\nMarvin McCallum and Christian Richard\nPrepared for:\nPipeline and Hazardous Materials Administration\nand\nPipeline Research Council International\nNovember 26, 2008\n\n<<<PAGE 2>>>\n\n\n\n<<<PAGE 3>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page i\nThis research was co-funded by the Department of Transportation, Pipeline and\nHazardous Materials Safety Administration (PHMSA) and by the Pipeline\nResearch Council International, Inc. (PRCI). The views and conclusions\ncontained in this document are those of the authors and should not be interpreted\nas representing the official policies, either expressed or implied, of PHMSA or the\nU.S. Government.\nThis document is furnished to Pipeline Research Council International, Inc.\n(PRCI) under the terms of PRCI contract Project No. PR-003-03405, between\nPRCI and Battelle Memorial Institute, Battelle Columbus Operations. Publication\nand dissemination of this report by PRCI should not be considered an\nendorsement by PRCI or Battelle of the accuracy or validity of any opinions,\nfindings, or conclusions expressed herein.\nIn publishing this report, neither PRCI nor Battelle make any warranty or\nrepresentation, expressed or implied, with respect to the accuracy, completeness,\nusefulness, or fitness for any particular purpose of the information contained\nherein, or that the use of any information, method, process, or apparatus disclosed\nin this report may not infringe on privately owned rights. Neither PRCI nor\nBattelle assume any liability for damages, including but not limited to any direct,\nspecial, punitive, incidental or consequential damages, resulting from the use or\nmisuse of, any information, method, process, or apparatus disclosed in this report.\n\n<<<PAGE 4>>>\n\n\n\n<<<PAGE 5>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page iii\nACKNOWLEDGEMENTS\nThe Battelle researchers would like to acknowledge the Government agencies, industry\nassociations, and the individuals who supported this project.\nThis project was co-funded and ably co-managed by the Pipeline and Hazardous Materials\nSafety Administration (PHMSA) and Pipeline Research Council International (PRCI).\nSeveral past and present managers from seven separate pipeline operating companies actively\nsupported this project through their participation in planning meetings, coordination of company\nresources, and their review and comment on numerous interim project products. Risk analysis\nprofessionals from two participating companies played a critical role in shaping the final risk\nassessment methodology.\nMore than 200 individual pipeline Controllers and control room supervisors from participating\ncompanies provided the detailed operational information that allowed the resulting methodology\nto be tailored to the realities of pipeline monitoring and control operations through their\ninterview participation, Controller Survey completion, and risk likelihood rating participation.\nFinally, the authors of this report relied heavily on the excellent database management and\nanalysis support provided by Jim Brown of Battelle and the outstanding administrative support,\ndata entry, and document preparation and management skills of Diane Williams of Battelle.\n\n<<<PAGE 6>>>\n\n\n\n<<<PAGE 7>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page v\nTABLE OF CONTENTS\nAcknowledgements ...................................................................................................................iii\nGlossary ............................................................................................................................vii\nIntroduction ..............................................................................................................................1\nBackground.............................................................................................................................1\nHuman Factors Risks in the Control Room.............................................................................1\nMitigating Control Room Human Factors Risks ......................................................................3\nProject Objectives, Activities, and Products............................................................................4\nOrganization of this Guide.......................................................................................................5\nMethodology Overview...............................................................................................................7\nMethodology Organization ......................................................................................................7\nStep 1: Assemble the Human Factors Risk Management Team.............................................9\nStep 2: Administer the Controller Survey...............................................................................10\nStep 3: Administer the Risk Likelihood Rating Activity ..........................................................11\nStep 4: Calculate Risk Levels and Rank-order Human Factors Topics for\nOperational Review...................................................................................................12\nStep 5: Select Operational Review Topics ............................................................................14\nStep 6: Conduct and Summarize Operational Reviews.........................................................15\nStep 7: Develop a Risk Mitigation Strategy ...........................................................................16\nStep 8: Develop and Implement Risk Mitigations ..................................................................17\nGeneral Issues in Applying this Guide ..................................................................................18\nRisk Management Process Overview ...................................................................................21\nAppendix A Step 1 Human Factors Risk Management Team Guidance .........................A-1\nStep 1 Human Factors Risk Management Team Assembly Guidance ............................... A-3\nRisk Management Team Guidance Handouts .................................................................... A-5\nAppendix B Step 2 Controller Survey and Administration Instructions ......................... B-1\nStep 2 Controller Survey Administration Instructions.......................................................... B-3\nLiquid Pipeline Control Room Human Factors Taxonomy .................................................. B-7\nController Survey .............................................................................................................. B-15\nAppendix C Step 3 Risk Likelihood Rating Activity Materials and Administration\nGuidance ...................................................................................................................C-1\nStep 3 Risk Likelihood Rating Activity Administration Guidance......................................... C-3\nRisk Likelihood Rating Activity Materials.............................................................................C-7\nAppendix D Step 4 Risk Level Calculation Instructions, Sample Results,\nand Summary Sheets ...............................................................................................D-1\nStep 4 Risk Level Calculation Instructions and Example.................................................... D-3\nRisk Level Score Calculation Example ...............................................................................D-5\nPreliminary Industry Risk Norm Data..................................................................................D-8\nRisk Level Calculation Summary Sheets .......................................................................... D-17\n\n<<<PAGE 8>>>\n\nPage vi Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide\nAppendix E Step 5 Operational Review Topics Selection Guidance and\nDocumentation Sheet............................................................................................... E-1\nStep 5 Operational Review Topics Selection Guidance...................................................... E-3\nOperational Review Topics Selection Documentation Sheet.............................................. E-7\nAppendix F Step 6 Control Room Operational Review Guidance and Worksheets ...... F-1\nStep 6 Operational Review Guidance................................................................................. F-3\nOperational Review Worksheets....................................................................................... F-13\nDetailed Operational Review Guidance ............................................................................ F-39\nAppendix G Step 7 Risk Mitigation Strategy Development Guidance and\nWorksheets ...............................................................................................................G-1\nStep 7 Risk Mitigation Strategy Development Guidance ....................................................G-3\nStep 7 Mitigation Assessment Worksheet and Guidance ...................................................G-5\nRisk Mitigation Descriptions................................................................................................G-9\nAppendix H Step 8 Mitigation Development and Implementation Guidance and\nWorksheet .................................................................................................................H-1\nStep 8 Risk Mitigation Development and Implementation Guidance .................................. H-3\nRisk Mitigations Development and Implementation Planning Worksheet and Instructions. H-7\nLIST OF FIGURES\nFigure 1. Sequence of Human Factors-Related Incident Investigation Causes .........................2\nFigure 2. Incident Causes and Defenses (Adapted from Reason, 1990) ...................................3\nFigure 3. Major Project Tasks and Products ..............................................................................4\nFigure 4. Overall Control Room Risk Management Methodology Activities ...............................7\nFigure 5. Graphic Depiction of Pipeline Operations Human Factors Taxonomy Organization...8\nFigure 6. Step 1 Human Factors Risk Management Team Assembly Activities ........................9\nFigure 7. Step 2 Controller Survey Administration Activities ....................................................10\nFigure 8. Step 3 Risk Likelihood Rating Administration Activities ............................................12\nFigure 9. Step 4 Risk Level Calculation Activities ....................................................................13\nFigure 10. Step 5 Operational Review Topic Selection Activities...............................................14\nFigure 11. Step 6 Operational Review Activities ........................................................................15\nFigure 12. Step 7 Risk Mitigation Strategy Development Activities............................................16\nFigure 13. Step 8 Risk Mitigation Development and Implementation Activities..........................17\nFigure 14. Flow Diagram of Risk Management Steps and Primary Outcomes ..........................21\n\n<<<PAGE 9>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page vii\nGLOSSARY\nFollowing are definitions for a number of terms that are used in this document to refer to specific\naspects of human factors and pipeline operations.\nHuman Factors is the study of how the various aspects of personal characteristics and\nexperience, job and task design, workspace design, tools and equipment design, and work\nenvironment affect both system operator and overall system performance.\nHuman Factors Taxonomy is the hierarchically organized list of human factors incorporated in\nthe current Guide that is comprised of 11 Human Factors Areas, 29 Human Factors Topics, and\n138 Performance Factors.\nHuman Factors Area is the highest level of organization in the Human Factors Taxonomy.\nThere are 11 Human Factors Areas: 1) Task Complexity and Workload, 2) Displays and\nControls, 3) Communications, 4) System Information Accuracy and Access, 5) Job Procedures,\n6) Alarm Presentation and Management, 7) Controller Training, 8) Coping with Stress, 9)\nController Alertness, 10) Automation, and 11) Control Room Design and Staffing.\nHuman Factors Topic is the intermediate level of organization in the Human Factors\nTaxonomy. Each of 29 Human Factors Topics is nested within one of the 11 Human Factors\nAreas, and is comprised of a group of related Performance Factors.\nPerformance Factor is the most detailed level of organization in the Human Factors Taxonomy.\nEach of 138 Performance Factors represents specific human factors control room working\nconditions, including the characteristics of Controllers (e.g., experience, fatigue), workspaces\n(e.g., display monitors, lighting), job tools (e.g., batch tracking, SCADA), job design (e.g.,\ncontrol tasks and activities), and other factors that affect the Controller’s ability to effectively\nmonitor and control pipeline operations.\nController Survey is a survey administered to Controllers that obtains both their ratings\nregarding the Prevalence with which they encounter each of 138 Performance Factors included\nin the Human Factors Taxonomy and their descriptions of working conditions associated with\nPerformance Factors that may be adversely affecting their job performance.\nWorking Conditions are the specific operating conditions or factors that Controllers encounter\nat their work site while conducting pipeline monitoring and control activities and other related\ntasks. Working Conditions are associated with specific Performance Factors (e.g., workload\nproblems at a specific console, specific field technician communications problems, specific\nalarms that are a particular nuisance, etc.).\nPrevalence is the estimated level of Controllers’ exposure to working conditions associated with\na Performance Factor in their control room. Prevalence is seen as influencing operational risk\nand efficiency by increasing Controllers’ exposure to conditions that may adversely affect their\nmonitoring and control performance.\n\n<<<PAGE 10>>>\n\nPage viii Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide\nRisk Likelihood is the rated likelihood that exposure to the working conditions associated with a\nPerformance Factor will directly lead to sub-optimal Controller pipeline monitoring and control\nperformance and thereby cause or contribute to the occurrence and/or increase in severity of an\nincident with an unacceptable consequence.\nRisk Level is the relative risk at a control room that working conditions associated with a\nPerformance Factor or Human Factors Topic will be present, that those working conditions will\nadversely affect Controller pipeline monitoring and control performance, and that the degraded\nperformance will result in the occurrence and/or increase in severity of an incident with an\nunacceptable consequence.\nControl Room Operational Reviews are activities conducted to supplement information\nobtained from the Controller Survey and Risk Likelihood rating activity that help in\nunderstanding the nature of specific operational risks and potential mitigations of those risks.\nTypes of operational review information collection activities include: 1) accident, incident, and\nnear-incident report review; 2) Controller interview; 3) observational review; and 4) materials\nreview.\nMitigations represent changes that can be made to working conditions, operating practices (e.g.,\nworkspace layout, training, software design, job requirements, procedures, etc.), and system\ndesign to improve overall system performance and reduce operational risk.\nSupervisory Control and Data Acquisition (SCADA) systems are computer based tools that\nprovide an integrated summary of remote pipeline sensors and controls. Pipeline Controllers\nengaged in SCADA operations to monitor and control pipeline operations from a console in a\npipeline control room, which is typically equipped with multiple SCADA consoles used to\nmonitor and control separate sections of a larger pipeline system.\n\n<<<PAGE 11>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page ix\nACRONYMS\nCBP......................................................................................................Computer-Based Procedures\nHF .............................................................................................................................Human Factors\nKSA................................................................................................ Knowledge, Skills and Abilities\nMOC ........................................................................................................... Management of Change\nMOP.................................................................................................. Maximum Operating Pressure\nNTSB .................................................................................... National Transportation Safety Board\nPBP .............................................................................................................Paper-Based Procedures\nPF .......................................................................................................................Performance Factor\nPHMSA...................................................Pipeline and Hazardous Materials Safety Administration\nPRCI...................................................................................Pipeline Research Council International\nRAS...................................................................................... Representation and Analysis Software\nSCADA..........................................................................Supervisory Control and Data Acquisition\nTLX........................................................................................................................ Task Load Index\n\n<<<PAGE 12>>>\n\n\n\n<<<PAGE 13>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page 1\nIntroduction\nINTRODUCTION\nBACKGROUND\nThe purpose of this guide is to document methodologies, tools, procedures, guidance, and\ninstructions that have been developed to provide liquid pipeline operators with an efficient and\neffective means of managing the human factors risks in their control rooms. A companion\ntechnical report to this document has been prepared, which documents the technical basis for\nthese methodologies, as well as the findings and recommendations resulting from this effort.\nSection 12 of the ‘‘Pipeline Inspection, Protection, Enforcement, and Safety Act of 2006’’\nprovides general guidance regarding regulations that will require operators to manage the human\nfactors risks in their control room. A partial quotation from Section 12 is provided below.\n§ 60137. Pipeline control room management\n‘‘(a) IN GENERAL.—Not later than June 1, 2008, the Secretary shall issue regulations\nrequiring each operator of a gas or hazardous liquid pipeline to develop, implement, and\nsubmit” … “a human factors management plan designed to reduce risks associated with\nhuman factors, including fatigue, in each control center for the pipeline.”\nBattelle and industry participants proactively developed methodologies that can be used by liquid\noperators to assess and manage control room human factors risks. These methodologies were\ndeveloped during a four-year Human Factors Analysis of Pipeline Monitoring and Control\nOperations project that was co-sponsored by the Pipeline and Hazardous Materials Safety\nAdministration (PHMSA) and a group of liquid pipeline operators represented by the Pipeline\nResearch Council International (PRCI). The methodologies were developed with the objective of\nproviding liquid operators with tools and procedures that can be used to identify potential\npipeline monitoring and control operational risks, prioritize those risks for further investigation,\nconduct operational reviews in their control room to fully understand the nature of the risks and\npotential mitigations, develop a feasible and appropriate mitigation strategy, and then implement\nand track the value of the implemented mitigations.\nHUMAN FACTORS RISKS IN THE CONTROL ROOM\nHuman factors is the study of how the various aspects of personal characteristics and experience,\njob and task design, work space design, tools and equipment design, and work environment\naffect system operator performance and overall system performance. The current methodology\naddresses those human factors that affect liquid pipeline Controller’s performance in monitoring\nand controlling pipeline operations. These factors are, in turn, assumed to affect overall pipeline\nsystem safety and operational efficiency.\nFew pipeline incidents are typically attributed to human factors. Indeed, the most-frequently\ncited causes of oil pipeline incidents are third-party damage, corrosion, and equipment-related\nfailure1. However, several recent investigations of severe pipeline incidents have determined that\nControllers did not correctly identify and respond to abnormal situations in an effective and\ntimely manner; thereby contributing to the severity of the accident2. In addition, a relatively\nsmall percentage of pipeline incidents have been directly attributed to Controller error3; where\nthe initiating cause of the incident did not involve equipment failure or damage. Although\n\n<<<PAGE 14>>>\n\nPage 2 Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide\nIntroduction\ncurrent industry-wide incident analysis and reporting systems do not support an accurate estimate\nof the extent that Controller ‘unsafe acts’ contribute to pipeline accidents, other industries with\nmore mature human factors incident reporting programs indicate that human performance plays a\nsignificant role in incidents. For example, human performance has been judged to be the major\ncontributor to loss of life, personnel injury, and property damage in the chemical process\nindustry4. In the civil and military aviation industry, where human factors accident investigation\nand reporting procedures are relatively mature, estimates of human performance involvement in\naccidents range between 70% and 80%5\n.\nThe term unsafe act is used to characterize operator behavior in relation to a hazard. It implies\nthat an operator’s action provided the opportunity for the occurrence or increased severity of an\nincident by exposing the system to a hazard or not actively defending the system from that\nhazard. Unsafe acts are often categorized as resulting from an operator error or from the\nintentional violation of rules and procedures. In investigating human factors-related accidents, an\noperator’s unsafe act is often identified as the proximal contributing factor to an incident.\nHowever, that should not necessarily lead to the conclusion that operator performance was the\nroot cause of the incident. Figure 1 depicts the opposing sequences of critical incident\ninvestigation activities and causes. Starting from the investigation perspective, someone\nreviewing the events and conditions leading up to an incident with a human factors contribution\nwill typically identify one or more unsafe acts (such as the misdiagnosis of an abnormal\ncondition or an incorrect control action) as the proximal cause. The incident investigator may not\ncontinue the analysis to consider workplace factors (such as displays and control layouts) or\noperational factors (such as job design and abnormal event training) that may have also\ncontributed to the occurrence of that unsafe act.\nCritical\nIncident\nMisdiagnosis, Incorrect Control\nAction\nSCADA Displays, Control\nLayout\nJob Design, Abnormal Event\nTraining\nUnsafe Acts\nCauses\nInvestigation\nOperational Factors\nFigure 1. Sequence of Human Factors-Related Incident Investigation Causes\nThe current methodology is based on the fundamental assumption that the causes of unsafe acts\nrepresent the full range of human performance, local workplace, and operational factors. For\nexample, if an inappropriate control response to an abnormal incident were identified as the\nunsafe act preceding a product leak, one contribution to that incident could be identified as the\nController misdiagnosing the nature of the abnormal condition. However, further analysis could\nreveal that a factor contributing to the Controller’s misdiagnosis was the layout of the physical\n\n<<<PAGE 15>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page 3\nIntroduction\npipeline on the SCADA display that made it difficult to determine the status of the affected\nportion of the pipeline system. Continuing the current example, further analysis of the\nController’s misdiagnosis could reveal that an additional factor contributing to this unsafe act\nwas the limited ability of the Controller to mentally focus on the abnormal conditions; due to a\njob design that required concurrent monitoring and control of several ongoing pipeline activities.\nThus, a very fundamental premise of this guide is that the full range of operator, local workplace,\nand operational factors can contribute to the occurrence of an incident.\nMITIGATING CONTROL ROOM HUMAN FACTORS RISKS\nThe interpretation of incident causation depicted in Figure 1 suggests that there is a broad range\nof strategies that can be adopted to reduce the likelihood that an unsafe act will occur.\nModification of the local workplace design can reduce the likelihood of unsafe acts by providing\ntools and equipment that better support correct diagnosis of abnormal conditions and the correct\nand timely selection of control actions. Additionally, operational factors can further reduce the\nlikelihood of unsafe acts by tailoring the job to match to the human operators’ capabilities and/or\nby better equipping Controllers to effectively monitor and control operations through the\ndevelopment and implementation of more effective policies, procedures, and training.\nA second perspective on incident causation that suggests additional strategies for mitigating\nhuman factors risk is depicted in Figure 2. This figure, adapted from James Reason’s ‘Swiss\nCheese’ model of accident causation6, depicts the trajectory of critical incident opportunities and\nthe value of multiple, redundant system defenses or incident barriers. Figure 2 depicts the basic\nperspective that the trajectory of most potential incidents resulting from a hazardous situation\ncan be avoided through the design and implementation of effective system defenses. Effective\nredundant defenses, such as redundant sensors that provide overlapping information regarding\nsystem status, automated alarm management that facilitates access to critical information, and\nrelief valves that minimize the result of over-pressurization, reduce the likelihood that a\nhazardous situation will result in an actual incident. A combination of mitigations that are\ndeveloped to augment Controllers capabilities and better match job requirements to Controllers’\ncapabilities (as depicted in Figure 1); and to provide additional system defenses (as depicted in\nFigure 2) can provide a broad range of effective strategies for reducing human factors risks in a\ncontrol room.\nCritical\nIncident\nRelief Valves\nAutomated Alarm Management\nRedundant Sensors\nFigure 2. Incident Causes and Defenses (Adapted from Reason, 1990)\n\n<<<PAGE 16>>>\n\nPage 4 Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide\nIntroduction\nPROJECT OBJECTIVES, ACTIVITIES, AND PRODUCTS\nThe systems perspective towards human factors risks and their mitigation presented in the\npreceding discussion served as the basis for defining the objectives, activities, and products of\nthe current project. The project was conducted to better understand the specific human factors\nrisks and potential mitigations in pipeline control rooms and to translate that knowledge into\nmethodologies, tools, and procedures that could be used by operators to manage their human\nfactors risks. Figure 3 presents an overview of these project tasks and products, which are briefly\ndiscussed below.\nProject Tasks\nProject Products\nTask 1\nIdentify human factors\ncontributing to monitoring and\ncontrol safety and efficiency\nHuman Factors Taxonomy\nTask 2\nConduct operational reviews\nat selected sites\nController Survey\nOperational Review Procedures\nTask 3\nIdentify the potential risk level\nof human factors\nRisk Likelihood Rating Activity\nRisk Level Calculation Procedure\nTask 4\nDefine cost-effective\nimprovement strategies for\nreducing risks\nMitigation Descriptions\nTask 5\nPrepare a human factors risk\nmanagement guide\nMitigation Selection Procedure\nFinal Risk Management Guide\nFigure 3. Major Project Tasks and Products\n\n<<<PAGE 17>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page 5\nIntroduction\nTask 1 consisted of a series of information gathering and analysis activities, including National\nTransportation Safety Board (NTSB) accident investigation report analysis, human factors\nresearch review, and structured interviews with control room personnel, to identify the specific\nhuman factors that contribute to pipeline monitoring and control safety and efficiency. Task 1\nprovided the technical basis for the development of the Human Factors Taxonomy, which is a\nhierarchically organized list of human factors that affect liquid pipeline monitoring and control\nperformance. This taxonomy is comprised of 11 Human Factors Areas, 29 Human Factors\nTopics, and 138 Performance Factors.\nTask 2 involved the development of operational review procedures and their trial application by\na group of participating operators. Two basic tools were developed and implemented during this\ntask. First, a Controller Survey was developed, which is a survey administered to Controllers to\nobtain both their estimates regarding the frequency with which they encounter each of the 138\nPerformance Factors included in the Human Factors Taxonomy and their descriptions of working\nconditions associated with Performance Factors that may be adversely affecting their job\nperformance. Second, draft versions of operational review procedures were developed and\napplied on a trial basis by the participating operators. These procedures define activities\nconducted to supplement information obtained from the Controller Survey to aid in\nunderstanding the nature of specific operational risks and potential mitigation of those risks.\nTask 3 was conducted to establish a risk-based means of prioritizing potential human factors\nrisks for mitigation management activities. This task resulted in the development and trial\napplication of a Risk Likelihood Rating Activity and Risk Level calculation procedure. The Risk\nLikelihood Rating Activity provided a structured procedure to obtain ratings of the likelihood\nthat exposure to the working conditions associated with each Performance Factor will result in\ndegraded Controller performance and contribute to the occurrence and/or increase in severity of\nan incident with an unacceptable consequence. The Risk Level calculation procedure integrates\nController Survey and Risk Likelihood rating data to prioritize Human Factors Topics and\nPerformance Factors on the basis of their relative Risk Level.\nTask 4 was conducted to identify potential mitigations that could be developed and implemented\nby an operator in order to reduce and manage human factors risks. Available theoretical,\nresearch, and applied operational literature, were integrated with operator input into a series of\nmitigation descriptions that can serve as a starting point for operators in developing a mitigation\nstrategy.\nTask 5 involved the development of procedures and guidance for operators to use in selecting\nfrom the potential mitigations and developing a mitigation strategy that best meets their\norganization’s potential human factors risks and operational environment. The mitigation\nselection procedures, along with this guide, were the major product of Task 5.\nORGANIZATION OF THIS GUIDE\nThis guide is organized into ten sections. This Introduction is followed by a Methodology\nOverview, which provides a summary of the full set of human factors risk management\nprocedures; and discusses some of the general issues regarding methodology limitations and\nimplementation guidance. Following the Methodology Overview, eight separate appendices –\none for each of the eight steps in the methodology – provide detailed instructions and guidance\nregarding the conduct of each step, along with specific materials designed to aid operators in\n\n<<<PAGE 18>>>\n\nPage 6 Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide\nIntroduction\ncarrying out each step of the current human factors risk management methodology. Each of these\neight appendices has been prepared as a stand-alone, inclusive document that provides the\nmaterials, procedures, instructions, and guidance required to support a pipeline operator in\nconducting each of the eight Human Factors risk management steps that comprise this\nmethodology.\n1 Trench, C. (2003). The U.S. Oil Pipeline Industry’s Safety Performance. New York, NY: Allegro Energy\nConsulting. Prepared for Association of Oil Pipelines. Available at\nhttp://www.aopl.org/posted/888/Safety_thru_2001.57651.pdf\n2 National Transportation Safety Board. (2005). Supervisory Control of Data Acquisition (Safety Study NTSB/SS-\n05/02). Washington DC: Author. Available at http://www.ntsb.gov/publictn/2005/SS0502.pdf\n3 The PHMSA Fact Sheet Incorrect Operations, reports that “Operating Errors generally cause approximately 7% of\ntotal pipeline and non-pipeline incidents. Available at\nhttp://primis.phmsa.dot.gov/comm/FactSheets/FSIncorrectOperation.htm\n4 Center for Chemical Process Safety of the American Institute of Chemical Engineers. (1994). Guidelines for\nPreventing Human Error in Process Safety. New York, NY: Author.\n5 Wiegmann, D.& Shappell, S. (2001). A Human Error Analysis of Commercial Aviation Accidents Using the Human\nFactors Analysis and Classification System (HFACS) (Report No. DOT/FAA/AM-01/3). Oklahoma City, OK: FAA\nCivil Aeromedical Institute. Available at\nhttp://www.faa.gov/library/reports/medical/oamtechreports/2000s/media/0103.pdf\n6 Reason, J. (1990). Human Error. Cambridge, UK: Cambridge University Press.\n\n<<<PAGE 19>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Methodology Overview\nPage 7\nMETHODOLOGY OVERVIEW\nMETHODOLOGY ORGANIZATION\nFigure 4 provides an overview of the human factors risk assessment and management\nmethodology that serves as the basis for this guide. The overall methodology consists of eight\nsteps that are conducted by an operator to establish a human factors risk management team,\nidentify and assess the human factors risks in their control room, develop a plan for mitigating\nthe highest-priority risks, and developing and implementing the selected mitigations. This Guide\nprovides detailed guidance, instructions, tools, and worksheets to support operators in their\nperformance of each of these eight steps.\nStep 1: Assemble the Control Center Human Factors\nRisk Management Team\nStep 2: Administer Controller Survey\nStep 3: Administer Risk Likelihood Ranking Activity\nStep 4: Calculate Risk Levels and Rank-Order Human\nFactors Topics for Operational Review\nRisk\nManagement\nFeedback Loop\nStep 5: Select Operational Review Topics\nStep 6: Conduct Operational Reviews and Summarize\nFindings\nStep 7: Develop a Risk Mitigation Strategy\nStep 8: Develop and Implement Risk Mitigations\nFigure 4. Overall Control Room Risk Management Methodology Activities\n\n<<<PAGE 20>>>\n\nPage 8 Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide\nMethodology Overview\nThe methodology includes a risk management feedback loop, depicted on the left-hand side of\nFigure 4. Human factors risk mitigations are implemented in an effort to reduce the risk levels\nassociated with targeted human factors. The effectiveness of implemented mitigations can be\nevaluated through this feedback loop by periodically assessing control room human factors risk\nlevels associated with the targeted human factors. Conducting a periodic human factors risk\nassessment will both provide evidence regarding the effectiveness of mitigations implemented in\nthe past, and help in determining appropriate future steps to further reduce potential human\nfactors risks.\nThe technical reference used in identifying and organizing potential human factors risks and\nmitigations throughout this guide is the Pipeline Operations Human Factors Taxonomy. This\ntaxonomy was developed during the current project, based on analyses of pipeline accident\ninvestigation reports, process control research literature reviews, an extensive series of structured\ninterviews with liquid pipeline Controllers, and an iterative review and refinement of the content\nand wording of the human factors taxonomy by the project researchers, pipeline operations\nmanagers, and risk management experts. Figure 5 graphically depicts the basic organization of\nthe Pipeline Operations Human Factors Taxonomy, omitting many of the details. The most\ngeneral Human Factors Area level of the taxonomy consists of 11 areas: (1) Task Complexity\nand Workload, (2) Displays and Controls, (3) Communications, (4) System Information\nAccuracy and Access, (5) Job Procedures, (6) Alarm Presentation and Management, (7)\nController Training, (8) Coping with Stress, (9) Controller Alertness, (10) Automation, and (11)\nControl Room Design and Staffing.\nHuman Factors\nAreas (11)\n1. Task Complexity and\nWorkload\nHuman Factors\nTopics (29)\nPerformance\nFactors (142)\n1.1. Task Design\n1.1.1. Execution of…\n1.1.2. Routine activities…\n1.2 Console Workload\n1.1.1. Execution of…\n1.1.2. Routine activities…\n2. Displays and\nControls\n2.1. Equipment Layout\n2.2. …\n2.3. …\n11. Control Room\nDesign and\nStaffing\n11.1. Control Room\nDesign\n11.2. Control Room\nStaffing\n11.1.1. The location…\n11.1.2. …\n11.2.1. Another Contr…\n11.2.2. …\nFigure 5. Graphic Depiction of Pipeline Operations Human Factors Taxonomy Organization\n\n<<<PAGE 21>>>\n\nLiquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page 9\nMethodology Overview\nThe intermediate Human Factors Topic level of the taxonomy includes 29 Human Factors\nTopics nested within the Human Factors Areas. For example, as depicted in the figure, there are\ntwo Human Factors Topics nested within Human Factors Area 1: 1.1.—Task Design and 1.2.—\nConsole Workload.\nThe most detailed Performance Factor level of the taxonomy includes 138 specific\ncharacteristics of the Controller (e.g., experience, fatigue), workspace (e.g., display monitors,\nlighting), job tools (e.g., batch tracking, SCADA), job design (e.g., control tasks and activities),\nand other factors that can affect a Controller’s ability to effectively monitor and control the\npipeline. For example, there are five Performance Factors nested within Human Factors Topic\n1.1, including: 1.1.1—Execution of a control action (e.g., open/close valve, start/stop pump,\nchange set point) requires too many steps (e.g., more than three); and 1.1.2—Routine activities\n(e.g.., line start up, batch cutting, or manifold flushing) are too complex. Following is a brief\noverview of each of the eight steps in the risk assessment and management methodology, along\n","truncated":true,"body_characters":713244}