# Liquid Operator RM Guide - **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:** Not available - **effective on:** Not available - **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 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 <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page i LIQUID PIPELINE OPERATOR’S CONTROL ROOM HUMAN FACTORS RISK ASSESSMENT AND MANAGEMENT GUIDE Prepared by: Marvin McCallum and Christian Richard Prepared for: Pipeline and Hazardous Materials Administration and Pipeline Research Council International November 26, 2008 <<>> <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page i This research was co-funded by the Department of Transportation, Pipeline and Hazardous Materials Safety Administration (PHMSA) and by the Pipeline Research Council International, Inc. (PRCI). The views and conclusions contained in this document are those of the authors and should not be interpreted as representing the official policies, either expressed or implied, of PHMSA or the U.S. Government. This document is furnished to Pipeline Research Council International, Inc. (PRCI) under the terms of PRCI contract Project No. PR-003-03405, between PRCI and Battelle Memorial Institute, Battelle Columbus Operations. Publication and dissemination of this report by PRCI should not be considered an endorsement by PRCI or Battelle of the accuracy or validity of any opinions, findings, or conclusions expressed herein. In publishing this report, neither PRCI nor Battelle make any warranty or representation, expressed or implied, with respect to the accuracy, completeness, usefulness, or fitness for any particular purpose of the information contained herein, or that the use of any information, method, process, or apparatus disclosed in this report may not infringe on privately owned rights. Neither PRCI nor Battelle assume any liability for damages, including but not limited to any direct, special, punitive, incidental or consequential damages, resulting from the use or misuse of, any information, method, process, or apparatus disclosed in this report. <<>> <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page iii ACKNOWLEDGEMENTS The Battelle researchers would like to acknowledge the Government agencies, industry associations, and the individuals who supported this project. This project was co-funded and ably co-managed by the Pipeline and Hazardous Materials Safety Administration (PHMSA) and Pipeline Research Council International (PRCI). Several past and present managers from seven separate pipeline operating companies actively supported this project through their participation in planning meetings, coordination of company resources, and their review and comment on numerous interim project products. Risk analysis professionals from two participating companies played a critical role in shaping the final risk assessment methodology. More than 200 individual pipeline Controllers and control room supervisors from participating companies provided the detailed operational information that allowed the resulting methodology to be tailored to the realities of pipeline monitoring and control operations through their interview participation, Controller Survey completion, and risk likelihood rating participation. Finally, the authors of this report relied heavily on the excellent database management and analysis support provided by Jim Brown of Battelle and the outstanding administrative support, data entry, and document preparation and management skills of Diane Williams of Battelle. <<>> <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page v TABLE OF CONTENTS Acknowledgements ...................................................................................................................iii Glossary ............................................................................................................................vii Introduction ..............................................................................................................................1 Background.............................................................................................................................1 Human Factors Risks in the Control Room.............................................................................1 Mitigating Control Room Human Factors Risks ......................................................................3 Project Objectives, Activities, and Products............................................................................4 Organization of this Guide.......................................................................................................5 Methodology Overview...............................................................................................................7 Methodology Organization ......................................................................................................7 Step 1: Assemble the Human Factors Risk Management Team.............................................9 Step 2: Administer the Controller Survey...............................................................................10 Step 3: Administer the Risk Likelihood Rating Activity ..........................................................11 Step 4: Calculate Risk Levels and Rank-order Human Factors Topics for Operational Review...................................................................................................12 Step 5: Select Operational Review Topics ............................................................................14 Step 6: Conduct and Summarize Operational Reviews.........................................................15 Step 7: Develop a Risk Mitigation Strategy ...........................................................................16 Step 8: Develop and Implement Risk Mitigations ..................................................................17 General Issues in Applying this Guide ..................................................................................18 Risk Management Process Overview ...................................................................................21 Appendix A Step 1 Human Factors Risk Management Team Guidance .........................A-1 Step 1 Human Factors Risk Management Team Assembly Guidance ............................... A-3 Risk Management Team Guidance Handouts .................................................................... A-5 Appendix B Step 2 Controller Survey and Administration Instructions ......................... B-1 Step 2 Controller Survey Administration Instructions.......................................................... B-3 Liquid Pipeline Control Room Human Factors Taxonomy .................................................. B-7 Controller Survey .............................................................................................................. B-15 Appendix C Step 3 Risk Likelihood Rating Activity Materials and Administration Guidance ...................................................................................................................C-1 Step 3 Risk Likelihood Rating Activity Administration Guidance......................................... C-3 Risk Likelihood Rating Activity Materials.............................................................................C-7 Appendix D Step 4 Risk Level Calculation Instructions, Sample Results, and Summary Sheets ...............................................................................................D-1 Step 4 Risk Level Calculation Instructions and Example.................................................... D-3 Risk Level Score Calculation Example ...............................................................................D-5 Preliminary Industry Risk Norm Data..................................................................................D-8 Risk Level Calculation Summary Sheets .......................................................................... D-17 <<>> Page vi Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Appendix E Step 5 Operational Review Topics Selection Guidance and Documentation Sheet............................................................................................... E-1 Step 5 Operational Review Topics Selection Guidance...................................................... E-3 Operational Review Topics Selection Documentation Sheet.............................................. E-7 Appendix F Step 6 Control Room Operational Review Guidance and Worksheets ...... F-1 Step 6 Operational Review Guidance................................................................................. F-3 Operational Review Worksheets....................................................................................... F-13 Detailed Operational Review Guidance ............................................................................ F-39 Appendix G Step 7 Risk Mitigation Strategy Development Guidance and Worksheets ...............................................................................................................G-1 Step 7 Risk Mitigation Strategy Development Guidance ....................................................G-3 Step 7 Mitigation Assessment Worksheet and Guidance ...................................................G-5 Risk Mitigation Descriptions................................................................................................G-9 Appendix H Step 8 Mitigation Development and Implementation Guidance and Worksheet .................................................................................................................H-1 Step 8 Risk Mitigation Development and Implementation Guidance .................................. H-3 Risk Mitigations Development and Implementation Planning Worksheet and Instructions. H-7 LIST OF FIGURES Figure 1. Sequence of Human Factors-Related Incident Investigation Causes .........................2 Figure 2. Incident Causes and Defenses (Adapted from Reason, 1990) ...................................3 Figure 3. Major Project Tasks and Products ..............................................................................4 Figure 4. Overall Control Room Risk Management Methodology Activities ...............................7 Figure 5. Graphic Depiction of Pipeline Operations Human Factors Taxonomy Organization...8 Figure 6. Step 1 Human Factors Risk Management Team Assembly Activities ........................9 Figure 7. Step 2 Controller Survey Administration Activities ....................................................10 Figure 8. Step 3 Risk Likelihood Rating Administration Activities ............................................12 Figure 9. Step 4 Risk Level Calculation Activities ....................................................................13 Figure 10. Step 5 Operational Review Topic Selection Activities...............................................14 Figure 11. Step 6 Operational Review Activities ........................................................................15 Figure 12. Step 7 Risk Mitigation Strategy Development Activities............................................16 Figure 13. Step 8 Risk Mitigation Development and Implementation Activities..........................17 Figure 14. Flow Diagram of Risk Management Steps and Primary Outcomes ..........................21 <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page vii GLOSSARY Following are definitions for a number of terms that are used in this document to refer to specific aspects of human factors and pipeline operations. Human Factors is the study of how the various aspects of personal characteristics and experience, job and task design, workspace design, tools and equipment design, and work environment affect both system operator and overall system performance. Human Factors Taxonomy is the hierarchically organized list of human factors incorporated in the current Guide that is comprised of 11 Human Factors Areas, 29 Human Factors Topics, and 138 Performance Factors. Human Factors Area is the highest level of organization in the Human Factors Taxonomy. There are 11 Human Factors Areas: 1) Task Complexity and Workload, 2) Displays and Controls, 3) Communications, 4) System Information Accuracy and Access, 5) Job Procedures, 6) Alarm Presentation and Management, 7) Controller Training, 8) Coping with Stress, 9) Controller Alertness, 10) Automation, and 11) Control Room Design and Staffing. Human Factors Topic is the intermediate level of organization in the Human Factors Taxonomy. Each of 29 Human Factors Topics is nested within one of the 11 Human Factors Areas, and is comprised of a group of related Performance Factors. Performance Factor is the most detailed level of organization in the Human Factors Taxonomy. Each of 138 Performance Factors represents specific human factors control room working conditions, including the characteristics of Controllers (e.g., experience, fatigue), workspaces (e.g., display monitors, lighting), job tools (e.g., batch tracking, SCADA), job design (e.g., control tasks and activities), and other factors that affect the Controller’s ability to effectively monitor and control pipeline operations. Controller Survey is a survey administered to Controllers that obtains both their ratings regarding the Prevalence with which they encounter each of 138 Performance Factors included in the Human Factors Taxonomy and their descriptions of working conditions associated with Performance Factors that may be adversely affecting their job performance. Working Conditions are the specific operating conditions or factors that Controllers encounter at their work site while conducting pipeline monitoring and control activities and other related tasks. Working Conditions are associated with specific Performance Factors (e.g., workload problems at a specific console, specific field technician communications problems, specific alarms that are a particular nuisance, etc.). Prevalence is the estimated level of Controllers’ exposure to working conditions associated with a Performance Factor in their control room. Prevalence is seen as influencing operational risk and efficiency by increasing Controllers’ exposure to conditions that may adversely affect their monitoring and control performance. <<>> Page viii Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Risk Likelihood is the rated likelihood that exposure to the working conditions associated with a Performance Factor will directly lead to sub-optimal Controller pipeline monitoring and control performance and thereby cause or contribute to the occurrence and/or increase in severity of an incident with an unacceptable consequence. Risk Level is the relative risk at a control room that working conditions associated with a Performance Factor or Human Factors Topic will be present, that those working conditions will adversely affect Controller pipeline monitoring and control performance, and that the degraded performance will result in the occurrence and/or increase in severity of an incident with an unacceptable consequence. Control Room Operational Reviews are activities conducted to supplement information obtained from the Controller Survey and Risk Likelihood rating activity that help in understanding the nature of specific operational risks and potential mitigations of those risks. Types of operational review information collection activities include: 1) accident, incident, and near-incident report review; 2) Controller interview; 3) observational review; and 4) materials review. Mitigations represent changes that can be made to working conditions, operating practices (e.g., workspace layout, training, software design, job requirements, procedures, etc.), and system design to improve overall system performance and reduce operational risk. Supervisory Control and Data Acquisition (SCADA) systems are computer based tools that provide an integrated summary of remote pipeline sensors and controls. Pipeline Controllers engaged in SCADA operations to monitor and control pipeline operations from a console in a pipeline control room, which is typically equipped with multiple SCADA consoles used to monitor and control separate sections of a larger pipeline system. <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page ix ACRONYMS CBP......................................................................................................Computer-Based Procedures HF .............................................................................................................................Human Factors KSA................................................................................................ Knowledge, Skills and Abilities MOC ........................................................................................................... Management of Change MOP.................................................................................................. Maximum Operating Pressure NTSB .................................................................................... National Transportation Safety Board PBP .............................................................................................................Paper-Based Procedures PF .......................................................................................................................Performance Factor PHMSA...................................................Pipeline and Hazardous Materials Safety Administration PRCI...................................................................................Pipeline Research Council International RAS...................................................................................... Representation and Analysis Software SCADA..........................................................................Supervisory Control and Data Acquisition TLX........................................................................................................................ Task Load Index <<>> <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page 1 Introduction INTRODUCTION BACKGROUND The purpose of this guide is to document methodologies, tools, procedures, guidance, and instructions that have been developed to provide liquid pipeline operators with an efficient and effective means of managing the human factors risks in their control rooms. A companion technical report to this document has been prepared, which documents the technical basis for these methodologies, as well as the findings and recommendations resulting from this effort. Section 12 of the ‘‘Pipeline Inspection, Protection, Enforcement, and Safety Act of 2006’’ provides general guidance regarding regulations that will require operators to manage the human factors risks in their control room. A partial quotation from Section 12 is provided below. § 60137. Pipeline control room management ‘‘(a) IN GENERAL.—Not later than June 1, 2008, the Secretary shall issue regulations requiring each operator of a gas or hazardous liquid pipeline to develop, implement, and submit” … “a human factors management plan designed to reduce risks associated with human factors, including fatigue, in each control center for the pipeline.” Battelle and industry participants proactively developed methodologies that can be used by liquid operators to assess and manage control room human factors risks. These methodologies were developed during a four-year Human Factors Analysis of Pipeline Monitoring and Control Operations project that was co-sponsored by the Pipeline and Hazardous Materials Safety Administration (PHMSA) and a group of liquid pipeline operators represented by the Pipeline Research Council International (PRCI). The methodologies were developed with the objective of providing liquid operators with tools and procedures that can be used to identify potential pipeline monitoring and control operational risks, prioritize those risks for further investigation, conduct operational reviews in their control room to fully understand the nature of the risks and potential mitigations, develop a feasible and appropriate mitigation strategy, and then implement and track the value of the implemented mitigations. HUMAN FACTORS RISKS IN THE CONTROL ROOM Human factors is the study of how the various aspects of personal characteristics and experience, job and task design, work space design, tools and equipment design, and work environment affect system operator performance and overall system performance. The current methodology addresses those human factors that affect liquid pipeline Controller’s performance in monitoring and controlling pipeline operations. These factors are, in turn, assumed to affect overall pipeline system safety and operational efficiency. Few pipeline incidents are typically attributed to human factors. Indeed, the most-frequently cited causes of oil pipeline incidents are third-party damage, corrosion, and equipment-related failure1. However, several recent investigations of severe pipeline incidents have determined that Controllers did not correctly identify and respond to abnormal situations in an effective and timely manner; thereby contributing to the severity of the accident2. In addition, a relatively small percentage of pipeline incidents have been directly attributed to Controller error3; where the initiating cause of the incident did not involve equipment failure or damage. Although <<>> Page 2 Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Introduction current industry-wide incident analysis and reporting systems do not support an accurate estimate of the extent that Controller ‘unsafe acts’ contribute to pipeline accidents, other industries with more mature human factors incident reporting programs indicate that human performance plays a significant role in incidents. For example, human performance has been judged to be the major contributor to loss of life, personnel injury, and property damage in the chemical process industry4. In the civil and military aviation industry, where human factors accident investigation and reporting procedures are relatively mature, estimates of human performance involvement in accidents range between 70% and 80%5 . The term unsafe act is used to characterize operator behavior in relation to a hazard. It implies that an operator’s action provided the opportunity for the occurrence or increased severity of an incident by exposing the system to a hazard or not actively defending the system from that hazard. Unsafe acts are often categorized as resulting from an operator error or from the intentional violation of rules and procedures. In investigating human factors-related accidents, an operator’s unsafe act is often identified as the proximal contributing factor to an incident. However, that should not necessarily lead to the conclusion that operator performance was the root cause of the incident. Figure 1 depicts the opposing sequences of critical incident investigation activities and causes. Starting from the investigation perspective, someone reviewing the events and conditions leading up to an incident with a human factors contribution will typically identify one or more unsafe acts (such as the misdiagnosis of an abnormal condition or an incorrect control action) as the proximal cause. The incident investigator may not continue the analysis to consider workplace factors (such as displays and control layouts) or operational factors (such as job design and abnormal event training) that may have also contributed to the occurrence of that unsafe act. Critical Incident Misdiagnosis, Incorrect Control Action SCADA Displays, Control Layout Job Design, Abnormal Event Training Unsafe Acts Causes Investigation Operational Factors Figure 1. Sequence of Human Factors-Related Incident Investigation Causes The current methodology is based on the fundamental assumption that the causes of unsafe acts represent the full range of human performance, local workplace, and operational factors. For example, if an inappropriate control response to an abnormal incident were identified as the unsafe act preceding a product leak, one contribution to that incident could be identified as the Controller misdiagnosing the nature of the abnormal condition. However, further analysis could reveal that a factor contributing to the Controller’s misdiagnosis was the layout of the physical <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page 3 Introduction pipeline on the SCADA display that made it difficult to determine the status of the affected portion of the pipeline system. Continuing the current example, further analysis of the Controller’s misdiagnosis could reveal that an additional factor contributing to this unsafe act was the limited ability of the Controller to mentally focus on the abnormal conditions; due to a job design that required concurrent monitoring and control of several ongoing pipeline activities. Thus, a very fundamental premise of this guide is that the full range of operator, local workplace, and operational factors can contribute to the occurrence of an incident. MITIGATING CONTROL ROOM HUMAN FACTORS RISKS The interpretation of incident causation depicted in Figure 1 suggests that there is a broad range of strategies that can be adopted to reduce the likelihood that an unsafe act will occur. Modification of the local workplace design can reduce the likelihood of unsafe acts by providing tools and equipment that better support correct diagnosis of abnormal conditions and the correct and timely selection of control actions. Additionally, operational factors can further reduce the likelihood of unsafe acts by tailoring the job to match to the human operators’ capabilities and/or by better equipping Controllers to effectively monitor and control operations through the development and implementation of more effective policies, procedures, and training. A second perspective on incident causation that suggests additional strategies for mitigating human factors risk is depicted in Figure 2. This figure, adapted from James Reason’s ‘Swiss Cheese’ model of accident causation6, depicts the trajectory of critical incident opportunities and the value of multiple, redundant system defenses or incident barriers. Figure 2 depicts the basic perspective that the trajectory of most potential incidents resulting from a hazardous situation can be avoided through the design and implementation of effective system defenses. Effective redundant defenses, such as redundant sensors that provide overlapping information regarding system status, automated alarm management that facilitates access to critical information, and relief valves that minimize the result of over-pressurization, reduce the likelihood that a hazardous situation will result in an actual incident. A combination of mitigations that are developed to augment Controllers capabilities and better match job requirements to Controllers’ capabilities (as depicted in Figure 1); and to provide additional system defenses (as depicted in Figure 2) can provide a broad range of effective strategies for reducing human factors risks in a control room. Critical Incident Relief Valves Automated Alarm Management Redundant Sensors Figure 2. Incident Causes and Defenses (Adapted from Reason, 1990) <<>> Page 4 Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Introduction PROJECT OBJECTIVES, ACTIVITIES, AND PRODUCTS The systems perspective towards human factors risks and their mitigation presented in the preceding discussion served as the basis for defining the objectives, activities, and products of the current project. The project was conducted to better understand the specific human factors risks and potential mitigations in pipeline control rooms and to translate that knowledge into methodologies, tools, and procedures that could be used by operators to manage their human factors risks. Figure 3 presents an overview of these project tasks and products, which are briefly discussed below. Project Tasks Project Products Task 1 Identify human factors contributing to monitoring and control safety and efficiency Human Factors Taxonomy Task 2 Conduct operational reviews at selected sites Controller Survey Operational Review Procedures Task 3 Identify the potential risk level of human factors Risk Likelihood Rating Activity Risk Level Calculation Procedure Task 4 Define cost-effective improvement strategies for reducing risks Mitigation Descriptions Task 5 Prepare a human factors risk management guide Mitigation Selection Procedure Final Risk Management Guide Figure 3. Major Project Tasks and Products <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page 5 Introduction Task 1 consisted of a series of information gathering and analysis activities, including National Transportation Safety Board (NTSB) accident investigation report analysis, human factors research review, and structured interviews with control room personnel, to identify the specific human factors that contribute to pipeline monitoring and control safety and efficiency. Task 1 provided the technical basis for the development of the Human Factors Taxonomy, which is a hierarchically organized list of human factors that affect liquid pipeline monitoring and control performance. This taxonomy is comprised of 11 Human Factors Areas, 29 Human Factors Topics, and 138 Performance Factors. Task 2 involved the development of operational review procedures and their trial application by a group of participating operators. Two basic tools were developed and implemented during this task. First, a Controller Survey was developed, which is a survey administered to Controllers to obtain both their estimates regarding the frequency with which they encounter each of the 138 Performance Factors included in the Human Factors Taxonomy and their descriptions of working conditions associated with Performance Factors that may be adversely affecting their job performance. Second, draft versions of operational review procedures were developed and applied on a trial basis by the participating operators. These procedures define activities conducted to supplement information obtained from the Controller Survey to aid in understanding the nature of specific operational risks and potential mitigation of those risks. Task 3 was conducted to establish a risk-based means of prioritizing potential human factors risks for mitigation management activities. This task resulted in the development and trial application of a Risk Likelihood Rating Activity and Risk Level calculation procedure. The Risk Likelihood Rating Activity provided a structured procedure to obtain ratings of the likelihood that exposure to the working conditions associated with each Performance Factor will result in degraded Controller performance and contribute to the occurrence and/or increase in severity of an incident with an unacceptable consequence. The Risk Level calculation procedure integrates Controller Survey and Risk Likelihood rating data to prioritize Human Factors Topics and Performance Factors on the basis of their relative Risk Level. Task 4 was conducted to identify potential mitigations that could be developed and implemented by an operator in order to reduce and manage human factors risks. Available theoretical, research, and applied operational literature, were integrated with operator input into a series of mitigation descriptions that can serve as a starting point for operators in developing a mitigation strategy. Task 5 involved the development of procedures and guidance for operators to use in selecting from the potential mitigations and developing a mitigation strategy that best meets their organization’s potential human factors risks and operational environment. The mitigation selection procedures, along with this guide, were the major product of Task 5. ORGANIZATION OF THIS GUIDE This guide is organized into ten sections. This Introduction is followed by a Methodology Overview, which provides a summary of the full set of human factors risk management procedures; and discusses some of the general issues regarding methodology limitations and implementation guidance. Following the Methodology Overview, eight separate appendices – one for each of the eight steps in the methodology – provide detailed instructions and guidance regarding the conduct of each step, along with specific materials designed to aid operators in <<>> Page 6 Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Introduction carrying out each step of the current human factors risk management methodology. Each of these eight appendices has been prepared as a stand-alone, inclusive document that provides the materials, procedures, instructions, and guidance required to support a pipeline operator in conducting each of the eight Human Factors risk management steps that comprise this methodology. 1 Trench, C. (2003). The U.S. Oil Pipeline Industry’s Safety Performance. New York, NY: Allegro Energy Consulting. Prepared for Association of Oil Pipelines. Available at http://www.aopl.org/posted/888/Safety_thru_2001.57651.pdf 2 National Transportation Safety Board. (2005). Supervisory Control of Data Acquisition (Safety Study NTSB/SS- 05/02). Washington DC: Author. Available at http://www.ntsb.gov/publictn/2005/SS0502.pdf 3 The PHMSA Fact Sheet Incorrect Operations, reports that “Operating Errors generally cause approximately 7% of total pipeline and non-pipeline incidents. Available at http://primis.phmsa.dot.gov/comm/FactSheets/FSIncorrectOperation.htm 4 Center for Chemical Process Safety of the American Institute of Chemical Engineers. (1994). Guidelines for Preventing Human Error in Process Safety. New York, NY: Author. 5 Wiegmann, D.& Shappell, S. (2001). A Human Error Analysis of Commercial Aviation Accidents Using the Human Factors Analysis and Classification System (HFACS) (Report No. DOT/FAA/AM-01/3). Oklahoma City, OK: FAA Civil Aeromedical Institute. Available at http://www.faa.gov/library/reports/medical/oamtechreports/2000s/media/0103.pdf 6 Reason, J. (1990). Human Error. Cambridge, UK: Cambridge University Press. <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Methodology Overview Page 7 METHODOLOGY OVERVIEW METHODOLOGY ORGANIZATION Figure 4 provides an overview of the human factors risk assessment and management methodology that serves as the basis for this guide. The overall methodology consists of eight steps that are conducted by an operator to establish a human factors risk management team, identify and assess the human factors risks in their control room, develop a plan for mitigating the highest-priority risks, and developing and implementing the selected mitigations. This Guide provides detailed guidance, instructions, tools, and worksheets to support operators in their performance of each of these eight steps. Step 1: Assemble the Control Center Human Factors Risk Management Team Step 2: Administer Controller Survey Step 3: Administer Risk Likelihood Ranking Activity Step 4: Calculate Risk Levels and Rank-Order Human Factors Topics for Operational Review Risk Management Feedback Loop Step 5: Select Operational Review Topics Step 6: Conduct Operational Reviews and Summarize Findings Step 7: Develop a Risk Mitigation Strategy Step 8: Develop and Implement Risk Mitigations Figure 4. Overall Control Room Risk Management Methodology Activities <<>> Page 8 Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Methodology Overview The methodology includes a risk management feedback loop, depicted on the left-hand side of Figure 4. Human factors risk mitigations are implemented in an effort to reduce the risk levels associated with targeted human factors. The effectiveness of implemented mitigations can be evaluated through this feedback loop by periodically assessing control room human factors risk levels associated with the targeted human factors. Conducting a periodic human factors risk assessment will both provide evidence regarding the effectiveness of mitigations implemented in the past, and help in determining appropriate future steps to further reduce potential human factors risks. The technical reference used in identifying and organizing potential human factors risks and mitigations throughout this guide is the Pipeline Operations Human Factors Taxonomy. This taxonomy was developed during the current project, based on analyses of pipeline accident investigation reports, process control research literature reviews, an extensive series of structured interviews with liquid pipeline Controllers, and an iterative review and refinement of the content and wording of the human factors taxonomy by the project researchers, pipeline operations managers, and risk management experts. Figure 5 graphically depicts the basic organization of the Pipeline Operations Human Factors Taxonomy, omitting many of the details. The most general Human Factors Area level of the taxonomy consists of 11 areas: (1) Task Complexity and Workload, (2) Displays and Controls, (3) Communications, (4) System Information Accuracy and Access, (5) Job Procedures, (6) Alarm Presentation and Management, (7) Controller Training, (8) Coping with Stress, (9) Controller Alertness, (10) Automation, and (11) Control Room Design and Staffing. Human Factors Areas (11) 1. Task Complexity and Workload Human Factors Topics (29) Performance Factors (142) 1.1. Task Design 1.1.1. Execution of… 1.1.2. Routine activities… 1.2 Console Workload 1.1.1. Execution of… 1.1.2. Routine activities… 2. Displays and Controls 2.1. Equipment Layout 2.2. … 2.3. … 11. Control Room Design and Staffing 11.1. Control Room Design 11.2. Control Room Staffing 11.1.1. The location… 11.1.2. … 11.2.1. Another Contr… 11.2.2. … Figure 5. Graphic Depiction of Pipeline Operations Human Factors Taxonomy Organization <<>> Liquid Pipeline Operator’s Control Room Human Factors Risk Management Guide Page 9 Methodology Overview The intermediate Human Factors Topic level of the taxonomy includes 29 Human Factors Topics nested within the Human Factors Areas. For example, as depicted in the figure, there are two Human Factors Topics nested within Human Factors Area 1: 1.1.—Task Design and 1.2.— Console Workload. The most detailed Performance Factor level of the taxonomy includes 138 specific characteristics of the Controller (e.g., experience, fatigue), workspace (e.g., display monitors, lighting), job tools (e.g., batch tracking, SCADA), job design (e.g., control tasks and activities), and other factors that can affect a Controller’s ability to effectively monitor and control the pipeline. For example, there are five Performance Factors nested within Human Factors Topic 1.1, including: 1.1.1—Execution of a control action (e.g., open/close valve, start/stop pump, change set point) requires too many steps (e.g., more than three); and 1.1.2—Routine activities (e.g.., line start up, batch cutting, or manifold flushing) are too complex. Following is a brief overview of each of the eight steps in the risk assessment and management methodology, along - **truncated:** true - **body characters:** 713244