Articles

New York—An exhausted employee at the end of a long shift can sometimes be the most dangerous component in a chemical facility, particularly those that run "24-7." As Peggy Westfall-Lake writes in the Spring issue of Process Safety Progress, "Research across multiple industries indicates common threads of observable and preventable behaviors that can lead to catastrophic events. Fatigue, monotony, overwork and a multitude of other cultural factors and organizational policies can trigger these mental and physical human errors."

In an article enitled "Human Factors: Preventing Catastrophic Human Error in 24-Hour Operations," Westfall-Lake of the Tulsa, Oklahoma-based Williams Company, points out that, "operational fatigue has been on the National Transportation Safety Board's list of Most Wanted Transportation Safety Improvements since the list's inception in 1990." With this in mind, her paper, which was recently honored as a joint winner of the William H. Doyle Award, presented by the Safety and Health Division of American Institute of Chemical Engineers' (AIChE's) for the best paper delivered at the 1999 Loss Prevention Symposium, seeks to help plant managers, "understand strategies to prevent shiftwork-related human error."

Westfall-Lake examines such factors as interactions with co-workers, interpretation of procedures, and the danger of tired employees misreading equipment displays. To combat the latter, she recommends visiting shiftworkers "mid-way and at the end-of-shifts to get the real picture." She also points out that re-structuring and downsizing have complicated safety management in 24-hour facilities. "Moderate overtime levels of 20 percent have increased to 30 or 40 percent in the past several years, due to reduced manpower and increased production," she observes, and "schedules that were implemented back in the 1980's may become difficult to manage with increased overtime and the aging workforce vacation issue. Some of these schedules are intolerant to overtime, causing more fatigue and disruption of home life. Managing training becomes impossible as employees fail to retain knowledge and dread the training setting."

Factor in personal health, financial concerns and other pressures, and sleep disorders, and the stage is set for both mental and physical errors which "may lead to a near-miss, an accident or catastrophic event," Westfall-Lake writes. "Often, there are multiple set-ups or links to the chain of error prior to the accident. These errors can occur at the same time as other errors, hours previous to the final error (such as the shift previous), or even days, weeks, or months previous to the event. Also, individual set-ups of excessive fatigue can lead to cardiovascular problems and sleep disorders, or even social problems with family members, which can then trigger fatigue-related human errors."

To resolve these problems, Westfall-Lake recommends using a shiftwork assessment to identify areas for improvement. Performance interventions "may include a variety of solutions i.e. policy review or adjustment, wellness or sports training, schedule modification, committee involvement, cultural or behavioral training, and shiftwork training for spouses," she states. Additionally, "work/rest guidelines should be established as policy, limiting number of hours worked-in-a-row, number of rotations permissible, number of days/nights worked-in-a-row, number of hours prior to return-to-shift, and callout procedures. This is best achieved through education and cross-team involvement and consensus of human resource, safety, operations, wellness and field personnel."

In conclusion, Westfall-Lake reminds decision-makers that they "should keep in mind that human beings will remain at the heart and control of our 24-hour operations. The 24-hour worker is empowered with increasing responsibility to ensure safety and smooth operations, yet at the same time, he/she is faced with personal challenges as he/she attempts to maintain peak alertness throughout the shift. A human-centered operations system that incorporates both strategies at the organizational and personal levels can prevent primary back-up inversion and ensure operators keep a pulse on their personal performance ability."

Process Safety Progress is a quarterly publication of the American Institute of Chemical Engineers which concentrates on the design, operation, and maintenance of cost-effective facilities in the chemical process industries, as well as new techniques and advances in risk management and the promotion of loss prevention and efficient safety and health operations in plants. An online edition of the publication was launched in the Winter of 1999. For information on subscribing to either or both editions, call 1-800-242-4363. Orders can also be faxed to 212/591-8888.

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