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Bullemer P.T.,Human Centered Solutions | Laberge J.C.,Honeywell
11AIChE - 2011 AIChE Spring Meeting and 7th Global Congress on Process Safety, Conference Proceedings | Year: 2011

The Abnormal Situation Management® Consortium funded a study to investigate common failure modes and root causes associated with operations practices. A total of 20 public and 12 private incidents across the refining, chemical, and oil and gas industries was examined for common operations practice failure modes, including the BP Texas City Incident. Ineffective first-line supervision was one of the most frequent operations practice failures. A number of potential proactive indicators of weaknesses in operations practices was observed. Organizations seeking to establish a strong safety culture need to ensure that there is an effective first-line supervision practice. An operations audit checklist to enable plant personnel to assess their potential vulnerability to this common failure mode is put forward. This is an abstract of a paper presented at the 2011 AIChE Spring Meeting & 7th Global Congress on Process Safety (Chicago, IL 3/13-17/2011). Source


Bullemer P.,Human Centered Solutions | Laberge J.C.,Honeywell
Journal of Loss Prevention in the Process Industries | Year: 2010

The Abnormal Situation Management® (ASM®) Consortium (This research study was sponsored by the Abnormal Situation Management (ASM) Consortium. ASM® and Abnormal Situation Management® are registered trademarks of Honeywell International, Inc.) funded a study to investigate common failure modes and root causes associated with operations practices. The study team analyzed 20 public and 12 private incident reports using the TapRoot® methodology to identify root causes. These root causes were mapped to operations practice failures. This paper describes the top ten operations failure modes identified in the analysis. Specific recommendations include how to analyze plant incident reports to better understand the sources of systemic failures and improve plant operating practices. © 2010 Elsevier Ltd. Source


Laberge J.C.,Honeywell | Bullemer P.,Human Centered Solutions | Tolsma M.,Sasol Limited | Reising D.V.C.,Human Centered Solutions
International Journal of Industrial Ergonomics | Year: 2014

Despite efforts to improve alarm systems, alarm flooding remains a significant problem in the process industries. Alarm summary displays for managing alarm floods do not fully support operator needs when responding to plant upsets. This Abnormal Situation Management Consortium (asmconsortium.org) funded study tested two alarm summary display designs in a simulated process control environment using twenty-four certified operators. The first display represented the traditional list-based alarm summary display typically used in control rooms. The second display was a new alarm tracker summary display, which showed alarms in a time series represented by icons and a short alarm description. Results of the simulated evaluation showed that when operators used a formal alarm response strategy that focused the new alarm tracker summary display by equipment area, they responded to more process events overall and had fewer false responses compared to when operators used the traditional list-based alarm summary. Relevance to industry: New alarm summary displays can combine the benefits of list-based displays with time series presentation of alarm information. Process operators can be trained on formal alarm response strategies and should be given ample time to familiarize themselves with new displays as part of an effective deployment strategy. © 2013 Elsevier B.V. Source


Bullemer P.T.,Human Centered Solutions | Kiff L.,Honeywell | Tharanathan A.,Honeywell
Journal of Loss Prevention in the Process Industries | Year: 2011

The Abnormal Situation Management® Consortium11This research study was sponsored by the Abnormal Situation Management® (ASM®) Consortium. ASM and Abnormal Situation Management are registered trademarks of Honeywell International, Inc. funded a study to investigate procedural execution failures during abnormal situations. The study team analyzed 20 publically available and 12 corporate confidential incident reports using the TapRoot® methodology to identify root causes associated with procedural execution failures. The main finding from this investigation was the majority of the procedural execution failures (57%) across these 32 incident reports were associated with abnormal situations. Specific recommendations include potential information to capture from plant incident to better understand the sources of procedural execution failures and improve use of procedures in abnormal situations. © 2011 Elsevier Ltd. Source


Tolsma M.,Sasol Limited | Jones M.,Sasol Limited | Reising D.V.,Human Centered Solutions | Bullemer P.T.,Human Centered Solutions | And 2 more authors.
InTech | Year: 2010

ASM Consortium has introduced effective practice areas that ensure the reduction of process safety incidents in the manufacturing industry caused by human error. It is recommended to understand abnormal situations including the broad scope of investigating the causes and impacts of abnormal situations with the aim to prioritize future research and to efficiently and accurately inform continuous improvement programs that reduces abnormal situations. Organizational roles, responsibilities, and processes focus on determining the management systems, work practices, organizational structures, and continuous improvement culture that support the prevention of abnormal situations. Training and the continuous learning environment ensures that the personnel can effectively respond and cope with abnormal situations. The effective use of information media ensures work continuity between operational and functional team members of an organization. Source

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