1. HF Design for Operability and Maintenability Dipl.-Ing. Simon G. Kariuki & Dr.-Ing. Katharina Löwe Technical University of Berlin Presented at The PRISM Seminar, FG2 Athens, 3rd & 4th Sept, 2003 Technische Universität Berlin

2. What is covered: Technische Universität Berlin Background, why the need for HF in design. HF Models for design, inspection and maintenance. Examples where design ignored HF.

3. Technische Universität Berlin Why Human Factor? Time Safety Improvement Engineering/ Hardware age (Upto 1970s) Safety Management Systems age (Upto mid- 1980s ) Industrial Revolution 2003 Human Factors Age (Current)

4. Technische Universität Berlin Desig n Outpu t The Design Team Human Factors Experts -Ergonomists -Psychologists Designers - Engineers -Chemists Operator (User ) -ProcessOperators-MaintenanceTechnicians Management

5. Technische Universität Berlin  Participatory design that involves operator (as the user) participation and task modelling at early stages.  To make all departments feel that they own the design process.  Human Factors are included from early stages and not to only for cosmetic purposes. The Principle  To train Engineers to be HF experts  To involve cognitive and physical ergonomists permanently & actively in design projects

6. Technische Universität Berlin Manage- ment Systems Human (User) Plant (Machine) Design Operator (active errors) Task performance Training, Communication Equipment reliability HF BARRIER Design and Management (latent errors) Minimise consequences HF Design Guidelines Design solution to address error causes Error causes Undesired Event Local trigger OR Minimise error occurence

7. Technische Universität Berlin Conceptual Design Basic Design Commissioning & Installation Check Evaluate Review Detailed Design HF Iterative design Model

8. Technische Universität Berlin Conceptual Design Basic Design Abstract of design HF reviews Overview of tasks Commissioning & Installation Check Evaluate Review Detailed Design HF Iterative design Model

9. Technische Universität Berlin Conceptual Design Basic Design Abstract of design HF reviews Overview of tasks User profile: Biometrics Task analysis Critical tasks, Task scenarios Subtasks formulation Function analysis Link analysis Commissioning & Installation Check Evaluate Review Detailed Design HF Iterative design Model

10. Technische Universität Berlin Conceptual Design Basic Design Abstract of design HF reviews Overview of tasks User profile: Biometrics Task analysis Critical tasks, Task scenarios Subtasks formulation Function analysis Link analysis Commissioning & Installation HF training for contractors Feedback for an improvement Check Evaluate Review Detailed Design HF Iterative design Model

11. Technische Universität Berlin Conceptual Design Basic Design Abstract of design HF reviews Overview of tasks User profile: Biometrics Task analysis Critical tasks, Task scenarios Subtasks formulation Function analysis Link analysis Commissioning & Installation HF training for contractors Feedback for an improvement Check Evaluate Review Detailed Design HF Iterative design Model

12. Technische Universität Berlin Detailed presentation of design Application of HF guidelines Task analysis review Detailed design Check Evaluate Review

13. Technische Universität Berlin Detailed presentation of design Application of HF guidelines Task analysis review Simulation Prototyping Operator testing & training Cognitive walkthroughs Detailed design Check Evaluate Review

14. Technische Universität Berlin Detailed presentation of design Application of HF guidelines Task analysis review Simulation Prototyping Operator testing & training Cognitive walkthroughs Specifications Error causes & precursor Analysis and mitigation Evaluate results New concepts needed? Detailed design Check Evaluate Review

15. Technische Universität Berlin Detailed presentation of design Application of HF guidelines Task analysis review Simulation Prototyping Operator testing & training Cognitive walkthroughs Specifications Error causes & precursor Analysis and mitigation Evaluate results New concepts needed? Are the error causes & precursors designed out? Are they guarded against? Warn against? Training to avoid error occurrence? Detailed design Check Evaluate Review

16. Designing to reduce Human Error Precursors = HF Guidelines Work Environment Ventilation, Air Conditioning Noise reduction Lighting and Glaring Work space layout Maintainability and Operability Accessibility issues Process Equipment Line Valves & Relief Valves Pipes, hoses and connectors Fasteners, gaskets and seals Automation Fault Management False Alarms Training Process Control & Monitoring Control Room Design Field Control Panels Alarm Management Control Panel Design Display Design Technische Universität Berlin Process Operations & Layout Process (Equipment) Layout Pathways design HF Main Areas

17. Analysis of accidents Uth, 1999 TUB Internet Survey Technische Universität Berlin

18. Fatality due to maintenance accidents Lees, 1996 Technische Universität Berlin

19. InitiateAccessSearch Decision & Response Action Example HF Design Requiremen t Steps Inspection Model Technische Universität Berlin

20. Initiate Access Search Decision & Response  Read & understandwork card  Select inspection tools.  Calibrate if necessary (NDIequipment)  Work card design  Permit –to-work procedures Action Example HF Design Requiremen t Steps Inspection Model Technische Universität Berlin

21. Initiate Access Search Decision & Response  Read & understandwork card  Select inspection tools.  Calibrate if necessary (NDIequipment)  Locate area on theplant  Move to work site  Work card design  Permit –to-work procedures  Proper & clear labelling.  Avoid difficult-to-reach areas.  Easy & safe isolation.  Purging Action Example HF Design Requiremen t Steps Inspection Model Technische Universität Berlin

22. Initiate Access Search Decision & Response  Read & understandwork card  Select inspection tools.  Calibrate if necessary (NDIequipment)  Locate area on theplant  Move to work site  Move eyes or probe onsearch areas  Work card design  Permit –to-work procedures  Proper & clear labelling.  Avoid difficult-to-reach areas.  Easy & safe isolation.  Purging  Clear access routes.  Good lighting  Reachable locations Action Example HF Design Requiremen t Steps Inspection Model Technische Universität Berlin

23. InitiateAccessSearch Decision & Response  Read & understandwork card  Select inspection tools.  Calibrate if necessary (NDIequipment)  Re-examine area ofindication andmark as a defectif necessary.  Write a Non routine repair(NRR)  Locate area on theplant  Move to work site  Move eyes or probe onsearch areas  Work card design  Permit –to-work procedures  Proper & clear labelling.  Avoid difficult-to-reach areas.  Easy & safe isolation.  Purging  Clear access routes.  Good lighting  Reachable locations  Training of maintenancepersonnel. Action Example HF Design Requiremen t Steps Inspection Model Technische Universität Berlin

24. Initiate Site Access Part Access Buy-back Steps Repair/Maintenance Model Reset HF Design Requirement Action Example Technische Universität Berlin

25. Initiate Site Access Part Access Buy-back  Make tools ready,collectparts,inspectparts  Well design parts storeswith partsclearly,logicallylabelled &numbered Steps Repair/Maintenance Model Reset HF Design Requirement Action Example Technische Universität Berlin

26. Initiate Site Access Part Access Buy-back  Make tools ready,collectparts,inspectparts  With tools, parts,equipment  Isolate equipment/plant  Well design parts storeswith partsclearly,logicallylabelled &numbered  Sufficient pathways toworksite withall requiredtools &equipmentincluded  Easy & Safe Isolation Steps Repair/Maintenance Model Reset HF Design Requirement Action Example Technische Universität Berlin

27. Initiate Site Access Part Access Buy-back  Make tools ready,collectparts,inspectparts  With tools,parts,equipment  Isolate equipment/plant  Isolate equipment.  Open the parts thatneed repair  Well design parts storeswith partsclearly,logicallylabelled &numbered  Sufficient pathways toworksite withall requiredtools &equipmentincluded  Easy & Safe Isolation  Accessibility of part. toavoid workingat awkwardpositions  Easy &safe isolation  Purging Steps Repair/Maintenance Model Reset HF Design Requirement Action Example Technische Universität Berlin

28. Initiate Site Access Part Access Buy-back  Make tools ready,collectparts,inspectparts  With tools,parts,equipment  Isolate equipment/plant  Isolate equipment.  Open the parts thatneed repair  Well design parts storeswith partsclearly,logicallylabelled &numbered  Sufficient pathways toworksite withall requiredtools &equipmentincluded  Easy & Safe Isolation  Accessibility of part. toavoid workingat awkwardpositions  Easy &safe isolation  Purging Steps Repair/Maintenance Model Reset  Adjust systems tospecs andinspectadjustment.  Gauges and otherindicatorseasily readableand shall bewithin eyereach HF Design Requirement Action Example Technische Universität Berlin

29. Initiate Site Access Part Access Buy-back  Make tools ready,collectparts,inspectparts  Examine if repairmeetsstandards.  Close & document  With tools,parts,equipment  Isolate equipment/plant  Isolate equipment.  Open the parts thatneed repair  Well design parts storeswith partsclearly,logicallylabelled &numbered  Sufficient pathways toworksite withall requiredtools &equipmentincluded  Easy & Safe Isolation  Accessibility of part. toavoid workingat awkwardpositions  Easy &safe isolation  Purging  Training of maintenancepersonnel.  Good communication Steps Repair/Maintenance Model Reset  Adjust systems tospecs andinspectadjustment.  Gauges and otherindicatorseasily readableand shall bewithin eyereach HF Design Requirement Action Example Technische Universität Berlin

30. Repair/Maintenance Example Pasadena Incident, October 23rd 1989 Loop reactor Schematic Product Take Off Valve Technische Universität Berlin Settling leg

31. Repair/Maintenance Example Pasadena Incident, October 23rd 1989 Settling leg of a reactor: General Piping  Settling legs clogged by plastic material.  Frequent cleaning was needed.  The clogged leg is isolated but reactor keep on operating. Technische Universität Berlin

32. Repair/Maintenance Example Pasadena Incident, October 23rd 1989 DEMCO R Valve  Valve operated by air.  Connectors for „open“ and „close“ were identical. Technische Universität Berlin

33. Repair/Maintenance Example Pasadena Incident, October 23rd 1989 Consequences  Explosion with the force of 2.4 tons of TNT  23 fatalities  More than 130 injuries  Nearly a billion dollars in asset damaged HF design questions  Was the isolation easy and safe?  Was the alarm system detectable, could it be discriminated?  Were the access/escape routes designed to contain an emergency situation, were they clearly marked? Technische Universität Berlin

34. Tank 1 Tank 2 Tank 3 Valve 1 Valve 2 Valve 3 From loading rack Product1 Product3 Product2 Task To fill tank 1: Close Valves 2 & 3 and open valve 1. Possible error: Either valve 1 or 2 or both valves are left open  Product to the wrong tank Task To fill tank 1: Close Valves 2 & 3 and open valve 1. Possible error: Either valve 1 or 2 or both valves are left open  Product to the wrong tank Operational example Technische Universität Berlin

35. Solution Each tank to be connected to filling point by an independent pipe 1.Each filling pipe to have a different size or a special coupling 2.Work space big enough accomodate operators hands with PPE 3.Filling point lifted to avoid too much bending Technische Universität Berlin

36. Conclusions Technische Universität Berlin HF should be as old as the conceptual stage of a design process. Iterative design process helps to reduce error causes before the whole design process is concluded. The Primary function of a design engineer is to make things difficult for the fabricator and impossible for the the serviceman. Most important is to eliminate the Myth:

37. Thank you for your kind attention Technische Universität Berlin