Abstract

The overall purpose of this project was to extend our understanding of the impact of human and organizational factors (HOF) on pipeline process safety incidents. Six pipeline incident reports were systematically analyzed using a two-phased approach developed in the Abnormal Situation Management (ASM�) Consortium research program [1]. The first phase of the incident analysis approach used the TapRoot methodology [2] to chart the event sequence, identify contributing factors including organizational practice failures, and identifying root causes of the organizational practice failures. The second phase of the analysis characterized the organizational failures as Common Failure Modes based on the HCS Effective Operations Practices and the specific expression of the root causes in terms of Common Root Cause Manifestations based on the Dirty Dozen human factors taxonomy [3]. The Dirty Dozen taxonomy of human factors was found to have the potential to provide a tractable root cause framework for human and organizational factors. Specific limitations of the Dirty Dozen taxonomy as a HOF framework are discussed. This report has a related webinar.

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