Improve Process Safety Research Articles

Real-Time Analytics Improves Process Safety in a Drilling-Contractor Operations Center

This article, written by JPT Technology Editor Judy Feder, contains highlights of paper OTC 28824, “Operational and Safety Improvements of Applying Real-Time Analytics in a Drilling-Contractor RTOC,” by A.L.F. Madaleno, S.L.S. Neto, L.A. dos Santos, and C.A.L. de Oliveira, QGOG Constellation, prepared for the 2018 Offshore Technology Conference, Houston, 30 April–3 May. The paper has not been peer reviewed. Copyright 2018 Offshore Technology Conference. Reproduced by permission. Digitally enabled collaboration between operators and service companies is driving significant improvements in process safety in the upstream oil and gas industry. However, drilling contractors generally have been considered only the owners of the systems that generate part of the surface drilling data and, as such, have not been engaged in the development of real-time analytics tools. The role of a real-time operations center (RTOC) with a drilling contractor is itself a new factor. This paper explains how an ultradeepwater drilling contractor is applying real-time analytics and machine learning to leverage its RTOC to improve process safety and performance. Introduction The increasing availability of digital drilling data and the emergence of reliable communication between offshore rigs and well operators’ offices enabled a proliferation of RTOCs in the 2000s, spawning a collaborative environment between well operators and service companies that enabled enhanced support and optimized use of expert resources to improve process safety and operational efficiency. Drilling contractors generally were not engaged in developing the real-time analytics tools for the RTOCs. One consequence is that the majority of RTOC software solutions are only appropriate for wellsite information transfer standard markup language (WITSML) data visualization, or they feature embedded tools for well operators and service companies focused on drilling efficiencies but the data and models they use are not accessible to the rig operators. Essential aspects of process safety and operational performance, such as procedural discipline and critical equipment health, can be addressed by drilling contractors in real time if appropriate resources are in place. The contractor’s RTOC has enhanced process safety and surveillance after moving to an approach in which drilling engineers, assisted by software developers with robust experience in real-time data analytics, began writing automated operation-identification and problem-detection algorithms. The cooperative work allowed the creation of tools adapted to the company’s needs and provided a streamlined process to implement, customize, and repair these tools over time. During the planning phase, it was agreed that initial developments should be grouped into six important dimensions that strongly influence the overall process safety and operational performance of the rig. The contractor applied real-time analytics and machine learning to identify and alert RTOC engineers of abnormal situations automatically. The detection of the abnormal situations by RTOC engineers and the comparison of the standard by which various drilling crews react to them feeds a lessons-learned data base, which, in turn, sustains the procedural advancement initiatives, ensuring continuous improvement.

Improving Productivity of Multiphase Flow Aerobic Oxidation Using a Tube-in-Tube Membrane Contactor

The application of flow reactors in multiphase catalytic reactions represents a promising approach for enhancing the efficiency of this important class of chemical reactions. We developed a simple approach to improve the reactor productivity of multiphase catalytic reactions performed using a flow chemistry unit with a packed bed reactor. Specifically, a tube-in-tube membrane contactor (sparger) integrated in-line with the flow reactor has been successfully applied to the aerobic oxidation of benzyl alcohol to benzaldehyde utilizing a heterogeneous palladium catalyst in the packed bed. We examined the effect of sparger hydrodynamics on reactor productivity quantified by space time yield (STY). Implementation of the sparger, versus segmented flow achieved with the built in gas dosing module (1) increased reactor productivity 4-fold quantified by space time yield while maintaining high selectivity and (2) improved process safety as demonstrated by lower effective operating pressures.

Our Process Safety Journey Continues: Operational Discipline Today

In the late 1980s, DuPont defined Operational Discipline (OD) as the deeply rooted dedication and commitment by each member of an organization to carry out each task, the right way, each time. Many other companies have similar “operational discipline” definitions, and this emphasis has not changed. Furthermore, the dedication and commitment to OD has grown stronger. Operational discipline continues to reflect the strength of an organization's safety culture in making process safety programs effective and in providing tangible results for preventing injuries and incidents through effective process safety systems. What has changed is how we better apply Operational Discipline as one of the three essential process safety foundations. When combined with both a strong safety culture and leadership and robust process safety systems, the company's strong Operational Discipline foundation helps improve process safety performance. This article describes how collaborative efforts have helped us to better evaluate Operational Discipline in context of the Risk Based Process Safety's element Conduct of Operations, briefly presents how OD programs can be implemented using an example from the Dow Chemical Company, and provides some practical guidance and approaches that a company can use on their process safety journey to improve their OD program. © 2018 American Institute of Chemical Engineers Process Saf Prog 37: 478–492, 2018

Reporting (or Not) of Precursors to Disasters

Problem definition: Firms can reduce the risk of rare disasters by accounting for more frequent near misses: precursor events that could have escalated to a disaster but did not. Investigating a near miss reveals its root cause, allowing the firm to improve process safety and reduce disaster risk. A managing firm, however, usually does not directly observe the occurrence of a near miss, but instead relies on the report of a contractor who is also responsible for preventing such incidents by maintaining process safety. This paper explains why near miss reporting may not take place in such a decentralized setting. Academic/Practical Relevance:Literature and practitioners have acknowledged the crucial role of near miss reports in improving process safety. Nevertheless, even at sophisticated and experienced organizations, disaster inquiries invariably uncover a history of unreported or ignored near misses preceding an accident. We provide an explanation for this persistent phenomenon based on rational economic incentives. Methodology: We examine the firm's problem through a dynamic principal-agent model that captures the contractor's potential for under-reporting near misses along with \textit{moral hazard} related to preventive effort. Results: We find that the firm may fail to capitalize on near miss information due to conflicting incentives. This occurs, for instance, when the contractor is unwilling to report near misses because the resulting safety improvements replace the need for his unverifiable preventive effort, thereby lowering his compensation. However, even when the contractor is willing to report near misses, we find that the firm may choose not to record them, opting instead to create stronger incentives for prevention. In both scenarios, the firm forgoes opportunities for process-safety improvement, focusing on existing preventive measures. Managerial Implications: Our findings highlight the challenges in providing incentives for both reporting and prevention, that can result in a failure to leverage near miss information. We examine potential remedies to overcome these issues and increase reporting.

And now for something completely different

Process safety management systems are generally credited with reducing major accident risk in the process industries. While those systems have been around for many years—the EU introduced the Seveso Directive in 1982, and US OSHA promulgated the PSM regulation 10 years later— many companies today are challenged by inadequate and/or stagnant process safety management system performance. Several companies have experienced major incidents, particularly when they are subject to prescriptive regulations such as OSHA PSM.Reliance on compliance with prescriptive regulations is no guarantee of preventing major incidents. No regulator anywhere has ever thought of everything that can cause a process safety incident and then written a regulation to safeguard against that occurrence. Good process safety requires that hazards are identified, the risks of these hazards are understood, and those risks are managed by “doing the right thing.” This frequently requires additional activities that go beyond regulatory compliance.In 2007, CCPS introduced Risk Based Process Safety (RBPS), which builds on lessons learned since the early 1980s, and applies management system principles of Plan, Do, Check, Act. Being risk‐based, RBPS is not prescriptive. It recognizes that all hazards and risks are NOT equal, and focuses more resources on the higher hazards and risks that have been identified. This enables finite company resources to be optimally deployed to efficiently improve process safety performance. The 20 elements of RBPS go beyond OSHA PSM to include other elements, such as risk analysis and performance metrics.Some companies have embraced RBPS and moved away from compliance‐driven process safety management systems. However, RBPS is primarily focused on process plant operations. While some elements of RBPS can be applied to large and small projects, RBPS and its guidance does not comprehensively address projects or certain other aspects of process safety.The paper highlights “some completely different” process safety elements for which no RBPS guidance is currently available, and discusses the application of a more comprehensive RBPS approach to fill these gaps. © 2017 American Institute of Chemical Engineers Process Process Saf Prog 37:25–30, 2018

In Harm's way—after which nothing was the same again too close for comfort—part 2

Learning from experience is one of the four pillars of Risk‐Based Process Safety. Incidents that occur at one facility often provide opportunities to strengthen management systems at another. Sharing technical lessons learned from incidents is vital to improving process safety performance across the process industries. Most incidents also involve human factors, often as a key causal factor. Understanding performance‐shaping factors can be essential to minimizing future failures.Most case studies on process safety incidents are written by a third party who was not directly involved in the incident. As such, the papers may lack insights that can only be properly articulated by someone directly involved.In his early career the author was involved in two major incidents while managing day‐to‐day operation of refinery process units. This article describes the second incident involving several employees rendered unconscious from exposure to hydrogen sulfide. The first incident involving two major fires was published in Process Safety Progress [Broadribb, Process Safety Progress 32 (2013) 255–259]. In both incidents, the author found himself decidedly too close for comfort and could easily have become a casualty himself.The second incident occurred during commissioning of a major process unit in which eight men were exposed to sour gas. The blank isolating the Reactor from the Main Fractionator column was being removed and the work had progressed to the point where the flanges had been jacked open and the blank removed, when the men on the job were overcome by gas. Breathing apparatus was not being worn. Members of the rescue party were also affected by gas.This article will raise awareness of lessons learned relating to a number of elements of Risk‐Based Process Safety [CCPS, “Guidelines for Risk Based Process Safety”, New York, 2007] and human factors.“This article was prepared for presentation at American Institute of Chemical Engineers 2014 Spring Meeting, 10th Global Congress on Process Safety, New Orleans, Louisiana, March 30–April 2, 2014, and American Institute of Chemical Engineers 2017 Spring Meeting, 13th Global Congress on Process Safety, San Antonio, Texas, March 26–29, 2017.” © 2017 American Institute of Chemical Engineers Process Saf Prog 37: 140–144, 2018

Developing a framework for dynamic risk assessment using Bayesian networks and reliability data

Process Safety in the oil and gas industry is managed through a robust Process Safety Management (PSM) system that involves the assessment of the risks associated with a facility in all steps of its life cycle. Risk levels tend to fluctuate throughout the life cycle of many processes due to several time varying risk factors (performances of the safety barriers, equipment conditions, staff competence, incidents history, etc.). While current practices for quantitative risk assessments (e.g. Bow-tie analysis (BT), Layer of protection analysis (LOPA) etc.) have brought significant improvements in the management of major hazards, they are static in nature and do not fully take into account the dynamic nature of risk and how it improves risk-based decision making.In an attempt to continually enhance the risk management in process facilities, the oil and gas industry has put in very significant efforts over the last decade toward the development of process safety key performance indicators (KPI or parameters to be observed) to continuously measure or gauge the efficiency of safety management systems and reduce the risks of major incidents. This has increased the sources of information that are used to assess risks in real-time. The use of such KPIs has proved to be a major step forward in the improvement of process safety in major hazards facilities. Looking toward the future, there appears to be an opportunity to use the multiple KPIs measured at a process plant to assess the quantitative measure of risk levels at the facility on a time-variant basis.ExxonMobil Research Qatar (EMRQ) has partnered with the Mary Kay O'Connor Process Safety Center – Qatar (MKOPSC-Q) to develop a tool that monitors, in real time, the potential increases in risk levels as a result of pre-identified risk factors and process safety related data, using Bayesian Belief Networks (BN). The development of the tool involved two phases: 1) Development of a methodology that establishes the framework for the tool and 2) Development of the tool itself with the use of JAVA programming language. The overall tool is to be called PULSE, which stands for Process Unit Life Safety Evaluation.In this context, the paper presents a case study of the quantitative risk assessment of a process unit using BN. The different steps of the development of the BN are detailed, including: translation of a Bowtie into a skeletal BN, modification of the skeletal BN to incorporate reliability data, and insertion of equipment failure evidence into the BN for dynamic modeling. In addition, an overview of PULSE is presented. The outcomes of the dynamic modeling of the BN with real time insertion of evidence are discussed and recommendation for the framework for a dynamic risk assessment tool are made.

Leadership’s Role in Process Safety: An Understanding of Behavioral Science Among Managers and Executives Is Needed

ABSTRACTA recent prevalence of high visibility catastrophic events has garnered increased attention to process safety issues. While the use of Behavior-Based Safety interventions demonstrate a reduction in workplace injuries by targeting employee behavior, we believe that process safety requires a greater focus on the behavior of leaders (e.g., creating and executing strategy). One effective method to begin targeting leader behavior for the improvement of process safety is to teach leaders about the principles of behavior, including ways by which the science may be applied within their own organizational models.

Quantifying situation awareness of control room operators using eye-gaze behavior

In an attempt to improve process safety, today’s plants deploy sophisticated automation and control strategies. Despite these, accidents continue to occur. Statistics indicate that human error is the predominant contributor to accidents today. Traditionally, human error is only considered during process hazard analysis. However, this discounts the role of operators in abnormal situation management. Recently, with the goal to develop proactive strategies to prevent human error, we utilized eye tracking to understand the situation awareness of control room operators. Our previous studies reveal the existence of specific eye gaze patterns that reveal operators’ cognitive processes. This paper further develops this cognitive engineering based approach and proposes novel quantitative measures of operators’ situation awareness. The proposed measures are based on eye gaze dynamics and have been evaluated using experimental studies. Results demonstrate that the proposed measures reliably identify the situation awareness of the participants during various phases of abnormal situation management.

Refined convergent cross-mapping for disturbance propagation analysis of chemical processes

In chemical processes, determining the root causes of faults and disturbances is important for improving process safety and economic profit. Recently proposed convergent cross-mapping (CCM) is suitable for both linear and nonlinear systems. However, it cannot be directly applied to chemical processes. This is because chemical processes possess characteristics, such as nonlinearity, high dimensions, continuity, and time delay, that are significantly different from ecosystems, where CCM is applicable. In this paper, we propose refined CCM (RCCM), which integrates fast embedding dimension determinations with a modified procedure to improve the speed of the calculation and accuracy of the analysis. Examples show that RCCM fits chemical processes with the above characteristics. In addition, it shows better performance than other methods in finding the propagation paths of disturbances.

Improved Fault Detection and Process Safety Using Multiscale Shewhart Charts.

Process safety is a critical component in various process industries. Statistical process monitoring techniques were initially developed to maximize efficiency and productivity, but over the past few decades with catastrophic industrial disasters, process safety has become a top priority. Sensors play a crucial role in recording process measurements, and according to the number of monitored variables, process monitoring techniques can be classified into univariate or multivariate techniques. Most univariate process monitoring techniques rely on three fundamental assumptions: that process residuals contain a moderate level of noise, are independent, and are normally distributed. Practically, however, due to a variety of reasons such as modeling errors and malfunctioning sensors, these assumptions are violated, which can lead to catastrophic incidents. Fortunately, multiscale wavelet-based representation of data inherently possesses characteristics that are able to deal with these violations of assumptions. Therefore, in this work, multiscale representation is utilized to enhance the performance of the Shewhart chart (which is a well-known univariate fault detection method) to help improve its performance. The performance of the developed multiscale Shewhart chart was assessed and compared to the conventional chart through two examples, one using synthetic data, and the other using simulated distillation column data. The results of both examples clearly show that the developed multiscale Shewhart chart provides lower missed detection and false alarm rates, as well as lower ARL1 values (i.e., quicker detection) for most cases where the fundamental assumptions of the Shewhart chart are violated. Additionally, the relative simplicity of the proposed algorithm encourages its implementation in practice to help improve process safety.

Management system for enhancing chances to take inherently safer design options in LNG plant projects

Recent LNG facilities projects have grown in size and complexity (e.g., larger capacities, remote sites and modularized construction), thus requiring larger investments. This trend has not only increased the investment costs but also added further difficulties to project management during the design phase (e.g., large, joint venture organizations for both, Owner and Contractor, that combine partners with different company cultures, personnel hired specifically for the project, complicated contract formations and splits of work, and extensive and complex government permitting and approval requirements). In addition, the project schedule is also usually very tight in order to start up the facilities sooner.Recent projects apply a risk-based approach in defining and ensuring a safe design, rather than using the traditional deterministic approach. This formalized process (accountability, identification and demonstration for hazard and risk) has started since the Seveso Disaster, and has provided a new regulatory framework for the work place health and safety in Great Britain and Europe as the Safety Case Regulation following the Piper Alpha incident. However, due to the increasing project complexity, a risk-based approach and decisions based on a probabilistic cost-benefit analysis becomes inherently difficult. They require obtaining a firm output from various analyses and studies, which in turn, require firm design data that is only available at the latter stages of the design phase. Delays in HSE input to design may result in major schedule delays in project execution. The application of the risk-based approach has been the first step toward improving process safety, the next step, which is discussed in this paper, is to establish the Management System in order to effectively implement the risk-based approach in the current complex project environment and execution.Typical problems observed in such complex projects are differences in problem statements and optimal outcomes when there are multiple stakeholders, different philosophies, insufficient coordination and inefficient design change control, all leading to inconsistencies in HSE design.The HSE management system (HSE MS) typically focuses on site occupational HSE. However, due to the increased difficulties in engineering execution and project management in recent projects, detailed planning of how to handle Technical HSE aspects in engineering is becoming more and more important, and therefore, the traditional application of the HSE MS for occupational safety and for preparing HSE procedures and organizing and managing HSE studies (e.g., HAZID, HAZOP and SIL) do not suffice. Detailed consideration of how to handle and manage the Technical HSE aspects in engineering is critical for its successful implementation.This paper discusses a framework for the effective management of HSE MS in the design phase, and it provides some key considerations (e.g., philosophy of safety in engineering, project environment evaluation method, HSE organization and the recommended scheme for improving motivation for safety).

How to recognise a kick: A cognitive task analysis of drillers’ situation awareness during well operations

PurposeThe ability to monitor and detect anomalous changes in an oil well is a fundamental aspect of an offshore driller’s job, so as to maintain well control, the safety of the surrounding rig and minimize risk. Drillers are required to have a high level of situation awareness in order to recognise and interpret indicators that suggest that hazardous hydrocarbons may have entered the well bore (referred to as kick detection), allowing them to take the best actions to deal with the situation. The aim was to use cognitive task analysis methods to identify the expert SA skills required for the complex task of kick detection. MethodAn Applied Cognitive Task Analysis (ACTA) of the SA components required for kick detection was conducted. 1. A technical task description was produced, using material extracted from well control manuals and a five day training course. 2. The SA components required for the kick detection task using the preliminary Drillers’ SA model. 3. The ACTA data were validated by three drilling experts. ResultsThe specific cognitive skills associated with maintaining SA that were required for accurate kick detection were: attending to and recognizing changes in the drilling parameters, understanding their significance as kick indicators in the context of a mental picture of the well state, and anticipating what could result in a kick, necessitating flow checking and/or shutting in actions. LimitationsACTA methods are prone to research bias however actions were taken to minimize this. Practical implicationsTraining and work design recommendations based on the ACTA are outlined for supporting driller SA for effective well control and consequently to improve process safety. The study also illustrates how ACTA methods can be used to examine and support cognition in the workplace.

Surviving the black swan, strategies for process safety specialists, and companies to survive unpredicted catastrophic events

This article is a continuation of three articles that I have authored or coauthored on the “black swan,” the rare and unpredictable catastrophic event. The first two papers discussed the concept of the black swan as applied to the chemical and petroleum processing industries and the difficulty in predicting such events. The third paper discussed the fact that we have difficulty maintaining the lesson's learned from black swan events that have occurred. I have survived and witnessed several black swans. Each has affected me personally and professionally. Black swan events are rare but inevitable. Some individuals and companies survive black swan events and continue on while others do not. I have learned that many black swan events, although initially viewed as catastrophes, can result in opportunities from a process safety improvement, career, and personal perspective. This article presents examples of black swan events that have impacted my career in process safety, often in a positive way, and strategies for surviving these “black swan” events from a personal, professional, and a company point of view. © 2016 American Institute of Chemical Engineers Process Saf Prog 35: 13–17, 2016

Pupillometry Based Real-Time Monitoring of Operator’s Cognitive Workload To Prevent Human Error during Abnormal Situations

Ensuring process safety is widely regarded as critical to sustainable development. Despite numerous initiatives to improve process safety, severe accidents continue to occur in the process industries. This is commonly attributed to increased complexity of plants, reduced staffing levels, and the consequent cognitive challenges faced by process operators. Statistics indicate that human error is a dominant contributor in over 70% of accidents. Human error is traditionally considered only in the process design stage. In this work, we propose a methodology based on pupillometry (the measurement of pupil diameter) to noninvasively estimate the cognitive workload of control room operators in real time during process operations. Experimental studies conducted on 44 participants reveal that changes in the operators’ pupil size during abnormal situations contain distinct signatures of their ability to successfully manage the process abnormality. Our results demonstrate that pupillometry has the potential for onlin...

Eye gaze movement studies of control room operators: A novel approach to improve process safety

Process industries continue to suffer from accidents despite significant regulatory intervention since the mid-1980s. Human error is widely considered to be the major cause for most accidents today. Detailed analysis of various incidents indicates that reduced staffing levels in control rooms and inadequate operator training with complex automation strategies as common reasons for human errors. Therefore, there is a need to develop deeper understanding of human errors as well as strategies to prevent them. However, similar to hardware failures, traditionally human error has been quantified using likelihood approaches; this viewpoint abnegates the role of the cognitive abilities of the operators. Recent studies in other safety critical domains (aviation, health-care) show that operator's level of situation awareness as inferred by eye tracking is a good online indicator of human error. In this work, a novel attempt is made to understand the behavior of the operator in a typical chemical plant control room using the information obtained from eye tracker. Experimental studies conducted on 72 participants reveal that fixation patterns contain signatures about the operators learning and awareness at various situations. Implications of these findings on human error in process plant operations them are discussed.

An extended HAZOP analysis approach with dynamic fault tree

An extended hazard and operability (HAZOP) analysis approach with dynamic fault tree is proposed to identify potential hazards in chemical plants. First, the conventional HAZOP analysis is used to identify the possible fault causes and consequences of abnormal conditions, which are called deviations. Based on HAZOP analysis results, hazard scenario models are built to explicitly represent the propagation pathway of faults. With the quantitative analysis requirements of HAZOP analysis and the time-dependent behavior of real failure events considered, the dynamic fault tree (DFT) analysis approach is then introduced to extend HAZOP analysis. To simplify the quantitative calculation, the DFT model is solved with modularization approach in which a binary decision diagram (BDD) and Markov chain approach are applied to solve static and dynamic subtrees, respectively. Subsequently, the occurrence probability of the top event and the probability importance of each basic event with respect to the top event are determined. Finally, a case study is performed to verify the effectiveness of the approach. Results indicate that compared with the conventional HAZOP approach, the proposed approach does not only identify effectively possible fault root causes but also quantitatively determines occurrence probability of the top event and the most likely fault causes. The approach can provide a reliable basis to improve process safety.

Building the Foundations of Process Safety in Design

This article, written by Special Publications Editor Adam Wilson, contains highlights of paper SPE 170442, “Building the Foundations of Process Safety in Design,” by James Jessup, SPE, Julian Barlow, Damian Peake, and Manoj Pillai, Shell Global Solutions, prepared for the 2014 SPE Middle East Health, Safety, Environment, and Sustainable Development Conference and Exhibition, Doha, Qatar, 22–24 September. The paper has not been peer reviewed. The maximum level of process-safety performance an operational asset can attain is set indelibly in the early stages of a project. This is why it is crucial to lay a solid foundation for process safety during design. Before embarking on front-end engineering design (FEED) of the Al Karaana petrochemical project, a behavior-based process-safety program was created with the aim of entrenching process safety in the hearts and minds of design engineers and positively influencing behaviors. The nine foundations of projects process safety form the cornerstone of the program. Dangers Concealed in Design Over the past several decades, industry attentiveness to asset integrity and process safety has progressed. The advancement of industry codes and standards and governmental regulations improving the prescriptive minimum requirements in facility design has served to elevate the general level of asset process-safety performance. On an industrywide basis, during the 20th century, process-safety improvement was influenced initially by fundamental regulations and subsequently by technology, management-system implementation, and more-refined codes and regulations, which have served to improve the performance of process safety. However, little comfort can be taken from this general improvement; the continued occurrence of catastrophic incidents is a stark reminder that further strides need to be made. What should give engineers and designers pause for thought is that many of these catastrophic incidents in the operational phase have root causes in design and could have been avoided with proper attention. The contribution of errors in design is significant. Of accidents reported to the EU Major Accident Reporting System, statistical analysis shows that design inadequacies are present in approximately 70% of them. The company has compiled data from recent capital projects on items or issues that could have adverse effects on safety, production, quality, or costs and could subsequently affect successful commissioning, startup, and first-cycle operation of new facilities. Of these flaws experienced in projects, it has been suggested that nearly half have their origins in design stages (Fig. 1). These have resulted in, among other consequences, process-safety incidents that could have been avoided with effective consideration in design. A minor error or oversight in a design document can often be the source of a future process-safety incident. If the root cause of most incidents can be traced back to design, it is evident that a focus on the activities that take place in an engineering design office is imperative for delivery of a safe performing asset.

Towards predicting human error: Eye gaze analysis for identification of cognitive steps performed by control room operators

Today's plants use highly reliable equipment, state-of-the-art automation and control, and deploy sophisticated safety management regimes so as to make accidents rare. Despite these measures, a number of recent accidents point to the continued need to improve process safety. Various studies indicate that more than 70% of the accidents in process industries originate from human errors. Traditionally, human reliability is accounted for by using Human Error Probabilities, which emphasizes inevitability. In this work, we demonstrate that eye tracking serves as a reliable sensor of various cognitive tasks performed by the operator while managing process abnormalities. Experimental studies conducted on 11 participants reveal characteristic fixation patterns that contain information about their cognitive ability to orient, diagnose and execute recovery actions during abnormal situations. These results hold promise for predicting incipient cognitive failures which in turn would enable proactive measures to prevent human error.

A call to action—next steps for vision 20/20

Process safety protects and enhances our individual health, our company's success, and our region's business economy. Companies that handle toxic, flammable, and explosive materials understand the importance of process safety and risk management. So do regulators. So should the community and other stakeholders. Individually, these stakeholders have been working for years to improve process safety performance. Accidents continue to occur. It is time to leverage our resources, knowledge, and skills to all strive for a common goal of great process safety performance. CCPS's Vision 20/20 describes that vision, which calls for effort from individual companies and effort that goes well beyond any individual company, indeed beyond the industries. © 2015 American Institute of Chemical Engineers Process Saf Prog 34: 111–118, 2015