A Breakthrough Book in Error Reducing Safety Design.

This comprehensive 637-page book identifies two root causes that remain persistent contributors to major industrial accidents.

The first is the absence of published standards and practices that can repeatably and reliably prevent designed-in error types that are common causal contributors to major industrial accidents. Error types discussed here are those that mislead or degrade human performance. Prevention and mitigation requires new methods and tools underpinned by cognitive ergonomics and engineering psychology.

The second is the absence of a global standard dedicated to the design and lifecycle management of human-dependent, safety-critical functions, barriers and tasks. 

Inside, you’ll learn how and why the lifecycle model in the book and the proposed new standard are urgently needed. Both are essential to achieving a commonly stated global goal to eliminate primary causal contributors to major accidents.

The Deepwater Horizon accident triggered a global response.

It resulted in 11 fatalities, 17 injuries, long-term damage to a regional coastal ecosystem, and fines, penalties and other costs exceeding $60 billion dollars. 

In response, industry experts and organizations published recommendations and identified critical deficiencies in current practice. The model directly responds by adopting the applicable recommendations and preventing or mitigating the identified deficiencies. Further, the entire model is based on best-in-class models, constructs, and guidance from globally recognized experts and sources. For examples on how this was achieved, click “See Examples” below.

The design and lifecycle model performs different functions, depending on the lifecycle phase. 

The model includes 7 lifecycle phases (plus a modify phase) noted in the figure below.  This structure fully aligns with the dominant project execution models used across the globe.  

Model processes methodically and fully define, specify, design, implement, construct and verify every safety barrier, function or task and does so at the physical, human and organizational element level. It deploys solutions that fully address the environment and situations in which these activities take place. It defines and addresses the external systems and barriers on which each activity depends. New and modification to existing processes address time, display and workspace design, performance influencing factors, and verification and validations. A new cognitive assessment process achieves a level of assessment that is not possible with any other published process or tool. It looks for task demands that are inconsistent with normal human capabilities. Collectively the processes and tools are innately designed to reveal and address the cognitive demands placed on personnel, and the human resources and competencies needed to achieve activity success. Developed for use in capital projects, the model integrates best practice guidance to understand and explain the ‘who, what, and why’ challenges that must be addressed to assure project success.

In total, the full design and lifecycle model comprises 136 unique processes:

A – Conceptual design –  2

B – Preliminary design (FEL) –  27

C – Detailed Design and Engineering –  20

D – Procurement, fabrication, personnel & organizational elements –  25

E – Construction, installation & commissioning  – 33

F – Operate & Maintain –  29

The operate and maintain phase processes monitor and maintain human dependent safety functions to assure conformance to requirements for the full life of those functions. Example monitoring processes look for an seek to monitor and mitigate fatigue management, skill fade, drift in procedure use, and many more Others assess and monitor the effects of corporate and management leadership, safety culture, personnel management, O&M budgets, and competency and training programs. 

All facilities that process, store, or transport hazardous materials or perform dangerous activities rely on human-dependent safety functions to prevent, mitigate or respond to hazardous scenarios that place people, the community, or the environment at risk.

These functions have failed because the employed design methods introduced designed-in errors that mislead and degrade human performance. In the operate and maintain phase, seemingly minor deviations and problematic human behaviors can also lead to function failure if not detected and corrected.

A lack of knowledge and application of cognitive ergonomics and cognitive science assures those failure mechanisms and scenarios remain opaque and undetected. Unfortunately, the available training courses available to practitioners remain woefully deficient in those areas.  

It certainly seems plausible, if not likely, that the pattern of major accidents from the last half century will persist into the next.

When a major accident happens, investigators assess the accident, identify what they believe to be the accident root cause, and offer recommendations they believe will prevent or mitigate those causes in future systems. Implemented recommendations from the Deepwater Horizon accident reports did not achieve the intended improvement in human-dependent safety functions. The report used the term contingent barrierto refer to these function types. Perhaps, the investigators did not adequately consider cognitive ergonomics and engineering psychology in their investigation and recommendations.

Without a breakthrough, it seems plausible if not likely this cycle of safety critical function failures will persist into the next decade.  Further, the risk and consequences of incidents and accidents are increasing. Facilities are increasing in size, complexity, and reliance on complex new technologies and methods. Exposure to more severe environments ialso occurs as facilities move to more challenging environments and feel the potential effects of climate change.

Major accidents lead to litigation.

Common to such accidents, humans are often unwitting elements in the accident causal change.   To date, the offending organizations may receive a partial or full exoneration from fault from the most severe consequences by showing their conformance to regulations and ‘good engineering practice.’

What is changing is an emerging global awareness that current standards and practices have not and probably cannot create and manage human-dependent safety functions that meet the desired reliability and performance requirements. There seems to be little agreement on what changes are needed to achieve that end. Historically, injuries and fatalities caused by poor design in physical equipment (e.g., poor physical ergonomics application) can and do lead to litigants seeking and winning cases that result in damages and penalties.  At some point, the same will occur when expert witnesses (cognitive ergonomics and engineering psychology) provide science-guided testimony that identifies the persistent and readily preventable designed-in errors in human-dependent functions.

Outcomes benefiting litigants may increase if an offending organization ignores the intentions of a regulation or standard that recommends a more efficacious approach that is not mandatory, e.g., API RP 75, 4th edition. Being non-mandatory, US regulators lament their inability to assess those aspects even though history indicates them to be contributors to incidents and accidents. This is occurring on the heels of published industry white papers and call-to-action articles that acknowledge deficiencies in current standards and practice and indicate an industry that is aware of the situation and sources of failure.

Should the next major accident occur, feigned Ignorance and letter-of-the-law conformance to regulations and standards may be an insufficient legal argument.

This becomes more likely if the accident causal contributors resulted from the continued use of known-deficient standards and practice.   

Employing the best-of-class models and expert guidance, this book presents the mindset, knowledge, and solutions that shows why and how those causal contributors are preventable.

The book provides information to gain an understanding of cognitive ergonomics and engineering psychology and their application to human-dependent barriers, functions, and tasks.

Model processes are fully described and explained.  Topical analysis, new tools, comparison to existing practice, examples, and additional information contributes to the reader’s understanding of the cognitive ergonomics and cognitive science behind each process.

The book provides a crude but useful self-assessment tool to gauge one’s current level of progress in this journey using a six-level scale. Many may be at level 1 or 2. The book provides the information, guidance, processes and tools to achieve forward progress towards each level.

Download Chapters 1 & 8

Chapter 1, Introduction: 

• Intended audience
• Lifecycle model application
• Content and organization
• Industry insights and recommendations
• Suggested companion guides to this book
• Suggestions for readers with different interests

Chapter 8, The Case for Developing a New Standard for Active Human Barriers

• Deficiencies in current knowledge, standards and practice
• A Suggested Path Forward – Develop and New Global Consensu Standard

Structured for Usability & Comprehension