7.Scott Berger- human reliability and process safety culture.ppt

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1、Human Reliability and Process Safety Culture人员的可靠性和化工工艺过程安全文化Scott BergerExecutive DirectorCenter for Chemical Process SafetyScott Berger美国化工过程安全中心美国化工过程安全中心执行董事执行董事 Presentation to:至：The 3rd China International Forum on Petrochemical Industry Operation in Safety:Process Safety Symposium第三届中国石油和化工安全

2、国际论坛 暨化工工艺过程安全研讨会Zuhai,May 9,20092009年5月9日，珠海Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersAbout CCPS 美国化工过程安全中心美国化工过程安全中心简介简介Formed in 1985 as Chemical Engineering professions response to Bhopal and other tragic accidents于1985年成立，作为化学工程行业的代表以应对印度博帕尔事件和其它重

3、大事故Technical association organized within American Institute of Chemical Engineers(AIChE)美国化工工程师协会（AIChE）下属的技术协会 Nearly 125 member companies worldwide in 约有125个公司成员遍布全球：chemical,hydrocarbon,pharmaceutical,and diverse manufacturing 化工、碳氢化合物、制药和各类制造企业engineering companies and government agencies 工程公司以

4、及政府机构CCPS China Section established 2007CCPS中国分部于2007年成立Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersHuman Error?人为错误？Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical Engineers4People make misteaks!人类也会犯错！Making a Power Poi

5、nt Slide 制作一张幻灯片Calling the wrong telephone number 拨错电话号码Failing to see the red traffic light 没看到红灯Dipping into the wrong sauce蘸错了调味料Making a math error 做错一道数学题Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical Engineers5Under good conditions,mistakes are not frequent良好

6、的状态下，不会出现很多失误Moderate Stress:Many tasks required 适度压力：必须完成很多任务Following a written checklist 依照一张书面的清单进行操作No independent check 没有单独的检查Human Error Probability 0.03 0.003人的误差概率 0.03 0.003Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersBuilding Layout 装置布局图Secon

7、d set of reactors on opposite side of stair well楼梯井的另一面配有第二套反应釜防火墙楼梯井上面的聚合物操作工下面的爆破工Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersSequence of Events事故发生的顺序Operator descended stairs with several turns 操作工下楼时转了几个圈Went to wrong reactor 走到另一个反应釜了Used“emergency

8、”air hose to actuate the bottom valve使用“紧急”空气软管开动了底阀Hot solvent and polymer discharged onto floor 灼热的溶剂和聚合物流到地板上Ignition occurred 流出的物体被引燃Operator and 3 coworkers were killed 导致一名操作工和三名工人死亡Stair well 楼梯井Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical Engineers8The Re

9、lease 流出的液体Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical Engineers The Aftermath 严重的后果Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical Engineers10Preventing this kind of accident?能否防止此类事故的发生？Moderate Stress:Many tasks required适度的压力：必

10、须完成很多任务Checklist used 已使用清单An independent second check is used 也有单独的二次检查Radio check with other operator 与另一位操作工通过无线电检查Check of reactor number written into procedure 反应釜编号的检查，已写入操作程序The step is written and not committed to memory操作步骤虽然已经写入程序中，但是未能真正记入大脑中Human Error Probability 0.01 0.001人的失误概率人的失误概率

11、0.01 0.001Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersPreventing this kind of accident?能否防止此类事故的发生？Moderate Stress:Many tasks required适度的压力：必须完成很多任务DCS instructs valve to close 集散控制系统指示关闭阀门Valve proofed closed 阀门已被确定关闭Sequence table checks for expected w

12、eight gain 依照顺序表进行检查，确定是否有重量的增加Human Error Probability 0.001 0.0001人的失误概率 0.001 0.0001Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersPreventing this kind of accident?能否防止此类事故的发生？Why was an“emergency air hose”present at the base of the reactor,with the exact

13、 fittings to override the pneumatically actuated valve?为什么“紧急空气软管”会出现在反应釜的底部，而该装备正好会超驰控制由空气推动开启的阀门？Because bottom valves frequently failed closed?是因为底阀经常难以关闭？Because the level interlock frequently failed high?还是因为水平的联锁装置经常出现故障？Why did the blender operator not check with the reactor operator when he

14、couldnt open the valve?在不能开启阀门时，为什么掺混工未能与反应釜的操作工进行确认？Too lazy to go back upstairs?懒于再次上楼询问？No radio?没有无线电？He was used to connecting the emergency air hose?他已习惯于用紧急空气软管连接？Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersPreventing Accidents 预防事故的发生Good enginee

15、ring alone would not have prevented this accident,nor can it prevent accidents in general良好的技术设备本身并不足以防止此类事故的发生，也不足以预防多数事故A robust HSE management system operated along with good engineering would help prevent the accident,but would not be sufficient健全的环境、健康和安全管理体系以及良好的技术设备可以共同预防事故，但是同样不足以预防所有事故的发生Th

16、e third essential element in preventing accidents is a strong process safety culture第三个重要因素就是建立有力的过程安全文化Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersWhat is Culture?什么是文化？The combination of group values and behaviors that determine the manner in which pro

17、cess safety is managed 决定过程安全的管理方式的一种团队价值观和行为的组合“Its how we do things here”如何做事？“Its what we expect here”期待的目标是什么？“How we behave when no one is watching.”当没人监管时，我们会如何表现？Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersWhere does a Companys Process Safety Cult

18、ure Come From?公司的过程安全文化的起源？National culture 国家文化Regional culture 地区文化The history of the plant 工厂的历史Your leadership 你的领导才能Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersWhose responsibility?谁的责任？“The only thing of real importance that leaders do is to create

19、 and manage culture”“领导者所做的唯一重要的事就是创造并管理文化”Schein,E.H.,Organizational Culture and Leadership,3rd Ed.Schein,E.H.，组织文化与领导，第三版Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersSix Ingredients for Culture文化的六大因素1.Maintain a sense of vulnerability 保持敏感意识2.Combat no

20、rmalization of deviance 防止偏离正常化3.Establish an imperative for safety 建立安全规则4.Perform valid/timely hazard/risk assessments 实施有效的/及时的危险/风险评估5.Ensure open and frank communications 确保开放且坦诚的交流6.Learn and advance the culture 学习并推进文化的进一步发展Copyright 2009,Center for Chemical Process Safety,American Institute

21、of Chemical EngineersMaintaining a Sense of Vulnerability 保持敏感意识A shared recognition that the business is hazardous and care must be taken always大家公认：这个行业很危险，因此应该时刻保持警惕 Did the blend operator have a sense of vulnerability?那么这位掺混操作工是否具有敏感意识呢？Copyright 2009,Center for Chemical Process Safety,American

22、Institute of Chemical EngineersMaintaining a Sense of Vulnerability 保持敏感意识Strategies:战略：Communicate potential consequences传达潜在的后果Maintain vigilance for potential weaknesses对可能出现的薄弱环节保持警惕After near-misses,ask“How bad could it have been?”在未遂事件发生之后，试问“如果发生了，后果将会有多糟糕”？Copyright 2009,Center for Chemical

23、Process Safety,American Institute of Chemical EngineersCombating Normalization of Deviance 防止偏离正常化Tolerance of a small deviation from safe behavior,leading to accepting increasingly large deviation:this is called“Creeping deviation”对小的不安全行为的容忍，将会导致接受越来越大的偏差，即“蠕变偏离”What large deviation from safe beha

24、vior had the blend operator come to tolerate?这个掺混操作工将会容忍多大的不安全行为呢？Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersCombating Normalization of Deviance防止偏离正常化Strategies:战略：Zero tolerance for violating“cardinal rules”对违反“基本规则”行为的零容忍Be alert for work-arounds and

25、 unusable procedures对临时的解决方案和不能使用的程序保持警觉Establish standards and reinforce them建立标准并使其得以补充加强Discuss case histories and lessons learned讨论案例发生的过程并从中汲取教训Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersEstablish an Imperative for Safety 建立安全规则It should be clear t

26、o all employees that nothing takes precedence over safety所有的员工都应十分清楚：安全第一Was this clear to the blender operator?这位掺混操作工明白这一点吗？Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersEstablish an Imperative for Safety建立安全规则Strategies:战略：Defer to expertise 遵从专门知识Place

27、 a value on knowledge and development 重视知识和发展Communicate core values frequently and at all levels 经常全方位地沟通核心价值观Ensure all know responsibilities to self and coworkers 确保所有员工知道自己和同事的职责Create group intolerance for unsafe acts/situations 建立整个团队对不安全的行为/状况的不容忍习惯Never place an employee in a position where

28、he or she must prove a situation to be unsafe不要把员工置于一个他/她认为不安全的状况中Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersPerform Valid/Timely Hazard and Risk Assessments实施有效的/及时的危险和风险评估Do you think the plant identified the hazard enabled by the“Emergency air hose?”

29、你认为工厂能否发现“紧急空气胶管”造成的危险？Why didnt the blender operator assess the potential hazards of over-riding the valve?为什么掺混操作工未能评估超驰阀门的自动控制所带来的潜在的危险？Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersPerform Valid/Timely Hazard and Risk Assessments实施有效的/及时的危险和风险评估Strateg

30、ies:战略：Use formal methodologies 使用正规有效的方法Establish a credible schedule and enforce it建立合理可信的时间表，并积极执行该时间表Address action items timely及时完成行动项目Provide for quick communication and response to interim concerns迅速沟通并解决临时出现的问题Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical E

31、ngineersEnsure Open and Frank Communications确保开放且坦诚的交流Companys management has strong process safety policies and reports its performance publicly公司的管理方面应制定有力的过程安全政策并公开通报其工作成果 Why was the blender operator unaware of his companys strong support of process safety?为什么这位掺混操作员未能意识到该公司对过程安全的高度重视呢？Copyright

32、 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersEnsure Open and Frank Communications确保开放且坦诚的交流Strategies:战略：Promote four-way communication 促进全方位的交流沟通Create trust between management and staff建立管理层和员工之间的信任Monitor communication effectiveness监管沟通的有效性Copyright 2009,Center

33、 for Chemical Process Safety,American Institute of Chemical EngineersLearn and Advance the Culture学习并推进文化的进一步发展This company had another accident which revealed the same culture gaps only nine months before仅仅九个月之前，该公司又因同样的安全意识方面的差距发生了另一起事故Copyright 2009,Center for Chemical Process Safety,American Ins

34、titute of Chemical EngineersLearn and Advance the Culture学习并推进文化的进一步发展Strategies:战略：Continuous monitoring of performance对工作业绩的持续监管Clear metrics,with response as needed建立清晰的衡量标准，适时执行Frequent communication of policies,mission statements,and expectation经常传达公司政策、使命说明以及奋斗目标Obtain outside view of culture学

35、习其它公司的文化Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersSome Telltale Signs of a Culture Problem一些文化问题的警告信号Management says,“Process Safety?Yes,_管理人员说：”过程安全？有的，_we follow the regulation”我们遵守规则we do a lot of HAZOPS”我们进行了很多危险与可操作性研究we have an HSE management sys

36、tem 我们拥有环境、健康和安全管理体系we havent had an accident in years”我们已经很多年没有发生事故了Frequent production outages 经常发生停产Close calls,many drips,spills and emission“puffs”侥幸脱险的事件、液体的溢漏、烟尘的排放Poor housekeeping 设备的保养不到位Management and workers give different answers to questions about safety 管理人员和工人对有关安全的问题回答不一致Workers dis

37、agree with statement,“my supervisor cares about me”工人并不认同：“我的主管很关心我”Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersDo any of these conditions exist at your plant?你所在的工厂有以下情况出现吗？Complacency due to“good enough”safety performance安全业绩“已经很好了”的自满的心态Normalizing de

38、viance from safety critical requirements对安全方面的关键要求的偏离行为不闻不问，造成其经常发生Ineffective Hazard/Risk Assessments of systems无效的危险/风险评估体系Reversing the Burden of Proof when evaluating safety of operations 在评估操作行为的安全性时，倒置举证责任Employees Not Speaking Freely of their safety concerns员工不能自由地说出他们的安全方面的疑虑Business Pressur

39、es at odds with safety priorities经营的压力与安全第一的理念发生冲突Failure to Learn and apply learnings to improve culture未能学习并应用知识，以提升文化Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersSummary小结Process safety is good business过程安全，值得你的投入和付出The best technology is no match for

40、a poor culture安全文化（意识）的建立比任何高科技都有效If youre not improving,youre going backward（逆水行舟），不进则退It all starts with Leadership一切都起源于领导的能力Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersResources 资源Process Safety Culture Toolkit 过程安全文化整套资源CCPS website:www.ccpsonline.o

41、rgCCPS网站：www.ccpsonline.orgCCPS“Guidelines for Risk-Based Process Safety”CCPS基于风险的过程安全导则 Chapter 3:Process Safety Culture 第三章：过程安全文化Chapter 6:Workforce Involvement 第六章：全员参与Chapter 22:Management Review and Continuous Improvement第二十二章：管理评审和持续改进Available at 请参见The Business Case for Process Safety 过程安全的

42、商业案例CCPS website:www.ccpsonline.orgCCPS网站：www.ccpsonline.orgCopyright 2009,Center for Chemical Process Safety,American Institute of Chemical EngineersContact information联系信息Scott BergerExecutive Director,CCPSAmerican Institute of Chemical Engineers Scott Berger美国化工过程安全中心美国化工过程安全中心执行董事执行董事 Three Park

43、 AvenueNew York,NY 10016 USA美国纽约派克大街第33大街scotbaiche.org+1.646.495.1370Liu Yi 刘义CCPS China Sectionc/o China University of Petroleum(Huadong)刘义CCPS中国分部，由中国石油大学（华东）转交Qingdao,Shandong Province,China中国山东省，青岛市+86 13854683496 Copyright 2009,Center for Chemical Process Safety,American Institute of Chemical Engineers