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OrganizationaJ
1. Leadership
2. Teamwork
3. Decision Making
4. Safety
Organizational Control
. ........ _ .... ..
- _.._. --- ...... -- .. - . ,. .-. __ \, .:.,.. ..:.. , ...... , .. - ... ..,...
34
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. Situational Awareness
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4. Preventing Accidents bp
Exposure Reduction
3. Trigger Step (with Consequence)
- 1. Verify Configuration (Past)
- 2. Line of Fire
-3. Expected, Unexpected
(Present)
(Future)
53
/ ,,
~ ....... .
OIM's SIGNATURE APPROVING JSEA:
RECOMMENDATION TO ELIMINATE
OR REDUCE POTENTIAL HAZARDS WHO ?
, ''
4. Preventing Accidents bp
Exposure Reduction TechniqueP
3. Trigger Step (with Consequence)
-1. Verify Configuration
- 2. Line of Fire
-3. Expected, Unexpected
'.' D-. r" t'
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{Present)
(FLiture)
66
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Texas City
Isomerization Unit Explosion
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i.CV 5100
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t
''It's not a good hook,
unless you get out and look.''
Saia t o o r ~
Key Finding #3
The negative pressure test was accepted although well integrity had
not been established
Riser--7
BOP --7
Sofloor ~ ,
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Closed
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Spacer
- Seawater
Influx
Shoo -17. lair
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. . .. .... .. . ..
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Influx from Reservoir
through Shoe
Technical Knowledge
Psychology of
Decision-making
Dissimilar Verification
4. Safety bp
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Exposure Reduction
7. Challenge G::c. : Decisions
1. :. , / - (Stop, Hold, Deactiv.):
Often challenged, yet rarely result in
accidents
2. (Go, Launch, Activate):
Rarely challenged, but can result in
accidents
78
_n
4. Safety bp
Exposure Reduction Techniquefi
8. Balance Confidence with Humility
(Individual, Organization)
Health self-doubt- Awareness of Vulnerability
(general); Capture errors, stay alive
True Listen in - Desire to understand others'
opinions; value diversity of thought
Attitude - Performance conversations
81
bp
Exposure Reduction TechniqueP
9. Error-miti ation Techni ues
- 1. Reduce the liken hood of errors,
- 2. Prevent !nc!nier.t error before it occurs or has
consequences,
- 3. l\1iti ate the cor.seauences of errors after they
occur.
12. Error Wisdom
- Encourage analysis of human errors (individually
and group).
82
ULC 11IXD1ST
Disc of 103.1
20:00 Sun 12Jul20011
MSOS 0-075 DlSt l llate
Fl anwnable
SUtF-XRAY 3
NITROG-OIL 3
27 23796 1 / 2
:il ass esJGl oves
lJLC
Due of 103.1
103.JOISC -U
MIXDIST
20: 00 Sun 12- Jul-2009
0-075 M1xed
Fl a'Miat>le
GRAV OMA. 3
SMDST_86 3
2728N& 2 / 2
Glasses/Gloves
ULC
LUC at 134C
103.JOISC-U
LUC
20: 00 sun 12-.lul-2009
1\SOS N-064 Lt Ul tracrack'ate
Flammabl e - cont act
RVP- L.AB F
GRAV-O,"A 3
Sif'V371 0 3
134COIJT
DATE
20-Aug-02
12-0ct-02
12-Aug-02
31-0ct-02
13-May-02
20-Aug-02
27""un-02
4-Jun-02
12-Aug-02
6-Aug-02
12-0ct-02
12-Aug-02
12-Aug-02
4""un-02
26""ul-02
22-May-02
4""un-02
27-Aug-02
13-May-02
20-Aug-02
6-Aug-02
12-Aug-02
27""un-02
6-Aug-02
SYSTEM
CONTROL
CONTROL
DPS
DPS
DPS
DPS
DPS
DPS
DPS
DPS
FDF
GUID
GUID
OMS
RNDZ
BFS
BFS
DPS
DPS
DPS
DPS
DPS
DPS
DPS
MISTAKE
High NRG Gander: After bug < Therm line, didn't reduce Pitch fast enough
Low NRG Cherry Pt: Low to High (didn't follow Guidance after App/Lnd)
BFS recovery: Didn't complete AESP [pro to OPS 3] (TWICE)
BFS recovery: Didn't recognize recovery [pro to OPS 3] (TWICE)
BFS: 102 to 601(w/o 103)
FA2 dn: Didn't take FCS Ch to OFF
IMU: Didn't notice GPC3,1MU2,FF1 fail; Didn't Restring, Reselect IMU3
Set Split took 15 sec to see; (SSME dn simo)
Set Splits: Took too long to get BFS Sys Summ display
Strg 1 2 3 3 - Didn't recog 1/0 Term B, [Look at 3 dn arrow]
3 Out blank: Didn't select TAL
Cue SERC: Misdiagnosed R SSME dn, APU1 dn [Exec if APU 2 OR 3 dn]
Delayed TAL: Invoked at new no-comm bndry before MCC call
Multi DPS ASC: didn't do Man s/d L OMS
Low Z: F1 Manit dn, GPC 3 dn, Selected AUTO before restring
BFS PL 1 dn: Missed 1/0 Term A dn [Use Ack key if CRT in use]
Post Bus Tie: Didn't do 1/0 Reset to BFS
BFS 1/0 Term B failed low: Didn't pause in Norm (tb); didn't realize why Term
BFS: stuck in 102 (strg 3 & 4 dn), didn't see
FA2 dn: After Port mode recovered, didn't do 110 Rst to BFS
FF1 Pwr, No comm -Incorrectly did pwr cycle (w/o "go")
110 Term B: Restring, asked MCC if Stby/Halt needed
Set Split, Set Split: Misdiagnosed signature
Strg 4 trade case - stayed on FF4 (Ent)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
C'. l (\
4. Preventing Accidents bp
Exposure Reduction Techniquef
10. Maintain Positive Control {when
moving objects)
A. Control- Retain control of osition and
velocit ; Never relinquish control.
- Understand - ~ - - - ~ : ._:: __ (incl. automated and au mented
functions, and de raded modes;
-Override system, compensate quickly and accurately
B. Connection - Ensure load is Secured with
physical or mechanical connection (to prevent
undesired collisions)
90
'
,_,.,
i
,.... I
4. Preventing Accidents bp
Exposure Reduction TechniquefJ}
11. Prevent Undesired Collisions
Maintain accurate knowledge of:
1. State vector and control
2. Local environment
r Anticipate conflicts or
collisions
,. Assume the \vors.t
.,. Ne"Jer d tr !\.., '-.'ou can see
_r oJ W - I _, "- - ; " ._ 1 } l "
(and respond\
97
-----------------------------
I
4. Preventing Accidents bp
Exposure Reduction
17. Assessment of Competence
18. Divergence Recognition
L1 in Scope; Hurrying
Unexpected Event I Situation
Abnormal Situation, Minor Failure
Distraction Mitigation, Management
Fatigue; Stress Recognition
105

4. Preventing Accidents bp
Exposure Reduction Techniquef'
19. Mental Preparation
20. Methods to aid weak Prospective
Memory
21. Assertiveness (to Authority}
106
4. Preventing Accidents bp
Exposure Reduction
22. Mindfulness
+ Degrees of Vision {Wide, Focus)
Technical Knowledge
Team Effectiveness {Self, Others)
T -0 Thinking
Intense Concentration
In the Moment (Temporal Horizon = 10 sec}
107
4. Preventing Accidents bp
Exposure Reduction Techniquef
23. Selecting Mental Processes -
Controlled, Automatic
24. Share and Challenge Mental Model
(Self, Others, Board Operators, Central Control
Room)
Use different mental process;
Encourage questioning; Use non-experts
108
.. -
4. Preventing Accidents bp
-- ....
. y
. ~
Exposure Reduction Techniques
26. Think Fast, Act Slow
-Slow down to Speed up
-Never act impulsively
-Multitasking is sequential switching
113
4. Preventing Accidents bp
Exposure Reduction TechniqueP
27. Personal Limitations Cognizance
Self-imposed procedural limit
28. Acknowledgment of Weakness
(Specific)
29. Admission of Error
114