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Human Factors in Process Plant Operation by David A. Strobhar

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3

Performance Shaping Factors

In the 1980s, we were typically asked to perform a human factors analysis of an event only when there was “operator error” involving the best operator on the unit. An analysis was done where, in response to a heater flange fire at one plant, the best operator in the division inadvertently shutdown the charge pump on the unit at the adjacent console. The analysis highlighted that cases of “operator error” are rarely one-dimensional or random; they involve the interplay of numerous variables that result in design-induced operator error.

The scenario was simple; several units had recently been upgraded to distributed control and moved to a single control room. A flange fire on a fired heater in Unit A was interpreted ...

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