(64b) Owning Our Moments That Matter: Supercharged Human Factor Interventions That Guide the Safest Decisions Possible

When bad things happen it’s often asked, ‘How did we get to this?’. The answer is typically ‘one decision at a time’. On Friday May 3, 2019, a significant explosion and fire occurred at the AB Specialty Silicones facility in Waukegan, IL, when incompatible materials were inadvertently mixed, killing four employees and causing damage to other adjacent organizations. When reviewing this incident, as one would expect there are myriad causal factors including those related to human factors. This paper will highlight examples of how this and similar incidents can be prevented when safety management systems are designed with people and their brains in mind. Highly skilled employees make errors in visual recognition (looking but not seeing), typically rely on habits and assumptions that have worked in the past when doing similar work. These habits vary widely in level of risk perception and risk acceptance when not aligned to an embedded site or company standard. So, what can be done to fend off disaster when imperfect systems collide with an eroded process safety culture, and employees not well practiced in detecting critical errors in the making? A practical understanding is needed, regarding how Brain-Centered Hazards (internal states like fatigue, distraction and autopilot) foster error-prone conditions to naturally develop over time and cause important situational cues to be missed in those moments that matter most.

This paper will provide:

• A review of the decision science that typically plays out leading to significant unplanned events including LOPC, and how decisions can be systematically influenced for safe outcomes
• Information on how Brain-Centered Hazards act as precursors to critical performance errors that impact operations and company brand/reputation
• Examples of human factors interventions that can prevent incidents like the case study reviewed