(40t) Is It Really Operator Error? a Forensic Analysis

Often the go-to cause for a deviation of a parameter during a Hazard and Operability Analysis (HAZOP) or other types of Process Hazard Analysis (PHA) is operator error. Is this really the cause? It is important to identify the root cause for the deviation. Failure to identify this may lead to inadequate safeguards and recommendations.

While there are times when operator error is the only cause of the deviation, more often than not, it is used as a catch-all issue and often too vague, confounded or misleading. In many cases, operator error is not the issue and other causes need to be further investigated. Even if the root cause was operator error, common safeguards or recommendations for this would likely include vague procedures, training and accountability. It is important to find the actual cause for the operator error. This will give the PHA team the ability to review the safeguards and recommendations to determine if they are adequate to prevent the error.

A simple example of this is adding the wrong material to a batch reactor. This certainly be identified in a PHA as operator error. However, cause of the error can be for a very different reason. Such reasons can include unclear procedures, mislabeling of materials, missing labels, material availability and accessibility, failure to document past additions or a host of other causes.

Depending on the cause, the safeguards and recommendations for the example above can be tailored to the project to prevent the incident from occurring. This may include multi-disciplinary and cross-team review of procedures so any errors or existing bias can be identified and corrected. Simplified labeling of drums with devices such as RFID tags, barcodes or QR Codes that will verify if it is the right chemical and document the additions.

It is important during a PHA, that the root causes of a deviation are correctly identified so that existing safeguards can be evaluated, and the right recommendations can be made to prevent future deviations. This will likely require a deeper dive during the PHA. Identifying the precise and accurate causes deviations other than operator error during a PHA will take some practice. This presentation will identify the types of deviations that are typically reported as caused by operator error and provide tips and methodology to quickly identify the causes.