Application of PDCA Check-Sheet and Team Discussion in Reducing Human Errors
CCPS Global Summit on Process Safety
2017
4th Global Summit on Process Safety
2017 Global Summit on Process Safety
Human Factors I
Tuesday, September 12, 2017 - 1:25pm to 1:50pm
There are still near misses caused by human errors in Idemitsu Hokkaido Refinery in spite of our efforts for safe and stable operation through safety assessment, management of change, improvement of operation procedures, etc. In 2016, the number of near misses caused by human errors was 79, some of them had a potential of causing accidents. Therefore, we’re making an effort of prevention of human errors owing to improving the reliability of operation.
Human errors can be mainly caused by the lack of awareness, the shortage of knowledge and skills, the violation of rules, etc. According to the analysis of human errors, we found that most of them were caused by a lack of confirmation and a shortage of individual knowledge and skills. In order to make up for knowledge and skills, we have enforced the ‘know-why’ training (understanding the purpose and the technical background of operations) rather than ‘know-how’ training, and we have developed “PDCA Check-sheet†as the tool to practice understanding ‘know-why’.
In addition, in order to upgrade knowledge and skills and to confirm correct operation, we have utilized the Plan-Do-Check-Act cycle as a model for defining correct work processes. The operators share the information of the PDCA cycle in the team. It can make up for a shortage of knowledge and skills with each other. The PDCA Check-sheet contains important items for correct operations such as checking purpose, correct procedure and roles, hazard prediction, review of the operation and the necessity for revising the procedure. The sheet is managed by the shift supervisor before/after the operation, and should be discussed with team operators. After the team discussion, the operators can share the same understanding of ‘know-why’, and can upgrade not only their knowledge and skills but also their awareness of correct operation and confirmation. Finally, we succeeded in reducing human errors.
In the case of the introduction of the PDCA Check-sheet and team discussion, we have only one near miss caused by human errors in 2016.
Human errors can be mainly caused by the lack of awareness, the shortage of knowledge and skills, the violation of rules, etc. According to the analysis of human errors, we found that most of them were caused by a lack of confirmation and a shortage of individual knowledge and skills. In order to make up for knowledge and skills, we have enforced the ‘know-why’ training (understanding the purpose and the technical background of operations) rather than ‘know-how’ training, and we have developed “PDCA Check-sheet†as the tool to practice understanding ‘know-why’.
In addition, in order to upgrade knowledge and skills and to confirm correct operation, we have utilized the Plan-Do-Check-Act cycle as a model for defining correct work processes. The operators share the information of the PDCA cycle in the team. It can make up for a shortage of knowledge and skills with each other. The PDCA Check-sheet contains important items for correct operations such as checking purpose, correct procedure and roles, hazard prediction, review of the operation and the necessity for revising the procedure. The sheet is managed by the shift supervisor before/after the operation, and should be discussed with team operators. After the team discussion, the operators can share the same understanding of ‘know-why’, and can upgrade not only their knowledge and skills but also their awareness of correct operation and confirmation. Finally, we succeeded in reducing human errors.
In the case of the introduction of the PDCA Check-sheet and team discussion, we have only one near miss caused by human errors in 2016.