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Human Factors: Preventing

Catastrophic Human Error in

24-Hour Operations
Peggy Westfall-lake
Williams Inc., One Williams Center, MD 17-5, Tulsa, OK

Human factors can play havoc with quality of taskperfOrmance in safety-sensitiveoperations, especialb those that
run 24-hours, 7-daysa week. Research across multiple i&tries indicates common threadi ofobservableandpreventable
behaviors that can lead to catastrophic events. Fati monotony, overwork anda r n u l t i d of other culturaIg
factors and
organizationalpolicies can trij-ger these mental andpkysical
human errors. with recent extensive capital investments in
hardware andsof2ulare to automate continuow operutions, the
human operating the controls may become complacent and
fail tope$nn as antidpated
Since the chemicalplant, maritime, aviation andspace
disasters of the mid-1980$,there has been an increasedfocus
on operationalproceduws. operatinalfatip has been on the
National Transportation Sa$ty Board? list o Most Wanted
TransportationSajiq Improvementssince the ish inception in
I990 [l]. Edij it m y be time to re-visit humanf m n and
focus on the human in operational settinp in all modes of24hour operations. The key is tof;rst u h t a n d two strategies to
prevent shzf2work-related human mo~.Thejrst strategy is at
the organizationallevel where we can ali uman resource
and safety policies, address aging needs t rough better shift
scheduling, develop workhest guidelines and design wellness
obectivesto enhance 24-bour saf pe$rmance. The second
strategy is at the o erational leve where emphyees recognize
personal set-ups or buman error and take the appropriate
measures. These skills are learned through ptipe countermeasure training Both stratepks will be disnrsed throughout
this artick




The human factors umbrella covers three familiar

relationship areas that include: co-workers, processes
and procedures, and equipment.

with Co-workers
Research indicates that as duty time approaches 14hours post-waking, individual acuity and motivation
Process Safety Progress (Vol. 19, No.1)

may decrease. Shift change communications may

become difficult as o n e crew comes in to work
fatigued and one crew experiences get home-itus,
leaving the on-coming crew with limited details on
the previous shifts operations. Also, without proper
Crew Resource Management training, team members
may not have effective relationships to intervene in
unsafe acts with each other. As fatigue levels increase,
physical and mental motivation decline.
The lowest dip in the circadian cycle requires the
highest team alertness and team performance.

As duty time increases or as individuals work into

the circadian danger zones (2am to 5am, or 2pm to
5pm), even routine tasks can become more difficult to
perform (Figure 1). During the late night, even if they
are able to ward off sleep, fatigued employees may be
prone to skipping steps in procedures or forgetting
tasks altogether.
Simple tasks performed frequently may continue to
be performed well while fatigued, but tasks outside of
normal may become dangerously challenging. Wellwritten procedures are part of the first strategy to
improving 24-hour safety. The human factor of shiftwork, shift changes and fatigue should be captured as
separate items in procedures and discussed during
critical task pre-shift meetings.

Very often, shiftwork employees may capture false

readings on displays when drowsy. These readings
are recorded and documented for workers on the
next shift, possibly not relating the actual conditions
of the equipment. Misreading numbers, mis-judging
levels or distances while operating equipment, misoperating controls are all common human equipmentrelated errors. In addition, ergonomists have played a
major role in repetitive strain disorders minimization
at work stations, many of these disorders caused
Spring2000 9

In 24-Hour Operations,
Circadian Set-Ups Around the Clock!








Figure 1. Danger Zones illustrate low periods of the 24-

hour day. Body temperature at lowest points

along with acuity of judgment and alertness.
Extra steps are needed to assure alertness and
adequate communications, critical tasks should
typically not be scheduled during these periods.
betended shifts, stressed job tasks, improper posturing
or technique. As employees fatigue during shifts, they
may revert to previous practices. Ergonomists should
ensure that they visit shiftworkers mid-way and at the
end-of-shifts to get the real picture.

While the previous three areas of human factors

provide a plethora of opportunities to engineer-in
safety, t he r e is a not her area that focuses o n the
human. This fourth area is truly in the second strategy.
It targets a n individual's o wn situational awareness
and realistic critiquing of h id h er alertness, physical
performance ability and mental acuity. Competency in
these areas can enhance performance in safe plants
and dramatically reduce the occurrences of 24-hour
related human error.

Re-structuring has added to the stress of managing

safety in the 24-hour facility. Moderate overtime levels of

20% have increased to 30 to 40% in the past several years

due to reduced manpower and increased production.
Schedules that we re implemented back in the
1980's (such as the EOWEO, every other weekend off,
or the 7-day break) may become difficult to manage
with increased overtime a n d the aging workforce
vacation issue (Figure 2). Some of these schedules are
intolerant to overtime, causing more fatigue and disruption of homelife. Managing training becomes
impossible as employees fail to retain knowledge and
dread the training setting.
Personal health, financial, team, business strategies
and other pressures can lead to stressful situations for
straight day workers. For shiftworkers, this stress can
lead to high human error risk exposure and high levels of cardiovascular illness. Sleep disorders add to the
risk exposure for 24-hour employees.
Set-ups such as these can lead to human error slips,
both mental and physical errors. And finally, this chain
may lead to a near-miss, a n accident or catastrophic
event. Often, there are multiple set-ups or links to the
Chain of Error (Figure 3 ) prior to the accident. These
errors can occur at the same time as other errors, hours
previous to the final error (such as the shift previous), or
even days, weeks or months previous to the event (such
as the overtime levels of key personnel, the decisionmaking process, final committee decisions). Also, individual set-ups of excessive fatigue can lead to cardiovascular problems and sleep disorders, or even social problems with family members, which can then trigger
fatigue-related human errors.
There are many opportunities for improvement in
this area that can not only dramatically impact safety,
but also employee wellness, worker's compensation,
absenteeism. morale and other areas as well.

Sleep disorders i.e. sleep apnea can increase accident potential for employees in safety-sensitive operations; but this can also include straight day workers

Links in the Chain of Error

12 Hour Fast Alternating EOWEO

Sun 1 Mon
D !

Tues I Wed


' N i N

Fri I Sat

FIGURE 2. EOWEO - Popular 12-hour schedule allowing

for every-other-weekend-off, rotates six times

in one month. Limited sequences of nightshifts, consistent pattern. As it is configured,
the schedule is not conducive to overtime, but
it can be modified to allow better circadian
10 Spring 2000

FIGURE 3. Chain of Error model used to illustrate set-ups,

leading slips or directly leading to catastrophic


Process Safety Progress (V01.19, N o . 0

training via a cultural behavioral effort, sleep and

sleep disorder training and assessment, and time-off
The F.A.S.T. Tracking System [31 is a 4-quadrant
program (Figure 4) based on NASA astronaut training,
crew scheduling constraints, current chronobiological
research and industrial application.
The F.A.S.T. Tracking program was designed with
the track of the NASA space shuttle in mind and to
serve as a vehicle to promote a balanced delivery of
safety and performance wellness. When an individual
effort is made in one area of the quadrant, the results
can be seen in the other three areas as well. This is
called a spin-off effect that can enhance overall motivation and performance.
A F.A.S.T. Tracking project at any facility indicates
that a highly strategic effort has been made by safety,
engineering, human resources, wellness and operations departments. This alignment of objectives and
resources is a powerful team effort.

The FAST Tracking System!

OPPORTUNITIESto reduce human error!

Based on NASA astronaut training and
current human performance research.


FIGURE 4. Illustration represents the F.A.S.T. Tracking

system to enhance safety, communications and
wellness in 24-hour facilities. F.A.S.T. Tracking
utilizes a theme-based, motivating format
comparing industrial operations settings to that
of the shiftworking shuttle crew in orbit.

who drive vehicles to and from work. According to a

1998 article in the International Journal of LegalMedicine
major incidents (accidents) are preceded by selfawareness of sleepiness well beforehand and typically, subjects reach the state of fighting sleep when
these incidents happen. Even the most physically-fit
and experienced driver, when fatigued, goes through
the fightingstage to ward off sleep.
Sleep disorders exacerbate the fatigue problem.
The aging shiftworker may experience unique problems due to shiftwork. He may be more prone to
sleeping short segments at a time, and may not receive
adequate rest. Or, he may be unable to sleep during
the day, although his social life provides a more stable
environment than his younger counterparts. Both
younger and older employees may experience sleep
disorder problems and not be aware that they are
treatable and often preventable. They may not be
aware of their fatigue and grumpiness. In case studies,
we have found that many have experienced this jetlag for an entire career, feeling that the grumpiness
and lack of energy is normal. Families become accustomed to walking on egg-shells while the shiftworker
is home. Long-term deprivation can lead to many illnesses and possibly a shorter lifespan of the shiftworker, as well. Once a work crew has reached this
burnout level, it is very difficult to offer solutions such
as new schedules or any type of programs requiring
employee involvement, ideas or enthusiasm.


Fatigue countermeasures should be implemented

in 24-hour, safety-sensitive operations. This may

include fitness and diet training, alertness intervention

Process Safety Progress (Vol.19,No.1)

Very often, a shiftwork assessment can illustrate a

current snapshot of operations and identify areas for
improvement i.e. a relationship between one factory
unit human error trend and shift start/stop times, or
frequencies of drive-home microsleep and overtime.
Further analysis can illustrate demographically areas
for improvement i.e. fixed night shifts, young families
and marital disconnect.
The performance interventions may include a variety of solutions i.e. policy review or adjustment, wellness or sports training, schedule modification, committee involvement, cultural or behavioral training,
shiftwork training for spouses. Sometimes an opportunity can be found within the community with flexible
daycare, flexible college educational sessions, healthcare availability.
Additionally, worWrest guidelines should be established as policy, limiting number of hours worked-ina-row, number of rotations permissible, number of
days/nights worked-in-a-row, number of hours prior
to return-to-shift, and callout procedures. This is best
achieved through education and cross-team involvement and consensus of human resource, safety, operations, wellness and field personnel.
Engineers and decision-makers should keep in
mind that human beings will remain at the heart and
control of our 24-hour operations. It is very critical to
keep in mind that a new shift schedule is not a sole
solution for a 24-hour workforce fatigue problem.
Fatigue, communications and schedule adaptation
training are necessary components of an effective
change management system.
Since technical empowerment is only increasing, so
does employee responsibility and exposure to catastrophic events. The 24-hour worker is empowered
with increasing responsibility to ensure safety and
smooth operations, yet at the same time, he is faced
with personal challenges as he attempts to maintain
peak alertness throughout his shift. A human-centered
operations system that incorporates both strategies at
the organizational and personal levels can prevent priSpring 2000 11

mary back-up inversion and ensure operators keep a

pulse on their personal performance-ability.

International Journal of Legal Medicine (1998).

3. Westfall-Lake, Peggy, et al., Shiftwork Safety
and Performance - A Manual for Managers a n d
Trainers, Publ. CRC Press (1998).

1. Hall, Jim, National Transportation Safety Board

Safety Recommendations, Letter to Honorable

Rodney Slater, U.S. DOT, June 1, 1999, pp. 2.
2. Reyner L.A. & H o m e J.A. Falling Asleep Whilst
Driving: Are Drivers Aware Of Prior Sleepiness?

12 Spring 2000

Thispaper (2Gc) waspresented at the 33rd Loss Prevention

Symposium helddurjng the AIChE Spring National Meeting in
Howton, Tmm, March 14-18, 1999.