How Aviation and Large-Scale Chemistry Can Enrich Integrated Safety

As the saying goes: two heads are better than one! Similarly, synthesizing experience from two different fields can sometimes provide a new level of understanding on how to manage the negative manifestations of the "human factor."

It so happened that over the years, I was invited to lead and take responsibility for HSE departments in Large-Scale Chemistry (SIBUR invited me to Kemerovo JSC "AZOT", then I was invited to Togliattiazot Corporation). For the last 4 years, I have been leading the HSE function at the invitation of the Central Institute of Aviation Motors (CIAM) and the CIAM Research and Testing Center. Here are the CONCLUSIONS drawn from synthesizing experience in aircraft engine manufacturing, air transport systems (ATS), and the nitrogen industry (NI):

• Despite the improvement of ATS, the number of accidents, incidents, and their danger is not decreasing;
• The share of the "Human Factor" in the causes of both flight accidents and incidents at nitrogen industry enterprises is INCREASING.
• The author's conclusion for understanding the "Vision Zero" concept as applied to complex "Human-Machine Systems" based on aviation experience and work in chemical companies:

- Completely safe systems do not exist;

- all complex systems function despite non-hazardous errors by personnel and technical malfunctions that do not lead to accidents.

In AVIATION, the ratio of design and manufacturing causes of disasters (numerator) to errors by crews and flight support services (denominator) = 1/9 (10% and 90% respectively).

At the NITROGEN INDUSTRY (NI) ENTERPRISES where the author worked, the same ratio was even more pronounced: for example, 4% and 96% for Togliattiazot.

The human factor largely determines flight safety (FS) and aircraft efficiency (according to public data, for instance, the mean time between incidents for the Il-86 aircraft varied by 3.5 times across different airlines).

CROSS-FUNCTIONAL APPROACHES to "VISION ZERO" in ATS and NI

The "VISION ZERO" approach can also be extended to aviation:

• creation of a FAIL-SAFE AIRCRAFT (ENGINE);
• FAIL-SAFETY OF THE OPERATOR (OPERATOR – in general); PRINCIPLE: every crew member can make a mistake, but no single crew error should lead to an emergency situation (each of them has the potential for a group fatal accident).

As in HSE in the NITROGEN (or any other) industry: it is impossible to work without micro-injuries, but we strive for "ZERO" severe and minor injuries (and for a number of enterprises – at least without fatal injuries).

CROSS-FUNCTIONAL APPROACHES to INTENTIONAL violations and UNINTENTIONAL errors

Causes of incidents:

1) INTENTIONAL VIOLATION OF REQUIREMENTS:

a) labor discipline;

b) Flight Operation Manuals/rules for safe work and operation in NI (I do not call them "errors", but "violations"),

2) UNINTENTIONAL ERRORS due to incorrect assessment of situations suddenly arising during flight (engine testing or ammonia synthesis in NI), and as a result, INCORRECT DECISION MAKING.

A common "TREATMENT RECIPE" for ATS and NI for INTENTIONAL VIOLATIONS

The management and motivation system must be built so that a) it is UNPROFITABLE or IMPOSSIBLE to INTENTIONALLY VIOLATE requirements; b) any INTENTIONAL VIOLATION is REGISTERED by OBJECTIVE control means; c) the offender knows that PUNISHMENT IS INEVITABLE.

Ways to prevent UNINTENTIONAL ERRORS

The probability and severity of consequences can be minimized if the design of aircraft/ammonia units is carried out taking into account the limited capabilities of the operator (night flights/shifts, fatigue, time pressure, stress...), just as this should be considered in the work process.

And an integrated management system (IMS) in an organization (it includes the OHSMS) must ensure conditions in the "Human-Machine" system so that a SINGLE FAILURE or a SINGLE OPERATOR ERROR does not cause an emergency situation under all possible conditions (or those specified with a fixed probability).

This means it is necessary to provide for the possibility of parrying a SINGLE FAILURE or a SINGLE OPERATOR ERROR through REDUNDANCY within the OHSMS or IMS.

Subjective factors play a more significant role in the causes of accidents than designers assume.

The operator is prone to errors due to the limitations of their psychophysiological capabilities to resist fatigue, stress...

OPERATOR RELIABILITY also depends, in the author's opinion, on their PSYCHOPHYSIOLOGICAL RESOURCE and QUALIFICATIONS.

The author attempts to consider the functional and physiological resources of the operator along with the functional resources of the equipment (and one must also take into account the established relationships in the existing integrated management system).

And the need for the HSE department to work "side by side" with a psychologist and the HR (Human Resources) department becomes obvious.

In this note, I have only spoken about the negative side of the "human factor." And it can also manifest itself from a super positive side! For example, when the emergency manual did not contain scenarios for landing a passenger plane on water, yet the pilots did not lose their heads and saved the passengers and residents of metropolitan areas by landing the plane on Lake Huron or the Neva River (two well-known cases, for example)! But about the positive side of the notorious "human factor" - in other blogs.