“Closing the Holes in the Swiss Cheese Model”
Layers of protection for abnormal event management can be modeled as slices of swiss cheese according to James Reason. An operator’s response to an alarm is one of the first layers of protection to prevent a hazard from escalating to an incident. This presentation discusses a two-part approach to maximizing the operator’s reliability when responding to abnormal situations (“closing the holes in the swiss cheese layer”).
The first part focuses on following the best practices in the alarm management standards ANSI/ISA-18.2-2016 and IEC 62682. Examples include alarm rationalization to ensure all alarms are meaningful and to capture “tribal knowledge”, prioritization to help operators determine which alarms are most critical, alarm classification, monitoring of alarm system performance metrics, and creation of alarm response procedures. The second part addresses the impact of human factors on operator performance; including how nuisance alarms and alarm floods can lead to errant mental models, attention tunneling, misplaced salience and overall loss of situation awareness. We will also discuss how often “operator error” is really the underlying cause of alarm management incidents.
About the Presenter:
Todd Stauffer
Todd Stauffer, PE, is responsible for exida’s alarm management products and services (training, consulting, SILAlarm™ rationalization software). He is an editor and voting member of the ISA-18.2 standards committee on alarm management and currently is the co-chair of ISA-18.2’s Working Group 3 (Basic Alarm Design). He is an instructor for ISA’s training class “Introduction to the Management of Alarm Systems”. Todd is also exida’s representative on the EEMUA 191 committee. Todd has experience leading alarm philosophy development workshops for clients and performing alarm philosophy gap analyses. He has published and presented numerous papers on alarm management. Recent works include “Implementing an Effective Alarm Management Plan” and “Benchmarking the Use of Alarms as Safeguards and IPLs”. His article “Don’t be Alarmed: Avoid Unplanned downtime from alarm overload“ was selected as Intech magazine’s best article of the year in 2007.
