Page 4 - 312 Human Factors Primer for Front Line Leaders

1. Introduction

Incident investigations have often cited “poor decision-making by operators” or “lack of
operational discipline” as a contributing cause or root cause. This simplistic analysis does not
explain why the people involved made an incorrect decision or did things the way they did, nor
does it provide much useful learning about how to avoid future related incidents. As the
renowned process safety expert Trevor Kletz put it, “To say that accidents are due to human
failing is like saying falls are due to gravity. It is true but it doesn’t help us prevent them” (Kletz,
2001).

Understanding and using basic human factors concepts can help leaders understand why
people do the things they do and help workers perform their tasks successfully. There are
many reasons why someone might make an incorrect decision: for example, an unfamiliar
process, rushing to get the job done, poor instrumentation layout, high noise or low light levels,
a confusing procedure, as well as a lack of awareness of what could go wrong.

Any of these reasons may help explain an unintentional lapse in operational discipline. CCPS
defines operational discipline as the performance of all tasks correctly every time. The human
factors approach emphasizes “mindful operational discipline” which focuses on anticipating
how mistakes could arise in a specific task and finding ways to help people avoid such pitfalls
and make correct decisions. For example, where procedures are confusing, they are modified
in advance of the work, and where a task may be unfamiliar, the job site and task are reviewed
in advance to ensure clarity and appropriate working conditions. Mindful operational
discipline implies the need to understand the work before it is conducted, to set up the job to
help people succeed, and to avoid distractions while performing the task.

This monograph focuses on the every-day decisions made by plant operations and
maintenance front line leaders in their planning and conducting work. It identifies key human
factors concepts and tools for their use in decision-making and in support of mindful
operational discipline.

The objective is to help managers and supervisors to:

• enable workers to make good decisions and perform their work successfully,
and
• manage mistakes effectively and fairly when they inevitably occur.

The monograph supplements and provides concise, high-level summaries of key concepts
included in the Human Factors Handbook (CCPS, 2022a). For further detail, please refer to the
comprehensive explanations provided in the Human Factors Handbook. References to the
Human Factors Handbook sections are provided in italics, e.g. (HFH 1.1) to differentiate them
from bibliographical references, e.g. (CCPS, 20xx).

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Human Factors Primer for Front Line Leaders
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