In 2005, a refinery in Texas made headlines around the world, when some 7600 gallons of flammable chemicals overflowed, ignited, and set off a chain of explosions. Fifteen people died. Another 180 were injured. It was one of the worst disasters in American industrial history with financial losses estimated at $1.5 billion. According to an intensive investigation by the U.S. Chemical Safety and Hazard Investigation Board, inadequate refinery operator training, poor communication, and process instrumentation failures were all key factors in the incident. The investigation concluded that:
- Both tower level indicator and tower high level alarms failed.
- The DCS failed to provide correct data indicating the imbalance of flows into and out of the tower.
- Plant personnel lacked adequate technical training in startup procedures.
- Operating procedures were outdated and ineffective.
- The plant’s refinery operator training program was inadequate.
The report also noted that the central training team had recently been reduced from 28 to eight members and that refinery operator training provided no hands-on practice with abnormal situations and other infrequent operations, such as startups.
Competency Development and Abnormal Situation Management
The disaster in Texas was caused by several factors, including faulty and antiquated equipment, poorly designed procedures, and operator error due to fatigue, inexperience, and improper training. Let’s look at training. In his article, “A Human Factors Approach to Managing Competency in Handling Process Control Disturbances,” Dr. David Embrey explained that there are two common strategies for developing process plant training programs to teach operators to handle process upsets. The first trains operators to recognize a set of indicators directly linked to a predetermined diagnosis. As long as the particular scenario is built into the training program and the proper diagnostic parameters are effectively recognized by the operator, the training can kick in and the operator can successfully resolve the issue. But what happens when a predetermined diagnosis does not fit the parameters identified by the operator? What happens when the parameters line up with more than one diagnosis? What should the operator do? The second approach teaches operators to diagnose and resolve issues on their own. While this approach is more arduous and time consuming in training development and operator effort, when done properly, operators learn to recognize low-probability scenarios that could not have been predicted during training development. While each approach has its advantages, the most practical, cost-effective, and manageable approach combines both.
Before Training Begins
Well before the first lesson, effective operator training programs begin with employee recruiting, screening, and selection. These critical steps ensure that organizations find the right people with the right personal makeup, technical aptitude, and respect for safety necessary to succeed in these demanding positions. By screening people before hiring or promoting them into operations roles, you can determine their likelihood to work safely, work well with others, and show up every day. You can assess their attitudes, and also assess their ability to apply what they learn, focus on quality, solve problems, operate safely, and exhibit other key competencies that identify good performers. After selecting good candidates, it’s essential to develop a strong technical foundation for operator candidates, as well as the engineers and maintenance personnel. They must learn how the plant works and why it works the way it does.
Fundamentals for a Solid Foundation
Automation and technology have made plants more safe and efficient. But automation can also act as a crutch or barrier to an operators understanding of what is really happening in the plant. When equipment and automation fail, the operators, engineers, and maintenance personnel must have a firm grasp of the fundamental cause and effect to successfully complete troubleshooting of events. As a result, it’s vital to provide this solid foundation in the fundamentals of plant operation in a training environment. However, the time and effort required to teach fundamentals can become a burden to a training organization. Add to that the variety of unit operations found in a typical refinery, and the task becomes more daunting. One effective solution is web-based tutorials. Using such tutorials, trainees learn the application and function of process units and associated equipment, as well as how to operate and control the equipment. Tutorials explain complex chemical engineering theory and process operations in understandable terms. They provide self-paced, thorough and flexible training with minimal instructor involvement, allow the training organization to use their high valued training assets, such as the subject matter experts and custom operator training simulator (OTS), for high valued training on your specific plant conditions. After mastering the fundamentals through tutorials, trainees can immediately apply that knowledge in a simulated environment to help them practice and retain what they’ve just learned. Learning by doing on a universal simulator enables trainees to practice infrequent conditions, such as startup and shutdown, and possibly the specific process upsets operators have faced at their particular plant. By encountering scenarios within the simulator, refinery operators develop the knowhow to prevent or quickly recover from an upset. With a universal refinery simulator, trainers can teach operators about the Texas refinery incident, and enable them to experience it themselves. Instructors can simulate the tower overfill scenario by failing the instrumentation and alarms associated with the tower.
Build and Practice Plant Specific Scenarios with a Custom Operator Training Simulator (OTS)
Although a vital part of the learning process, on-the-job training cannot possibly expose operators to the wide variety of specific situations they could ultimately face in their plant. Even refineries that devote significant resources to on-the-job training cannot replicate the number of incidents or procedures that senior operators have experienced. Also, due to improved technology, it’s increasingly less likely that refinery operators actually experience the many types of disturbances they may be forced to mitigate. The best means of providing the required wide-ranging, in-depth experience with potential situations at a specific plant is through a custom operator training simulator (OTS). Unlike a universal simulator, an OTS is a plant-specific simulator closely replicating an organization’s plant control room. An OTS provides endless hours of realistic on-the-job training in a safe environment where no employee or expensive plant equipment can be harmed when mistakes inevitably occur. On an OTS, trainers can develop an unlimited number of scenarios to train operators so that if the unexpected happens, they’ll be ready.
Several things went wrong in Texas that day in 2005. Equipment failed. Procedures failed. Operators made mistakes. Even with well-trained and experienced operators, disasters will occur, but certainly with less frequency. Helping grow an employee from entry level to an autonomous expert requires a structured approach starting with selecting the right candidate, building a strong fundamental base of knowledge and skills and graduating them to becoming an expert in your plant. Ask yourself these questions to assess the likelihood that your program will succeed:
- Are you hiring people most likely to succeed in their positions?
- Do you ensure that they have the fundamental knowledge required to successfully manage all future situations?
- Do they have frequent opportunities to practice and build their confidence to effectively follow plant procedures and troubleshoot abnormal situations?