The Industrial Operator’s Handbook, Second Edition

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PREFACE

What's This Book About?

The Industrial Operator's Handbook presents the elements vital to systematic industrial operation Safe, efficient industrial operation is predicated, in part, upon conservative design and well-executed construction Ultimately, however, the responsibility for successful operation falls to skilled, alert humans systematically controlling the equipment that they are charged with operating Accordingly, this book is dedicated to the study of improved industrial performance through a team approach to operation Its premise is that there is no substitute for the alert, well-trained operator controlling equipment within specified operating bands in accordance with approved procedures.

Who Is This Book For?

This book is written to educate operators,maintenance technicians, laboratory analysts, craftsmen, engineers, team leaders-anyone engaged in the operation or technical support of an industrial complex-in the principles and skills of systematic industrial operation Although written from the perspective of the operator, the concepts presented herein apply equally to the maintenance technician, lab analyst, engineer, or team leader.

Why Read This Book?

Whether you're a company CEO or an entry level technician, The Industrial Operator's Handbook develops the strategy for systematic industrial operation in such a logical and fascinating way that you will be intrigued while you learn

The philosophy of industrial operation, if properly developed and applied, is essentially the same for every technology Whether you build microchips, manufacture automobiles, operate a nuclear power-generating station, fly commercially, or run the gravel crusher for your company's road construction operation, once you understand it, you can apply it wherever you go As a bonus, you will soon find that the principles and skills presented within this text are as important for driving, flying, hobby woodcraft and metal-working, or farming as they are for commercial industrial operation The text is divided into four parts: The Nature of Industrial Failure (Part I), A Strategy for Operating Success (Part II), Vital Operating Skills (Part III), and Implementing the Strategy (Part IV) Through a series of case studies and the lessons drawn from them, you will:

• Probe the methods of failure by which most industrial accidents occur,
• Investigate twenty common components of accidents,
• Explore a common-sense strategy for systematic industrial operations,
• Determine the purpose of operating limits and the safe operating envelope,
• Learn two simple, but immutable principles of operating success,
• Review how alert,well-trained operators are developed,
• Evaluate twelve vital operating skills that every operator and leader should master,
• Examine the importance of investigating abnormal events,
• Realize the worth of continuing training,
• Discover the role of self-assessment in implementing the strategy, and
• Analyze a case study in implementing the systematic approach

Principles with "Staying Power"

The principles and conventions presented in this book aren't "gimmicks" Rather, they are time-proven tenets that, once learned, renew and confirm themselves daily to every member of an industrial team Developed and refined over a several years, this text incorporates decades of learning, evaluating, and practicing the principles of successful industrial operations TechStar has provided training in these principles for industrial and nuclear facilities nationwide-principles that have become lifelong benchmarks for thousands of industrial professionals Consequently, one great feature of The Industrial Operator's Handbook is that it will never become outdated In fact, the text can be used again and again as a basis for analyzing your own successes and failures as well as those from other industries It provides a distinct and unchanging path to direct you and your team in improving industrial operations.

What's New in the Second Edition?

Our objective in this edition is still to assist industrial teams in improving performance through heightened awareness of the causes of industrial accidents and the techniques by which good teams avoid them We have added and discussed a twentieth common accident contributor-design deficiencies As we saw in the Chernobyl accident, it's hard to operate and maintain equipment and systems that are poorly designed at the outset There are three additional enlightening case studies which contain important lessons in communication, command and control, configuration management, procedural compliance, and leadership Our discussion of the operating organizational structure has been revised and clarified with particular emphasis on the role of supporting teams and their coordination to successfully accomplish the central facility mission Finally,we have enhanced and expanded the study of operating performance evaluation,emphasizing the need for both formal evaluation and informal self-assessment All great teams-whether in sports, business, or combat-continuously engage in critical self-analysis Great teams always find ways to get even better.

Use It for Training

At least as important as your own education is educating and training your team in the philosophy and skills of effective and efficient industrial operations This text provides an extraordinary tool for accomplishing just that The book progresses in a logical sequence intended to facilitate leading your team through a comprehensive study of industrial operations, one or two chapters at a time The Topic Summary and Questions to Consider at the end of each chapter provides an excellent forum to compare your operations with those described in the text, prompting you to ask, "Are we making the same mistakes we just read about?" Furthermore, after you've studied The Nature of Industrial Failure (Part I) and The Strategy for Operating Success (Part II), you can begin a sequential review of Part III's twelve Vital Operating Skills And, since the skills build on one another, you have a wonderful opportunity to study and practice one skill at a time In fact, by working through the book systematically in a "study one, practice one" sequence, you can build an effective one-year continuing training program that (rigorously applied) will dramatically improve your team's performance Remember, though, there aren't any "free lunches" Don't expect much if you approach it with an attitude of "I'll let them read it and hope they get the point" If you don't believe it, teach it, and reinforce it by your own example, no one else will take it seriously or put much effort into it, either.

PART I of this text focuses on the consequences of failure (discussing the twenty common components of accidents) in order to demonstrate the need for a systematic approach to industrial operations

PART II introduces the objectives and elements of a successful operating strategy, the concepts of operating boundaries and operating principles, and the need for alert, well-trained operators-the most important element of successful operations in any industry

PART III expands on the details of twelve essential skills for every industrial operator, including what they are, why they are important, and how to establish and use them

PART IV continues in the vein of implementing the strategy by discussing how to put all the elements together, going beyond simple failure avoidance to process and product improvement-true operating success

This book isn't just for industrial operators and managers Everyone will enjoy reading it

This textbook is used for TechStar's Systematic Industrial Operations course

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Part I: The Nature of Industrial Failure

• Chapter 1 3
Anatomy of an Accident
• Crash of Eastern Airlines Flight 401, December 1972 3
• A Chain of Insignificant Events 4
• Complex Failure Formation 5
• Lessons of Eastern 401 7
• Topic Summary and Questions to Consider 9


• Chapter 2 11
Common Components of Accidents
• Grounding of the Exxon-Valdez, March 1989 12
• Twenty Common Accident Components 16
• Topic Summary and Questions to Consider 30

Part II: A Strategy for Operating Success


• Chapter 3 33
Systematic Industrial Operations
• Objective of the Strategy 33
• Elements of the Strategy 33
• An Underlying Operating Philosophy 34
• Reliable Equipment and Facilities 36
• Well-Defined Operating Boundaries 38
• Valid Policies and Procedures 41
• An Efficient Operating Structure 42
• Alert,Well-Trained Operators 46
• Superb Leaders 48
• A Team Approach 50
• Topic Summary and Questions to Consider 55


• Chapter 4 57
Boundaries of Safe Operation
• Safety Analysis 57
• Identifying the Hazards 58
• Determining the Risk 58
• Establishing Protection 58
• Categories of Operating Limits 62
• Developing Operating Limits 63
• The Safe Operating Envelope 67
• Topic Summary and Questions to Consider 69


• Chapter 5 71
Principles of Operation
• Chernobyl Atomic Power Station Accident,
  April 1986 71
• The Primary Cause 75
• Principles of Operation 76
• Topic Summary and Questions to Consider 77


• Chapter 6 79
The Alert,Well-Trained Operator
• Big Bayou Canot Bridge Accident, September 1993 79
• Tenets of Training 85
• Determining Job Requirements 85
• Selection of Candidates 86
• Developing the Training Program 86
• Phases of Training 89
• Initial Training Phase 90
• Certification Phase 91
• Continuing Training Phase 91
• Fitness for Duty 91
• Effective Management Oversight 92
• Topic Summary and Questions to Consider 92

Part III: Vital Operating Skills


• Chapter 7 97
Controlling Equipment and Processes
• Fatal Gas Release at Bhopal, December 1984 97
• Combined Accident Contributors 101
• The Cost 103
• Twelve Vital Operating Skills 104
• Topic Summary and Questions to Consider 107


• Chapter 8 109
Conducting Pre-Task Briefings
• Utility Crew Electrocution, April 1994 109
• Accident Prevention through Pre-Task Briefing 113
• Elements of a Pre-Task Briefing 113
• Pre-Task Briefing Guidelines 115
• Common Pre-Task Briefing Errors 115
• Post-Task Debriefing 116
• Topic Summary and Questions to Consider 116


• Chapter 9 117
Understanding and Using Procedures
• Northwest Airlines Flight 255, August 1987 117
• The Accident 119
• The Cause: Failure to Use and Comply with Procedures 121
• Contributing Factors 123
• Policy or Procedure? 126
• Developing Procedures 126
• Desirable Characteristics of Procedures 126
• Procedure Format 127
• Review and Approval 127
• Controlling Procedures 128
• Revising Procedures 128
• Using Procedures 128
• An Example of Procedure Use 129
• Reporting Status Changes 130
• Training to Procedures 131
• Enforcing Procedural Compliance 131
• Topic Summary and Questions to Consider 132


• Chapter 10 133
Monitoring Critical Operating Parameters
• Why Monitor? 133
• When to Monitor 134
• How to Monitor 134
• Actions for Abnormal Values 135
• Special Concerns 135
• Topic Summary and Questions to Consider 136


• Chapter 11 137
Independent Verification
• What Is It? 137
• For All Tasks? 137
• Who Decides? 138
• Process or Point Verification? 138
• Guidelines for Independent Verification 139
• Informal Verification 139
• Topic Summary and Questions to Consider 140


• Chapter 12 141
Communicating Vital Information
• Sinking of R M S Titanic, April 1912 141
• Questions of Cause 143
• The Lesson of Communication 144
• Elements of Effective Communication 145
• Effective Verbal Communication 146
• Written Instructions 147
• Emergency Communications 148
• Topic Summary and Questions to Consider 149


• Chapter 13 151
Keeping Logs and Recording Data
• Data Record Sheets 151
• Narrative Logs 153
• Specialized Formats 154
• Topic Summary and Questions to Consider 155


• Chapter 14 157
Recognizing Abnormalities
• Crash of Air Florida Flight 90, January 1982 157
• An Accumulation of Abnormalities 164
• Sources of Abnormalities 164
• Recognizing Abnormalities 165
• Performing Inspection Tours 167
• Prioritizing Abnormalities 167
• Responding to Abnormalities 169
• Your Intuition 170
• Topic Summary and Questions to Consider 170


• Chapter 15 171
Combatting Emergencies and Casualties
• The TMI-2 Accident, March 1979 171
• The Problems 174
• Responding to Industrial Crisis 176
• Planning for Emergencies and Casualties 178
• Training for Emergencies and Casualties 179
• Responding to Emergencies and Casualties 182
• Learning from Emergencies and Casualties 184
• Topic Summary and Questions to Consider 186


• Chapter 16 187
Overseeing Maintenance, Modification, and Testing
• Phillips 66 Chemical Complex Explosion and Fire, October 1989 188
• A Preventable Accident? 196
• Configuration Management 197
• Maintenance,Modification, or Testing? 197
• Who is Responsible? 197
• Tiers of Maintenance 199
• Operations/Maintenance Interface 199
• Guidelines for Maintenance Control 201
• Types of Testing 201
• Operations/Testing Interfaceg 202
• Guidelines for Testing Control 203
• Topic Summary and Questions to Consider 204


• Chapter 17 205
Isolating Energy Hazards
• TOSCO Unit 50 Oil Refinery Fire, February 1999 205
• The Accident 210
• Primary Cause: Failed and Improper Isolation 211
• Contributing Factors 213
• Sources of Hazardous Energy 216
• Other Hazards 217
• Means of Isolation 218
• Lockout Isolation 219
• Tagout Isolation 220
• Using Danger and Caution Tags 220
• Determining Tag Locations 221
• Topic Summary and Questions to Consider 222


• Chapter 18 223
Training On-the-Job The Purpose of OJT
• Elements of a Good OJT Program 223
• On-the-Job Training Controls 225
• Topic Summary and Questions to Consider 227


• Chapter 19 229
Performing Shift Turnovers
• Continental Express Accident, September 1991 229
• The Problems 234
• Definition, Purpose, and Applicability 235
• Eight Principles of Shift Turnover 235
• The Process of Shift Turnover 237
• Preparing the Station for Turnover 237
• Pre-Shift Meeting 238
• Pre-Shift Tour 239
• Post-Turnover Meeting 240
• Guidance for Successful Turnoversr 241
• Topic Summary and Questions to Consider 241
• Station Turnover 242

Part IV: Implementing the Strategy


• Chapter 20 245
Investigating Abnormal Events
• The Challenger Accident, January 1986 245
• Cause of the Accident 249
• Contributing Problems 249
• An Investigative Model 251
• Deciding to Investigate 251
• Designating Investigators 251
• Gathering and Preserving Evidence 252
• Event Critique 253
• Analyzing the Evidence 255
• Determining Causes 256
• Correcting Causes 256
• Documenting the Investigation 257
• Disseminating the Lessons 257
• The Next Level: Investigating Success 258
• Topic Summary and Questions to Consider 258


• Chapter 21 259
Conducting Continuing Training
• What Is It? 259
• Airline Industry Approach 260
• Application to Industry 261
• Choosing Continuing Training Topics 262
• Integrating Continuing Training 263
• Impediments to Continuing Training 264
• Topic Summary and Questions to Consider 265


• Chapter 22 267
Evaluating Operating Performance
• Why Evaluate? 267
• The Benefits of Looking 268
• Evaluation Perspective 270
• Formal or Informal? 271
• Levels of Evaluation 273
• What Should Be Evaluated? 276
• Organizational Vital Signs 277
• Evaluation Tools 279
• Evaluation Strategy and Logistics 282
• Responding to Evaluation 284
• What to Do With What You Find 285
• The Costs 286
• Evaluation Strategy and Logistics 287
• Topic Review and Questions to Consider 287


• Chapter 23 289
A Case Study in Implementation
• The Situation 289
• Background 289
• The Problems 290
• Your Task 291
• What Should You Do? 291
• The Obstacles 291
• The Approach 292
• Preparing to Take Over 293
• Controlling Immediate Safety Risks 294
• Establishing Leadership Confidence 294
• Identifying the Problem 295
• Evaluating the Problem 296
• Establishing Written Guidance 297
• Teaching the Systematic Approach 298
• Guidelines for Conducting the Training 299
• Implementing and Evaluating 300
• How Long Will It Take? 300
• Measuring Improvement 302
• Topic Summary and Questions to Consider 303


• Chapter 24 305
Your Challenge
• Topic Summary 305
• Implementing the Systematic Approach to Operations 306
• Tailoring and Implementing Your Approach 306

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