Loss prevention at the startup stage in process safety management: From distributed cognition perspective with an accident case study

Abstract Organizational artifacts such as rules, procedures, or codes of practice play important roles in chemical process safety management. The violation of an organizational artifact can lead to major accidents. It is thus essential to understand the underlying significance of violations to coordination of organizational artifacts. Currently, there are rapid changes and development of chemical products which require developing new process in chemical plants. The pre-startup stage in the chemical process is especially prone to errors due to ill-defined work processes and the variety of jobs involved at this stage. However, human errors and understandings in the stage have not been given much of attention it deserves. This paper focuses on human errors in pre-startup stage: (1) An analysis of major industrial accidents in Korea was conducted. (2) A survey of related personnel in chemical plants was carried out to understand conditions of safety management on human error. (3) An accident case study at the pre-startup stage in a Korean chemical plant was conducted by applying the Fault Tree Analysis method to reveal failures of coordination of organizational artifacts. This paper adopted distributed cognition theories to analyze the underlying implications of such failures because these theories have the power to examine the relationship between human operators and artifacts in a system. This study highlights the importance of considering organizational artifacts related to human error in safety management. The results may help people, who are related to a process of pre-startup stage in chemical plants, to improve safety of the work.

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