Communication and Coordination Failures in the Process Industries

Abstract

Previous research shows that effective team communication and coordination is required for managing normal and abnormal situations (Laberge & Goknur, 2006). The purpose of this project is to quantify common communication and coordination failures and root causes of abnormal situations in the process industries. Fourteen incident reports were analyzed using the TapRoot® root cause analysis methodology. The top five communication and coordination failures were failures of: planning or preparatory activities (31%), individual and team execution (14%), work direction and supervision (13%), communication between functional groups (12%), and activity assessment (10%). The study of root causes showed that ineffective standards, policies, and administrative controls (SPAC); poor crew teamwork; a lack of communication; and no supervision were common reasons for failures.

Get full access to this article

View all access options for this article.

References

Center for Chemical Process Safety (2003). Guidelines for Investigating Chemical Process Incidents (2nd Ed). New York: American Institute of Chemical Engineers.

Cochran

E. L.

Bullemer

P. T.

(1996). Abnormal Situation Management: NOT By New Technology ALONE. Proceedings of the 1996 AICHE Conference on Process Plant Safety, Houston, TX.

Espinosa

J. A.

Lerch

F. J.

Kraut

R. E.

(2004). Explicit versus implicit coordination mechanisms and task dependencies: One size does not fit all. In Salas

Fiore

S. M.

Team cognition (pp. 107–129. Washington: American Psychological Association.

Klein

(2001). Features of team coordination. In McNeese

Salas

Endsley

New trends in cooperative activities: Understanding system dynamics in complex environments (pp. 68–95. Santa Monica, CA: HFES.

Laberge

J. C.

(2008). A conceptual model for team communication and coordination in complex sociotechnical systems. Unpublished manuscript.

Laberge

J. C.

Goknur

S. C.

(2006). Communication and coordination problems in the hydrocarbon process industries. Proceedings of the 50th Annual Meeting of the Human Factors and Ergonomics Society, San Francisco, CA, USA.

Paradies

Unger

(2000). TapRoot®. The system for root cause analysis, problem investigation, and proactive improvement. Knoxville, TN: System Improvement, Inc.

Soken

Bullemer

P. T.

Ramanathan

Reinhart

(1995). Human-Computer Interaction Requirements for Managing Abnormal Situations in Chemical Process Industries. Proceedings of the ASME Symposium on Computers in Engineering, Houston, TX.

Vicente

(1999). Cognitive work analysis. Mahwah, NJ: Lawrence Erlbaum Associates.

10.

Zwaga

H. J. G.

Hoonhout

H. C. M.

(1994). Supervisory Control Behaviour and the Implementation of Alarms in Process Control. In Stanton

Human Factors in Alarm Design (pp. 119–134. London: Taylor & Francis.