January 23, 2010

Pilot Error and Process Safety Management - The human connection

Today's paper indicates that Pilot's error caused the helicopter carrying Chief Minister Y.S.R to crash.The investigation report indicates "The cockpit voice recorder showed that there was poor crew resource management among them at any given stage of flying". They noticed a snag in transmission pressure on the instrument displays but failed to co-relate it with other indications associated with the snag. Both of them were busy trying to find out the cause of the snag, with the result that they were not aware that they were veering off course. Crew Resource Management (CRM) is a big issue in the cockpit of a plane or a helicopter. In simple terms, it is how jobs are shared during an emergency.
CRM is very relevant in chemical plant control rooms also. I have witnessed incidents due to wrong actions taken by control room personnel as there was no clear direction who would do what. Having said that, it becomes very difficult to compartmentalize actions during an emergency in a chemical plant. The practical solution to this is to have a senior control room operator monitoring the actions of the DCS operators and guiding them. The senior control room operator's job is like a conductor in an orchestra. Control Room Resource Management is one area where plant simulators can be used to train the personnel.
Another point which is in my mind is the provision of a voice recorder similar to that of a cockpit voice recorder and a CCTV camera in the control room monitoring the actions of the personnel during an emergency. Now I know this is going to get a lot of brickbats thrown at me but the purpose is not to spy on them. It is to make improvements in Control Room Resource Management after emergencies.

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