4. Process tracing Texas City BP explosion 2005
Channel: Adaptive Capacity Labs
Date: 2023-03-13

Humans communicate with symbols and speech is a remarkably rich form of symbolic expression. We can ask questions and receive answers and this is surely the result of cognitive processing in the other person. But we know from our own experience that our cognition is far more complicated than any utterance we make can possibly reveal. Speech processing is downstream from the cognition that recognizes and interprets signals, signs, and symbols and formulates intentions and plans. Researchers have therefore asked what sorts of inferences we should take from verbal reports as data. The three papers in this seminar address this question, each from a slightly different perspective.

Despite limitations, we can make inferences about individual episodes of human cognition in some situations. Using settings that are rich in actions (including utterances) that involve interactions with the external world, we can derive process traces that bound the range of possible cognition in the practitioners we observe. Woods and others have used this approach to explore cognition in situ in various process control settings. Airplane cockpits, nuclear power plants, and surgical operating theaters are some locations where such studies have proven useful. Once again, cognitive artifacts, including information technology, contribute to process tracing. They serve as external holders of information, particularly relevant relationships between data.

The 23 March 2005 BP oil refinery explosion and fire in Texas City was a chemical explosion in a process control setting. This older refinery was designed to technically and operationally contain the hazards of handling potentially explosive mixtures. Maintenance and operations were supposedly controlled by formal policies that limited both the likelihood of an explosion and constrained the extent of damage if one were to occur. But limited understanding in operators, decayed equipment, and the need to do maintenance nearby led to a disaster in a plant that supposedly had high safety performance and high productivity. One important implication of this event is that so called safety management systems are easily dissociated from the real world working conditions they are supposed to control.