Circumventing Human Error by Integrating HSE in System Design
Authors: Poyyara Ragi , George Shoy , Patil Prajakta , Konale Sumit 
Published: May 2016

Abstract
Health, Safety, and Environment (HSE) management systems have evolved through lessons learned from near misses, incidents, and accidents over the years. Often, these incidents/accidents occur because of equipment damage, faulty procedures, or human negligence. While equipment damage can be repaired and procedures corrected, human oversight cannot be easily controlled. Individuals are unique, and so is their approach toward HSE. Organizations with robust safety management systems will help ensure that personnel are trained to identify and mitigate HSE risks. Despite this effort, accidents still occur, providing a continuous source of lesson learned.
One approach to averting HSE risks caused by human error is to help ensure a robust design process that is centered on HSE requirements. This paper describes features of a laboratory that contains equipment and chemicals used in the oil and gas industry. The safety features discussed include access to enter this laboratory by authorized/trained personnel only and equipment designed with inherent safety features, thereby limiting exposure to most HSE risks. All of the laboratory equipment pieces are designed with double safety features, which help ensure their fail-safe function. Chemicals are also managed using a software program designed to warn the user about chemical expiration dates. The laboratory equipment testing is controlled through a software program designed to warn the user of a particular danger or potential disaster.
A HSE institutionalized organization aims for continuous improvement. A forward step is to design software programs that warn the user of a particular danger and prevent the user from continuing with such actions, in addition to using intelligent chemical management software programs that identify expired chemicals and prevent their use until appropriate actions are taken.

Introduction
HSE management systems are a statutory requirement in the oil and gas industry. The key to a successful HSE management system is continual improvement. An effective HSE management system becomes an integral part of every management initiative by continually applying lessons learned. This involves commitment from senior management to personally lead the effort and includes participation by all levels of employees in a company's drive to achieve zero incidents and accidents (Madkour 2000). Thus, the primary responsibility for the safety of personnel and the work environment lies with the individuals in the organization, irrespective of their field of work or position. Despite these efforts, accidents still occur, often leading to new or revised procedures to help prevent similar incidents in the future (Misra 2012).

Principal Sources of Incidents and Accidents
According to the Abnormal Situation Management (ASM) consortium, the three principal sources of abnormal situations are people, equipment, and processes (ASM Consortium 2014).
The ASM consortium is a research and development group founded in 1994 by Honeywell to identify problems facing industrial plant operations during abnormal conditions and to develop solution concepts (ASM Consortium 2014). These principal sources of abnormalities (i.e., degraded or failed equipment, process complexity, and unwarranted and unwanted human actions) are the cause for most incidents or accidents. As long as people, equipment, and processes are involved in an activity, HSE risks invariably will be present. Fig. 1 indicates the contribution of each of these sources to abnormal situations.