BACKGROUND: The treatment of bad actors consists of analyzing the most triggered alarms at a plant, seeking to make modifications that provide workers with more efficient and safer operational conditions. The consideration of plant operators’ practical knowledge in these proposed changes is both an opportunity and a challenge, as specific conditions are required. OBJECTIVE: To present and discuss how an alarm management report (AMR) could support the treatment of bad actors by promoting structured debates on real work situations and its contribution in improving the solutions proposed by alarm management committees (AMCs). METHODS: Data from nine AMC meetings were gathered and parsed using qualitative content analysis to classify the kind of information that the AMC used to justify the proposed changes and how these changes were decided. RESULTS: More than 60% of the changes were justified by information provided by the AMRs, indicating broad application and adoption. However, our findings suggest that the structured debates addressed variability and emerging strategies and may consider entire subsystems instead of single alarms. CONCLUSION: The use of structured debates is feasible for the treatment of bad actors and is an appropriate option that includes operating experience feedback for alarm optimization in industrial facilities.
As demanded at Collective Employment Agreement (CEA), three Ergonomic assessment of work (AEW) where made into an airport from a big Brazilian city (in particular, at the flight tower), with a 2 years interval between them. The objective was to produce a report pointing out problems and solutions. At the third time (2010), were verified that the work conditions where almost the same from 2006 and 2008, although all recommendations made in the reports. This work presents how the AET Team worked with this situation. At the third AEW, due the lack of real changes and the necessity of a report, the strategy was to know how workers where dealing with the complains and constraint detected at the previous reports, and how it interfere in abnormal or danger situations. Trying to explain this organizational phenomenon, we resort to Resilience Engineering to understand how those f/actors played to achieve its objectives.
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