DETERMINATION OF HUMAN ERROR PROBABILITIES

FOR OFFSHORE PLATFORM MUSTERS

Dino G. DiMattia
1
, Faisal I. Khan
2
an Pa!l R. A"#ott$
1,%
1
Department of Chemical Engineering, Dalhousie University,
Halifax, Nova Scotia, Canada B! "#$
%
Corresponding &uthor' (hone) *+",$*$,*-., /ax) *+",$"+,-.*, Email) paul0amyotte1dal0ca
"
/aculty of Engineering and &pplied Science, 2emorial University of Ne3foundland,
St0 !ohn4s, Ne3foundland and 5a6rador, Canada &1B #7
ABSTRA&T
8he focus of this 3or9 is on prediction of human error pro6a6ilities during the process of
emergency musters on offshore oil and gas production platforms0 Due to a lac9 of human error
data6ases, and in particular human error data for offshore platform musters, an expert :udgment
techni;ue, the Success 5i9elihood <ndex 2ethodology =S5<2>, 3as adopted as a vehicle to
predict human error pro6a6ilities0 8hree muster scenarios of varying severity =man over6oard,
gas release, and fire and explosion> 3ere studied in detail0 & panel of t3enty,four :udges active
in the offshore oil and gas industry provided data for 6oth the 3eighting and rating of six
performance shaping factors0 8hese data 3ere su6se;uently processed 6y means of S5<2 to
calculate the pro6a6ility of success for eighteen muster actions ranging from point of muster
initiator to the final actions in the temporary safe refuge =8S?>0 8he six performance shaping
factors considered in this 3or9 3ere stress, complexity, training, experience, event factors and
atmospheric factors0
KE'(ORDS) Human Error, Human /actors, ?is9 &ssessment, Emergency ?esponse
INTRODU&TION
8he study of human factors is a scientific discipline involving the systematic application of
information regarding human characteristics and 6ehaviour to enhance the performance of man,
machine systems0 8he ma:ority of 3or9 in human error prediction has come from the nuclear
po3er industry through the development of expert :udgment techni;ues such as S5<2 =Success
5i9elihood <ndex 2ethodology> and 8HE?( =8echni;ue for Human Error ?ate (rediction>
=S3ain @ Auttmann, 1*B>0 8he need for expert :udgment techni;ues arises 6ecause of the lac9
of human error data and the potentially severe conse;uences of nuclear industry accidents such
as Cherno6yl0 &nalogously, the (iper &lpha and Ccean ?anger disasters have generated a greater
a3areness of the effects and ramifications of human error in offshore hydrocar6on processing0
Humans play a significant role in 6oth accident causation and in emergency response =Bellamy,
1**$>0
Cffshore platform musters have significant potential for severe ramifications and present a
challenging scenario for human error prediction and reduction0 Due to the relatively slo3
progress in the field of ;uantification of human relia6ility, there is a need to advance this area of
research and provide techni;ues that could lin9 human factors 3ith ;uantitative ris9 assessment
=D?&>0 & primary issue is the concept of human error and ho3 it has entered the safety
voca6ulary as a catchall phrase 3ith a lac9 of consistent definition and application0 8he result is
an inade;uate understanding of ho3 human error identification may 6e applied in a useful
preemptive manner in high,ris9 scenarios0
& 6etter understanding of human error and its conse;uences can 6e achieved through the
application of human error identification models0 8o accomplish this, human error must first 6e
removed from the emotional domain of 6lame and punishment and placed in a systems
perspective0 Eith this vie3point, human error is treated as a natural conse;uence arising from a
discontinuity 6et3een human capa6ilities and system demands0 8he factors that influence human
error can then 6e recogniFed and managed0 Such efforts are an essential component in an overall
scheme of process safety management' see, for example, Eilson @ 2cCutcheon ="++> and
?&Eng ="++>0
"
Human error plays a significant and sometimes overriding role in accident causation0 Statistics
that attri6ute accidents or losses to human error are varied and are reported to 6e as high as B7 G
=Sanders @ 2cCormic9, 1*B->0 8his 3ide variation is dependent on the source of data and the
definitions applied to categoriFe human error0 Nonetheless, it is reasona6le to state that human
error plays a significant role in accidents through either direct action or inade;uate design0
Human error and human factors are often used interchangea6ly, thus creating confusion and
compromising the ;uality of human relia6ility assessments0 8herefore, defining human factors
and human error is necessary to esta6lish a 6asis for the discussion in the current paper0 &
definition of human factors, modified slightly from the UH4s Health and Safety Executive
=HSE, 1***>, is as follo3s)
Environmental and organizational and job factors, system design, task attributes and
human characteristics that influence behaviour and affect health and safety.
8he concept of human error, 3hether intentional or unintentional, is defined as =5orenFo, 1**+>)
Any human action or lack thereof, that exceeds or fails to achieve some limit of
acceptability, where limits of human performance are defined by the system.
Human factors play a ma:or role in platform musters and their successful outcome =Hennedy,
1**>0 8he importance of human factors in offshore operations has 6een recogniFed through
several reports pu6lished 6y the UH Health and Safety Executive dealing 3ith the inclusion of
human factors in the offshore industry =Eiddo3son @ Carr, "++"> and the human factors
assessment of safety critical tas9s in the offshore industry =!ohnson @ Hughes, "++">0 8hese
reports provide guidance for the integration of human factors principles into offshore system
design, development and operation0
Ho3ever, initiatives have not 6een developed to ;uantify the human error pro6a6ilities =HE(s>
associated 3ith the ma:or actions that ta9e place during a platform muster0 Cn a regulatory 6asis

there is generally no clear definition or specific re;uirement for the inclusion of human error
considerations in management systems or ris9 assessments0 8his may perhaps 6e attri6uted to the
am6iguity and comprehensiveness of the su6:ect area, 6ut is more li9ely due to the lac9 of
readily availa6le human relia6ility assessment =H?&> tools0
OB*E&TI+ES AND FRAME(ORK OF &URRENT STUD'
8he current 3or9 =Di2attia, "++$> 3as underta9en 3ith the follo3ing o6:ectives)
8o advance the field of human error identification for offshore platform musters in a
uni;ue manner0
8o promote and enhance safety in platform musters through the recognition and
;uantification of human error0
8o provide an accessi6le human relia6ility assessment tool yielding a meaningful and
useful result0
8o provide ris9 reduction recommendations to mitigate the potential for human error
during platform musters0
8he overall research pro:ect =Di2attia, "++$> applies the principles of optimal ris9 analysis
=C?&> =Hhan, "++1> in an attempt to ultimately develop a Human Error (ro6a6ility <ndex
=HE(<>0 C?& employs haFard identification =i0e0 human error identification>, haFard assessment
=i0e0 human error assessment>, ;uantification of haFards =i0e0 human error pro6a6ilities>, and ris9
estimation 6ased on human error pro6a6ilities and conse;uences0 8he foundation of this 3or9
rests on empirically determined human error pro6a6ilities derived from the Success 5i9elihood
<ndex 2ethodology =Em6rey et al0, 1*B$ and Em6rey et al0, 1**$>0
8hese human error pro6a6ilities are in turn 6ased on factors that affect human performance,
9no3n as performance shaping factors =(S/s>0 <n the present study, (S/s 3ere 3eighted and
rated through the S5<2 techni;ue to develop a success li9elihood index =S5<> for each muster
action from 3hich the pro6a6ility of success =(CS> and the human error pro6a6ility =HE(> are
estimated0 Eeight and rating data 3ere o6tained through a pre,selected set of :udges responding
to ;uestionnaires developed for three muster scenarios of varying severity =man over6oard, gas
release, and fire and explosion>0 8he overall process is sho3n conceptually in /igure 10
$
8he remainder of this paper descri6es the process 6y 3hich human error pro6a6ilities 3ere
determined according to the frame3or9 of /igure 10 Space considerations do not permit complete
coverage of all supporting details' readers are referred to Di2attia ="++$> for additional
information0 <n the current paper, emphasis is placed on) =i> data elicitation for the three muster
scenarios of man over6oard, gas release, and fire and explosion, and =ii> analysis of these data to
yield human error pro6a6ilities for the various stages of the muster scenarios0 &lthough not the
primary focus of the paper, some guidance is also given on the application of the human error
pro6a6ility results to the assessment of ris9 during platform musters0
HUMAN ERROR PROBABILIT' DATA ELI&ITATION AND ANAL'SIS
8he current 3or9 concerns itself 3ith the actions 6eginning at the time of muster initiation =t<>
and ending 3ith the tas9s performed in the temporary safe refuge =8S?> 6efore standing do3n or
moving on to the a6andonment phase =/igure ">0 Each phase of the muster has an associated
elapsed time =i0e0 t&, tEv, tEg, t?> that collectively ma9e up the total time of muster =t2>0 8his study
therefore focuses on the muster phases that precede evacuation and for 3hich there is significant
ris9 to personnel0
8he first three phases of muster =a3areness, evaluation and egress> are 6rief compared to the
total time of muster0 8hey are typically 1+ to + G of t20 <t is during these phases that individuals
have the greatest exposure to the effects of the muster initiator =e0g0 heat, smo9e, pressure> and to
high levels of physiological and psychological stress' these phases are identified as elevated
exposure phases =EE(s>0 During the EE(s an individual4s local egress route and surrounding
environment can rapidly degrade0 8he ;uality of the egress path and the surrounding
environment is referred to as tena6ility I a concept that is 3ell,esta6lished in the modeling of
human 6ehaviour during 6uilding fires =/raser,2itchell, 1***> and that lends itself 3ell to
muster scenarios as a factor influencing the success of muster tas9s0
Core and Elicitation Review Teams
8he lac9 of HE( data for platform musters 3as the motivation for employing an expert :udgment
techni;ue in this 3or90 &s previously mentioned the techni;ue adopted here 3as S5<2 I
Success 5i9elihood <ndex 2ethodology =Em6rey et al0, 1*B$ and Em6rey et al0, 1**$>0 Several
7
researchers have revie3ed the usefulness of S5<2 in relation to other availa6le H?& techni;ues
=e0g0 Hir3an, 1**B>0
<n essence, the use of an expert :udgment techni;ue involves people ma9ing su6:ective decisions
in as o6:ective a manner as possi6le0 & critical first step, therefore, 3as the formation of the team
of :udges 3ho 3ere to generate the relevant data =selection, 3eighting and rating of (S/s> for
this research pro:ect0 =&lthough the 3ord team is used throughout this paper, all 3or9 performed
6y the :udges 3as done independently0> & grouping of five :udges, 9no3n as the core revie3
team =C?8>, 3as selected for the initial tas9s of deciding on the muster scenarios, the specific
muster actions, and the set of performance shaping factors to 6e used0 8he follo3ing selection
criteria 3ere used for the C?8)
&ctively involved in offshore activities as a mem6er of a producing company or
regulator0
&ctively participated in platform musters or involved in the design or evaluation of
platform safety systems0
(articipated or led ris9 assessments in offshore related activities0
2inimum of 1+ years of industrial experience in hydrocar6on processing0
Capa6le of dedicating the re;uired time to perform evaluations and committed to
participate as re;uired0
Does not 3or9 directly for any other mem6er of the C?8 or 3ith any mem6er of the C?8
on a daily 6asis0
&vaila6le to meet in person during 3or9 hours0
<n addition to the set,up 3or9 descri6ed a6ove, the C?8 assisted in the development of
;uestionnaires used in the elicitation of (S/ 3eights and ratings 3hich 3ere su6se;uently used
in the HE( calculations0 8his data generation phase of the pro:ect 3as conducted 6y the
elicitation revie3 team =E?8>, consisting of the five mem6ers of the C?8 and an additional 1*
:udges0 &s sho3n in 8a6le 1, the E?8 3as thus composed of "$ :udges 3hose primary :o6
functions 3ere) engineering =1$ mem6ers>, operations =.>, health and safety =>, and
.
administrative =1>0 /urther details on :udges4 ;ualifications and 6ac9grounds are given 6y
Di2attia ="++$>0
Muster Scenarios
8hree muster scenarios 3ere esta6lished 6y the C?8 to encompass the 3idest possi6le range of
credi6le muster initiators0 8he follo3ing criteria 3ere used in the esta6lishment of these
scenarios)
Credi6le muster scenarios that can occur on an offshore platform0
2uster scenarios that provide a 3ide range of ris90
&t least one scenario that has a close relationship to empirical data0
&t least one severe scenario that can 6e referenced through 9no3n offshore incidents0
&t least one scenario that has 6een experienced 6y the ma:ority of the C?80
8he scenarios thus selected 3ere man over6oard =2C>, gas release =A?>, and fire and explosion
=/@E>0 8he specific details of each muster scenario 3ere further developed 6y the C?8 in the
process of esta6lishing the (S/ rating ;uestionnaires0
Muster Hierarchical Task Analysis
8he next step for the C?8 3as to conduct a hierarchical tas9 analysis =H8&> for a generic muster
scenario0 8he goal in this stage 3as to develop a series of muster steps =or actions> that 3ere
independent of the muster initiator =2C, A? or /@E>0 & preliminary H8& of a muster se;uence
3as developed 6y !udge & =author DAD' see 8a6le 1>, and provided to the other mem6ers of the
C?8 for revie3 and comment0 8he result of this revie3 of the original H8& is sho3n in 8a6le "
and also graphically in /igure 0 8he muster se;uence 6egins su6se;uent to the initiating event
and does not concern itself 3ith 3hy the event occurred0 8he se;uence ends 3ith the completion
of the muster actions in the 8S? 6efore standing do3n =i0e0 returning to normal activities> or
commencing evacuation actions0 Di2attia ="++$> presents a 6rea9do3n of the muster actions 6y
s9ill, rule and 9no3ledge =S?H> 6ehaviour' such discussion is outside the scope of the current
paper0
Performance Shaping actors
-
(erformance shaping factors =(S/s> are those parameters influencing the a6ility of a human
6eing to complete a given tas90 Similar to the muster H8& previously descri6ed, a draft list of
nine (S/s 3as developed 6y !udge & =author DAD' see 8a6le 1>, and provided to the other
B
mem6ers of the C?8 for revie3 and comment0 8he C?8 revie3 resulted in a set of 11 (S/s
3hich 3as reduced to the final set of six =8a6le > 6y means of a pair3ise comparison to
determine the most relevant (S/s0
Performance Shaping actor !eights
8he 3eight of a performance shaping factor is the relative importance of that (S/ in comparison
to the (S/ :udged to 6e the most important0 (S/ 3eights range from + to 1++, 3ith a value of
1++ 6eing assigned to the most important (S/ =i0e0 the (S/ most critical to the successful
completion of a given action>0 Here, the 3eight 3as determined for each of the six (S/s =8a6le
> for each of the 1B muster actions =8a6le ">, for each of the three muster scenarios =2C, A?
and /@E>0 8his procedure 3as completed 6y each of the "$ mem6ers of the E?8 using
;uestionnaires that had 6een developed 6y the C?80 8he follo3ing set of directions 3as provided
to the E?8 :udges to facilitate consistent completion of the ;uestionnaires)
Assume all P!s are as severe as possible in their own right. "ake the P! that if
improved would afford the greatest possibility of completing the task successfully. #ive
that P! a value of $%%. &ext, weight each of the remaining P!s against the one valued
at $%% 'from % to (%, in increments of $%). "he five remaining P!s may be of duplicate
value. *onsider the general scenario when weighting P!s for each task.
&n illustration of the mean (S/ 3eights =mean of the "$ :udges> thus o6tained is given in /igure
$ for the 2C scenario0 /ocusing on one (S/ sho3n in /igure $ 3ill permit a 6etter
understanding of the meaning of the term weight 3hen applied to performance shaping factors0
/or example, stress 3eights display a generally increasing trend throughout the muster se;uence
from the a3areness phase =actions 1 I as per 8a6le "> through to the recovery phase =actions 17
I 1B> in the 8S?0 8he importance of lo3 stress levels in completing the muster tas9s increases as
the muster progresses and the evaluation phase =actions $ I -> ends0 Stress 3eights throughout
most of the egress phase =actions B I 1$> do not vary significantly 6ecause muster conditions
3ere seen 6y the :udges not to 6e deteriorating under this scenario0 8here is, ho3ever, a nota6le
increase in stress 3eight at the end of the egress phase at action 1$ =assist others>0 8his action is
rarely practiced during muster drills and can slo3 progress to the 8S?' the increased 3eight is
*
thus a reflection of the importance of remaining calm to assist others effectively0 8here is a
nota6le drop in stress 3eight in the recovery phase at action 17 =register at 8S?>0 8his action
re;uires little s9ill to complete and no decision ma9ing is associated 3ith this relatively simple
act0 Stress 3eights increase through the final three recovery actions as lo3er levels of stress 3ill
improve a person4s a6ility to provide feed6ac9 and prepare for potential evacuation from the
facility0
& second illustration of the mean (S/s elicited from the E?8 :udges is given in /igure 70 Here,
the 3eights for one (S/ =event factors> across all 1B muster actions are sho3n for the three
muster scenarios0 8he event factors (S/ sho3s the 3idest range in 3eights 6et3een scenarios
among all six (S/s0 8he largest gap occurs in the a3areness, evaluation and egress phases' there
is then a narro3ing of the range in the final recovery stage0 Aas release and fire and explosion
3eights are more closely 3eighted and follo3 the same trends, sho3ing a step change in
importance from the more 6enign man over6oard event0 8he man over6oard scenario resem6les
the least severe form of muster I a drill, 3here event factors have little effect on the successful
completion of tas9s0
/igures $ and 7 are part of the test of reasona6leness =/elder @ ?ousseau, "+++> applied to the
elicited (S/ 3eight data0 8he data 3ere plotted and examined from various perspectives) 6y
muster scenario for all actions and (S/s =e0g0 /igure $>, 6y (S/ for all actions and muster
scenarios =e0g0 /igure 7>, and 6y E?8 su6group =C?8 mem6ers, non,C?8 mem6ers, engineers,
operators, etc0>0 8his 3or9 3as underta9en to verify that the data made sense and could 6e
explained 6y reasoned argument0 &dditionally, the (S/ 3eight data 3ere su6:ected to statistical
analysis =&NCJ& and Hrus9al,Eallis> to test various null hypotheses aimed at determining
3hether, for example, the muster scenarios affected the :udges4 (S/ 3eights for each muster
action0 8hese ;ualitative and ;uantitative tests are documented in detail in Di2attia ="++$>0 8he
conclusion reached is that the elicited (S/ 3eight data are rationally explaina6le and sho3 no
significant 6iases arising from the team of :udges that provided the data =e0g0 due to sample siFe,
6ac9ground ;ualifications, etc0>0
1+
Performance Shaping actor Ratings
8he rating of a performance shaping factor is a measure of the ;uality of that (S/0 (S/ ratings
range from + to 1++, 3ith a value of 1++ 6eing optimal0 Here, the rating 3as determined for each
of the six (S/s =8a6le > for each of 1- muster actions =8a6le ", excluding action 1 I gather
personal survival suit if in accommodations at time of muster>, for each of the three muster
scenarios =2C, A? and /@E>0 (S/ ratings 3ere not elicited for action 1 6ecause, as descri6ed
6elo3, the muster scenarios 3ere set up 3ith the mustering individual outside the
accommodations module at the time of muster initiation0
Similar to the (S/ 3eights, the rating elicitation procedure 3as completed 6y each of the "$
mem6ers of the E?8 using ;uestionnaires that had 6een developed 6y the C?80 &s previously
mentioned, the process of esta6lishing the (S/ rating ;uestionnaires re;uired the C?8 to further
develop the specific details of each muster scenario0 8hese details are given in 8a6le $ 3hich
clearly illustrates the philosophy of the musters 6eing of varying severity0 8he 2C scenario 3as
set up so that the muster se;uence provided as fe3 o6stacles as possi6le during the event0 <n the
A? scenario, all six (S/s are of lo3er ;uality than in the 2C scenario, 3hile the /@E scenario
represents the most severe com6ination of events0 8a9ing one (S/ as an example, one can see a
degradation in the experience (S/ from 17 years offshore experience =2C> to three years =A?>,
to six months =/@E>0
Using the rating scales sho3n in 8a6le 7 as a guide, the E?8 :udges 3ere directed to rate the
(S/s according to the muster actions for each scenario =from + to 1++, in increments of 1+>0 &n
illustration of the mean (S/ ratings =mean of the "$ :udges> thus o6tained is given in /igure . for
the 2C scenario0 Similar to the (S/ 3eights, focusing on one (S/ sho3n in /igure . 3ill permit
a 6etter understanding of the meaning of the term rating 3hen applied to performance shaping
factors0 /or example, ratings for experience =and other (S/s> are high throughout the entire
muster se;uence0 8his means the E?8 felt that the operator4s 17 years of offshore experience 3as
a positive factor in completing all muster actions =particularly action 17 of registering at the
8S?>0 8his may 6e contrasted 3ith /igure -, 3hich illustrates the relationship among the three
reference scenarios for the experience (S/ ratings0 &lthough the trends throughout the se;uences
of actions are generally the same, the experience ratings are clearly lo3est =i0e0 least optimal> for
11
the /@E scenario0 8his illustrates the poor ;uality of this (S/ in the most severe of the muster
scenarios0
&s 3ith the (S/ 3eights, the elicited rating data 3ere su6:ected to extensive reasona6leness and
statistical testing =documented in Di2attia, "++$>0 8he conclusion from these tests is that the
rating data, similar to the 3eight data, are rationally explaina6le and sho3 no significant 6iases
arising from the team of :udges that provided the data =e0g0 due to sample siFe, 6ac9ground
;ualifications, etc0>0 8hese are important conclusions, 6ecause it is the (S/ 3eight and rating
data that form the 6asis of the human error pro6a6ilities calculated in this 3or90
Human Error Pro"a"ilities
8he final step in this phase of the research 3as the actual determination of human error
pro6a6ilities follo3ing the S5<2 protocol =Em6rey et al0, 1*B$>0 8he details can 6e found in
Di2attia ="++$> and are 6riefly recapitulated here0 /or a given muster action, the 3eight of each
(S/ is normaliFed 6y dividing the 3eight 6y the sum of all (S/ 3eights for that action0 8he
resulting ;uotient is termed the (S/ n,3eight0 &gain for a given action, the product of the n,
3eight and the rating yields the success li9elihood index =S5<> for a given (S/0 8he S5< values
for all six (S/s are then summed to yield the total S5< =or simply the S5<> for a given action0
8he higher the S5< value, the greater the pro6a6ility of successfully completing a particular
muster action0
8he results of these calculations are sho3n in /igure B in terms of the mean S5< values =mean of
the "$ E?8 :udges>0 <t can 6e seen that the /@E scenario actions are predicted to have the least
li9elihood of success among the three reference muster se;uences0 8he li9elihood of success is
lo3er through the high ris9 phases =a3areness, evaluation and egress> for 6oth the A? and /@E
series, 3hile the 2C se;uence maintains a similar S5< through all four muster phases0 8hese and
other reasona6leness tests, along 3ith appropriate statistical analyses, are detailed in Di2attia
="++$>0
1"
Having esta6lished the validity of the S5< data, it 3as then possi6le to determine the HE( values
for a given action 6y means of the logarithmic relationship of (ontecorvo =1*.7>, 3hich is a
foundational aspect of S5<2)
log=(CSi> K a=S5<i,m> L 6 M1N
3here (CSi K (ro6a6ility of Success for action i K 1 I HE(i
S5<i,m K arithmetic mean of Success 5i9elihood <ndex values =from E?8 data> for action i
a, 6 K constants
Determination of the constants a and b re;uires an evaluation of the HE(s for the actions having
the lo3est and highest S5< values0 8hese 6ase HE(s =BHE(s> permit the solution of a and b via
e;uation M1N I 3hich is simply the e;uation of a straight line I and then su6se;uent calculation of
the HE(s for the remaining 1. muster actions =again via e;uation M1N>0 <n accordance 3ith /igure
B, action 17 =register at 8S?> 3as selected as having the maximum S5< for all three reference
scenarios0 8he minimum S5< actions 3ere then specified as action 1$ =assist others if needed or
as directed> for the 2C scenario and action 1" =choose alternate route if egress path is not
tena6le> for 6oth the A? and /@E scenarios0 8hree approaches 3ere then used to complete the
6ase action analysis 6y 3hich the constants a and b 3ere determined)
Empirical BHE(s from limited availa6le muster data,
Elicited BHE(s from a randomly selected su6set of the E?8, and
Estimated BHE(s from limited 8HE?( data of S3ain @ Auttmann =1*B> and data of
Hir3an =1**$>0
&s documented in Di2attia ="++$>, the last approach mentioned a6ove provided ade;uate rigor
to permit its adoption as the 6asis for calculating the remaining HE(s for each muster scenario
according to e;uation M1N0 8a6le . gives a summary of the human error pro6a6ilities predicted in
this manner, along 3ith a list of possi6le failure modes =loss of defences>0 <n essence, 8a6le .
represents the culmination of the 3or9 of the Elicitation ?evie3 8eam and the endpoint of the
Success 5i9elihood <ndex 2ethodology0
1
APPLI&ATION OF HUMAN ERROR PROBABILIT' DATA TO RISK ASSESSMENT
8he human error pro6a6ility data in 8a6le . are useful in and of themselves0 8hey present a
;uantitative measure of the li9elihood component of ris9 due to human error during offshore
platform musters of varying severity0 Confidence in the predicted HE( values arises due to the
rigorous and scientifically validated process of data elicitation and analysis afforded 6y the
Success 5i9elihood <ndex 2ethodology0
8he applica6ility of these data can 6e extended in the follo3ing 3ays)
By generaliFation of the human error pro6a6ilities to muster scenarios other than the
three scenarios =2C, A? and /@E> investigated via S5<2, and
8hrough incorporation of conse;uence severity into the analysis to ena6le the full
assessment of ris9 from human error during platform musters =i0e0 consideration of both
li9elihood and conse;uences>0
Both of the a6ove points are the su6:ect of ongoing activities 3ithin our research group 3hich
3ill form the 6asis of a su6se;uent pu6lication' preliminary ideas and approaches are given 6y
Di2attia ="++$>0 8he ultimate aim of our further 3or9 is to present the aforementioned Human
Error (ro6a6ility <ndex =HE(<> as a ris9 assessment tool in 6oth manual and electronic formats0
<deally, this tool 3ill provide a generaliFed procedure 6y 3hich any credi6le muster scenario can
6e assessed for the li9elihood of human error arising in the completion of the various muster
tas9s0 Use of the human error pro6a6ilities thus predicted, in con:unction 3ith a conse;uence
ta6le specific to the act of mustering, 3ill ena6le estimation of the ris9 for each muster action0
8he provision of suggested ris9 reduction measures =??2s> 3ill allo3 a re,ran9ing of ris9 in an
effort to determine an accepta6le level0
8a6les -, B and * demonstrate our current thin9ing on some of the points in the a6ove paragraph0
8a6le - gives possi6le human error conse;uences according to four receptor categories' the
potential conse;uences range from simple time delays to loss of life0 Use of 8a6le - =or a similar
compilation> 3ould involve assigning a severity level to each of the four conse;uence categories
for each muster action =8a6le ">0 8his could 6e done via empirical data from muster drills, expert
:udgment elicitation =similar to that used for the (S/ 3eights and ratings>, or simply agreement
1$
of 9no3ledgea6le individuals0 Bringing together such a conse;uence ta6le 3ith HE( data to
determine the level of ris9 3ould 6est 6e accomplished via the 3ell,accepted industry practice of
a ris9 matrix0 8he HE( data in 8a6le . are suggestive of three li9elihood categories covering
ranges separated 6y an order of magnitude =i0e0 +0++1 I +0+1, +0+1 I +01, and +01 I 10+>0
?is9 reduction and re,ran9ing can 6e addressed 6y first adapting the general human error
literature to the specific tas9s of mustering offshore, as illustrated 6y the examples in 8a6le B0 By
identifying human errors, one is then in a 6etter position to suggest ris9 reduction measures that
crossover into the field of human factors0 Examples of potential ??2s in various categories are
given in 8a6le * for the first muster action of detecting the alarm0 Aiven the close lin9 6et3een
human factors and inherent safety =see, for example, Hhan and &myotte, "++>, identification of
??2s 6ased on the principles of inherent safety 3ould 6e highly 6eneficial0 Such 3or9 is
under3ay 3ithin our research group in addition to the other considerations mentioned in this
section0
&ON&LUSION
<n this paper 3e have presented 6oth human error pro6a6ility data for offshore musters and the
methodology employed to elicit and analyFe the data0 8hree muster scenarios covering a range of
initiator severity 3ere purposely chosen to yield a 3ide range in pro6a6ilities0 8he pro6a6ility
data thus o6tained 3ere thoroughly examined to ensure their suita6ility for extension to other
muster scenarios0 Eor9 is under3ay 3ithin our research group to accomplish this generaliFation
of the HE( data, as 3ell as incorporation of ;ualitative conse;uence analysis I 3ith the ultimate
o6:ective of producing an engineering tool for human error ris9 assessment0
A&KNO(LEDGEMENTS
8he authors gratefully ac9no3ledge the support of (etroleum ?esearch &tlantic Canada =(?&C>
and the Natural Sciences and Engineering ?esearch Council =NSE?C> of Canada0
17
REFEREN&ES
Bellamy, 50!0 =1**$>08he influence of human factors science on safety in the offshore industry0
+ournal of ,oss Prevention in the Process -ndustries, ,=$>, -+,-70
Di2attia, D0A0 ="++$>0 .uman error probability index for offshore platform musters0 (h0D0
8hesis, Department of Chemical Engineering, Dalhousie University, Halifax, NS, Canada0
Em6rey, D0E0, Humphreys, (0C0, ?osa, E0&0, Hir3an, B0, @ ?ea, H0 =1*B$>0 ,-/0/A123 an
approach to assessing human error probabilities using structured expert judgment0 ?eport No0
NU?EAOC?,71B =BN5,NU?EA,71-1.>, Department of Nuclear Energy, Broo9haven National
5a6oratory, Upton, NP0
Em6rey, D0E0, Hontogiannis, 80, @ Areen, 20 =1**$>0 #uidelines for preventing human error in
process safety0 Ne3 Por9) Center for Chemical (rocess Safety, &merican <nstitute of Chemical
Engineers0
/elder, ?020, @ ?ousseau, ?0E0 ="+++>0 Elementary Principles of *hemical Processes =rd ed0>0
Ne3 Por9) Eiley0
/raser,2itchell, !0N0 =1***>0 2odelling human 6ehaviour 3ithin the fire ris9 assessment tool
C?<S(0 !ire and /aterials, 2-, $*,770
HSE =1***>0 4educing error and influencing behavior0 ?eport No0 HSA$B, Health and Safety
Executive, UH0
!ohnson, ?0, @ Hughes, A0 ="++">0 Evaluation report on 5"5 $(((6%(7, human factors
assessment of safety critical tasks0 ?eport No0 , Health and Safety Executive, UH0
Hennedy, B0 =1**>0 A human factors analysis of evacuation, escape and rescue from offshore
operations0 ?eport No0 C8C * ++$, Health and Safety Executive, UH0
Hhan, /0<0 ="++1>0 Use maximum credi6le accident scenarios for realistic and relia6le ris9
assessment0 *hemical Engineering Progress, .,=11>, 7.,.$0
1.
Hhan, /0<0, and &myotte, (0?0 ="++>0 Ho3 to ma9e inherent safety practice a reality0 *anadian
+ournal of *hemical Engineering, /1=1>, ",1.0
Hir3an, B0 =1**$>0 A guide to practical human reliability assessment0 5ondon) 8aylor and
/rancis0
Hir3an, B0 =1**B>0 Human error identification techni;ues for ris9 assessment of high ris9
systems I part 1) revie3 and evaluation of techni;ues0 Applied Ergonomics, 2.=>, 17-,1--0
5orenFo, D0H0 =1**+>0 A guide to reducing human errors, improving human performance in the
chemical industry0 8he Chemical 2anufacturers4 &ssociation, <nc0, Eashington, DC0
(ontecorvo, &0B0 =1*.7>0 & method of predicting human relia6ility0 Annals of 4eliability and
/aintainability, 0, -,$"0
?&Eng ="++>0 4isk posed by humans in the control loop0 Eor9ing Aroup ?eport, 8he ?oyal
&cademy of Engineering, UH0
Sanders, 20S0, @ 2cCormic9, E0!0 =1*B->0 .uman factors in engineering and design =.th ed0>0
Ne3 Por9) 2cAra3,Hill0
S3ain, &0D0, @ Auttmann, H0E0 =1*B>0 .andbook of human reliability analysis with emphasis
on nuclear power plant applications0 ?eport No0 NU?EAOC?,1"-B, U0S0 Nuclear ?egulatory
Commission, Eashington, DC0
Eiddo3son, &0, @ Carr, D0 ="++">0 .uman factors integration3 implementation in the onshore
and offshore industries0 Sud6ury, UH) HSE Boo9s0
Eilson, 50, @ 2cCutcheon, D0 ="++>0 -ndustrial safety and risk management0 Edmonton,
Canada) University of &l6erta (ress0
1-
NOMEN&LATURE
A112$3iation4S#"1ol E56lanation
a Constant in e;uation M1N
6 Constant in e;uation M1N
BHE( Base Human Error (ro6a6ility
C Critical =conse;uence severity level>
C?8 Core ?evie3 8eam
EE( Elevated Exposure (hase =of muster>
E?8 Elicitation ?evie3 8eam
/@E /ire @ Explosion =muster scenario>
A? Aas ?elease =muster scenario>
H High =conse;uence severity level>
HE( Human Error (ro6a6ility
HE(< Human Error (ro6a6ility <ndex
H?& Human ?elia6ility &ssessment
H8& Hierarchical 8as9 &nalysis
i &ction =su6script>
5 5o3 =conse;uence severity level>
m &rithmetic mean =su6script>
2 2edium =conse;uence severity level>
2C 2an Cver6oard =muster scenario>
C<2 Cffshore <nstallation 2anager
C?& Cptimal ?is9 &nalysis
(CB (ersonnel Cn Board
(CS (ro6a6ility of Success
(S/ (erformance Shaping /actor
D?& Duantitative ?is9 &ssessment
??2 ?is9 ?eduction 2easure
S5< Success 5i9elihood <ndex
S5<2 Success 5i9elihood <ndex 2ethodology
1B
S?H S9ill, ?ule, Hno3ledge
1*
8HE?( 8echni;ue for Human Error ?ate (rediction
8S? 8emporary Safe ?efuge
t& Elapsed time for a3areness phase of muster
tEg Elapsed time for egress phase of muster
tEv Elapsed time for evaluation phase of muster
t< 8ime of muster initiating event
t2 8otal elapsed time of muster
t? Elapsed time for recovery phase of muster
"+
Ta1l$ 1 E?8 :udges and relevant 6ac9grounds0
*!7$ &lassi8i9ation
&% Engineer, /acility Engineer =author DAD>
B% Engineer, ?egulatory Engineer
C% Cperations, Control ?oom Cperator
D% Cperations =supervisory 6ac9ground>
E% Health and Safety =operations 6ac9ground>
/ Engineer, /acility Engineer
A Engineer, /acility Engineer
H Engineer, /acility Engineer
< Engineer, /acility Engineer
! Engineer, /acility Engineer
H &dministrative
5 Engineer, /acility Engineer
2 Health and Safety =operations 6ac9ground>
N Engineer, Contract (rocess Engineer
C Engineer, /acility Engineer
( Cperations =survival training 6ac9ground>
D Cperations, 2aintenance (lanner
? Engineer, /acility Engineer
S Engineer, ?eservoir Engineer
8 Cperations, 8rainer
U Engineer, 2aterials Engineer
J Health and Safety =operations 6ac9ground>
E Cperations =supervisory 6ac9ground>
# Engineer, Contract <nstrumentation and
Control Engineer
%C?8 mem6er
"1
Ta1l$ 2 2uster actions 6ro9en do3n 6y muster phase0
1 Detect alarm
" <dentify alarm
&ct accordingly
$ &scertain if danger is imminent
7 2uster if in imminent danger
. ?eturn process e;uipment to safe state
- 2a9e 3or9place as safe as possi6le in limited time
B 5isten and follo3 (& announcements
* Evaluate potential egress paths and choose route
1+ 2ove along egress route
11 &ssess ;uality of egress route 3hile moving to 8S?
1" Choose alternate route if egress path is not tena6le
1 Collect personal survival suit if in accommodations at time of
muster
1$ &ssist others if needed or as directed
17 ?egister at 8S?
1. (rovide pertinent feed6ac9 attained 3hile enroute to 8S?
1-
Don personal or 8S? survival suit if instructed to a6andon
1B /ollo3 C<24s instructions
""
R$9o3$2# Phas$
E3al!ation Phas$
A:a2$n$ss Phas$
E72$ss Phas$
Ta1l$ - Descriptions of performance shaping factors0
PSF D$s92i6tion
Stress
(S/ affecting the completion of actions as ;uic9ly as possi6le to
effectively muster in a safe manner0 8his is essentially the effect from
the muster initiator on the conse;uences of not completing the tas90
Complexity
(S/ that affects the li9elihood of a tas9 6eing completed successfully
6ecause of the intricacy of the action and its su6,actions0 8his,
com6ined 3ith a high level of stress, can ma9e actions that are
normally simplistic in nature complicated or cum6ersome0 8his (S/
can cause individuals to ta9e shortcuts =violations> to perform a tas9 as
;uic9ly as possi6le or not to complete the tas90
8raining
(S/ that directly relates to an individual4s a6ility to most effectively
identify the muster alarm and perform the necessary actions to
complete the muster effectively0 8raining under simulation can provide
a complacency factor as a highly trained individual may lac9 a sense of
urgency 6ecause of training4s inherent repetitiveness0
Experience
(S/ related to real muster experience0 &n individual may not 6e as
highly trained as other individuals 6ut may have experienced real
musters and the stressors that accompany real events0 Strong 6iases
may 6e formed through these experiences0
Event factors
(S/ that is a direct result from the muster initiator and the location of
the individual 3ith respect to the initiating event0 Distractions that can
affect the successful completion of a muster include smo9e, heat, fire,
pressure 3ave and noise0
&tmospheric
factors
(S/ that influences actions due to 3eather0 High 3inds, rain, sno3 or
sleet can affect manual dexterity and ma9e egress paths haFardous
3hen traversing slippery sections0 Extremely high 3inds negatively
impact hearing and flexi6ility of movement0
"
Ta1l$ 0 2uster scenario descriptions0
&o"6on$nt
M!st$2 S9$na2io
MO GR F;E
Situation
& person falls
over6oard resulting in
the activation of the
muster alarm0
& hydrocar6on gas
release in the process
units0
& fire and explosion in
the process units0
2uster
person in
;uestion
& very experienced
=17 years> operator
3ho at the time of
muster alarm is in the
process units draining
a process vessel0
&n experienced =
years> operator 3ho at
the time of muster
alarm is changing
filters in a solids
removal unit0
&n inexperienced =.
months> operator 3ho
at the time of muster
alarm is in the process
units 3or9ing valves
to isolate a vessel0
Eeather
8he incident occurs in
good 3eather and
calm seas0
8he incident occurs in
cold, 3et 3eather0
8he incident occurs
during a 3inter storm0
8ime of day
8he muster is
conducted during
daylight hours0
8he muster is
conducted during
daylight hours0
8he muster is
conducted during
nighttime hours0
5ocation of
muster
initiator
8he operator is on a
different dec9 than the
person 3ho has fallen
over6oard0 8he
operator does not see
or hear the muster
initiator0
8he operator is on the
same dec9 as the gas
release0
8he operator is on the
same dec9 as the fire
and explosion0
"$
Ta1l$ < (S/ rating scales for each muster action0
Ratin7
S9al$
P$28o2"an9$ Sha6in7 Fa9to2
St2$ss &o"6l$5it# T2ainin7 E56$2i$n9$
E3$nt
Fa9to2s
At"os6h$2i9
Fa9to2s
1++ no stress not complex
highly
trained
very
experienced
no effect no effect
7+
some
stress
some3hat
complex
some
training
some3hat
experienced
some
effect
some effect
+
highly
stressed
very
complex
no training
no
experience
large
effect
large effect
"7
Ta1l$ = Summary of predicted human error pro6a6ilities0
No. A9tion
HEP
Phas$ Loss o8 D$8$n9$s
MO GR F;E
1 Detect alarm +0++$** +0++B +0*.
&3areness
Do not hear alarm0
Do not properly
identify alarm0 Do
not maintain
composure =panic>0
" <dentify alarm +0++*B +0+"* +0B.
&ct accordingly +0++7$- +0+77 +0$$B
$
&scertain if danger is
imminent
+0++-$1 +0+-.7 +0$.7
Evaluation
2isinterpret muster
initiator seriousness
and fail to muster in a
timely fashion0 Do
not return process to
safe state0 5eave
3or9place in a
condition that
escalates initiator or
impedes others
egress0
7
2uster if in imminent
danger
+0++7B* +0+-+. +0$1.
.
?eturn process
e;uipment to safe state
+0++B.. +0+-B" +0$-$
-
2a9e 3or9place as safe
as possi6le in limited
time
+0++*+ +0+B7 +0$B*
B
5isten and follo3 (&
announcements
+0++7+- +0+.+7 +0$"+
Egress
2isinterpret or do not
hear (&
announcements0
2isinterpret
tena6ility of egress
path0 /ail to follo3 a
path 3hich leads to
8S?' decide to
follo3 a different
egress path 3ith
lo3er tena6ility0 /ail
to assist others0
(rovide incorrect
assistance 3hich
delays or prevents
egress0
*
Evaluate potential
egress paths and choose
route
+0++-1B +0+B+7 +0$-.
1+
2ove along egress
route
+0++$7 +0+-". +0$+7
11
&ssess ;uality of egress
route 3hile moving to
8S?
+0++.-- +0+-BB +0$*
1"
Choose alternate route
if egress path is not
tena6le
+0++B.* +01+++ +07++
1$
&ssist others if needed
or as directed
+0+1+1+ +0+.$* +07B
17 ?egister at 8S? +0++1". +0+1++ +0"++
?ecovery
/ail to register 3hile
in the 8S?0 /ail to
provide pertinent
feed6ac90 (rovide
incorrect feed6ac90
Do not don personal
survival suit in an
ade;uate time for
evacuation0
2isinterpret C<24s
instructions or do not
follo3 C<24s
instructions0
1.
(rovide pertinent
feed6ac9 attained 3hile
enroute to 8S?
+0++-B1 +0+$1 +0"B*
1-
Don personal survival
suit or 8S? survival
suit if instructed to
a6andon
+0++71- +0+".+ +01**
1B
/ollo3 C<2Qs
instructions
+0++7-+ +0+"+B +0"1+
".
Ta1l$ , Conse;uence ta6le for offshore platform musters0
S$3$2it# E72$ssa1ilit# Oth$2 POB M!st$2 Initiato2 H$alth
Critical
=C>
Can no longer
reach 8S? or
any other safe
refuge0 Can no
longer have a
dry evacuation0
(revents one or
more persons
from reaching
8S? or any safe
refuge0 (revents
others from
having a dry
evacuation0
?aises muster
initiator severity to
a level 3here
muster is no longer
possi6le0
?esults in
loss of life0
High
=H>
Can no longer
reach 8S? or
complete
actions in 8S?0
(revents one or
more persons
from reaching
8S? or prevents
others from
completing
actions in 8S?0
?aises muster
initiator severity to
a level 3here
muster is in
:eopardy0
?esults in
significant
physical
in:ury0
2edium
=2>
2oderate to
significant
delay in
arriving at 8S?0
2oderate to
significant
delay in
completing 8S?
actions0
2oderately to
significantly
delays others
from reaching
8S? or their
actions in 8S?0
?aises muster
initiator severity to
a level that
produces moderate
to long delays in
reaching 8S?0
(otential for
minor to
moderate
in:uries0
5o3
=5>
2inor delay in
reaching 8S? or
in performing
actions in 8S?0
2inor delay for
others reaching
8S?, or on others
completing
actions in 8S?0
<s not li9ely to
raise muster
initiator severity
and does not affect
time to muster to
any significant
level0
No in:uries
li9ely0
"-
Ta1l$ / Human error mechanisms =adapted from Hennedy, 1**>0
E22o2
M$9hanis"
E22o2 Fo2" M!st$2 E5a"6l$
Shortcut invo9ed & 3rong intention is formed 6ased on
familiar cues that activate a shortcut
or inappropriate rule0
8he 3or9place is not made safe 6efore
starting egress to the 8S?0
/ailure to
consider special
circumstances
& tas9 is similar to others 6ut special
circumstances prevail 3hich are
ignored and the tas9 is carried out
inappropriately0
&n egress path is chosen 3ithout
considering its proximity to a gas
release0
Need for
information not
prompted
8here is a failure of internal or
external cues to prompt the need to
search for information0
& malfunction of the muster alarm
system prevents important messages
from reaching personnel0
Stereotype
overrule
Due to a strong ha6it, actions are
diverted along a familiar 6ut incorrect
path3ay0
&n egress route ta9en during muster
drills is chosen during a gas release
despite the path4s close proximity to the
muster initiator0
&ssumption ?esponse is 6ased, inappropriately,
on data supplied through recall or
guesses 3hich do not correlate 3ith
availa6le external information0
(rior to opening a door, no chec9s are
performed on surface temperature
despite a 9no3n fire in the local area0
2isinterpretation ?esponse is 6ased on incorrect
interpretation of data or the
misunderstanding of a ver6al
message command or re;uest0
& (& announcement is misinterpreted
and an egress path of lo3 tena6ility is
ta9en0
2ista9e among
alternatives
Several options are availa6le, of
3hich the incorrect one is chosen0
8he muster process offers alternative
modes of egress and the incorrect path is
chosen0
5osing one4s
place
8he correct position in the se;uence
of actions is misidentified as 6eing
later than actual0
Cnce in the 8S?, an individual does not
register, generating a missing person
scenario0
2otor varia6ility 8here is a lac9 of manual precision,
or incorrect force is applied0
&n individual does not effectively close
a valve 3hile ma9ing the 3or9place
safe0
(anic 8here is a lac9 of composure, and the
result is disorientation, incoherence
and possi6ly static movement0
Upon hearing the muster alarm or
3itnessing the muster initiator, a person
6ecomes incapacitated0
2emory slip (erformance of an action or some
component of the action is forgotten0
2ustering individuals forget 3hich
direction the 8S? is from their current
location0
Spatial
orientation
inade;uate
Despite an individual4s correct
intention and recall of identification
mar9ings, an action is performed in
the 3rong place or on the incorrect
o6:ect0
&n individual chooses a similar 6ut
incorrect valve 3hile in haste to ma9e
the 3or9place safe 6efore starting egress
to the 8S?0
"B
Ta1l$ . (ossi6le ris9 mitigation measures for action 10
A9tion T2ainin7
P2o9$!2$s an
Mana7$"$nt S#st$"s
E>!i6"$nt
Detect
alarm
10 /amiliariFation of
personnel 3ith
alarms
"0 2uster training at
infre;uent intervals
0 Enlisting feed6ac9
after training
exercises on alarm
effectiveness
$0 Behavioural
studies to determine
panic potential
70 8raining of control
room operators to
limit and remove
inhi6its as soon as
possi6le
.0 8raining of
experienced
personnel to assist
others as identified
10 ?egular preventative
maintenance of alarm
system
"0 ?egular testing of
alarm system
0 Survey of alarm
effectiveness in severe
3eather conditions
$0 5imiting num6er of
alarm types that can 6e
enunciated to lessen
potential confusion
70 <dentification of ne3
personnel 3ith
different coloured
clothing
.0 Buddy system for
ne3 personnel
-0 5ocation 6oard in
control room
identifying 3or9
locations and
personnel
B0 E;uipping all
personnel in process
units 3ith t3o,3ay
radios
*0 (ush6uttons in
strategic process
locations
10 Strategic
placement of alarm
systems to ensure
coverage in all
areas
"0 &larm
redundancy
through 6oth audio
and visual
enunciation
0 ?evie3 of alarm
system and
comparison 3ith
advances in
technology
$0 ?evie3 of
applica6le
regulations and
standards
"*
FIGURE &APTIONS
Fi7!2$ 1 &pplication of S5<2 in D?&0
Fi7!2$ 2 Araphical representation of the phases comprising a muster se;uence0
Fi7!2$ - 2uster se;uence0
Fi7!2$ 0 (S/ 3eights for man over6oard scenario0
Fi7!2$ < Comparison of 3eights for event factors (S/ for all three muster initiators0
Fi7!2$ = (S/ ratings for man over6oard scenario0
Fi7!2$ , Comparison of ratings for experience (S/ for all three muster initiators0
Fi7!2$ / S5< values for each action and muster scenario0
+
Fi7!2$ 1
1
5ac9 of event data
=2uster>
Choose structured expert
:udgment techni;ue
?SLIM@
(reparation
=Duestionnaires, !udges>
Elicitation
=Eeights, ?atings>
Calculation
=S5<s, HE(s>
&nalysis of data
?esults
S5<2
process
Fi7!2$ 2
"
<nitiating
Event
=t< >
8ime to 2uster =t2>
&3areness
(hase
=t&>
Evaluation
(hase
=tEv>
Egress
(hase
=tEg>
?ecovery
(hase
=t?>
Elevated Exposure
(hases =EE(s>
?is9 increasing 3ith time to muster





2uster &ctions
&6andon or
Stand Do3n
Fi7!2$ -

Detect alarm
<dentify alarm
&ct accordingly
&scertain if danger is
imminent
no
?eturn process
e;uipment to safe state
2a9e 3or9place safe
2usterOEgress
#$s
Evaluate potential egress
paths and choose route
2ove along egress
route
5isten @ follo3 (&
announcements
Collect personal survival suit
if in accommodations at time
of muster
&ssist others if needed
or as directed
Choose
alternate egress
route
?egister at 8S?
(rovide pertinent feed6ac9
attained 3hile enroute to
8S?
Don survival suit if
directed to
/ollo3 C<24s
instructions
not t$na1l$
t$na1l$
&ssess ;uality of egress
path
+
1+
"+
+
$+
7+
.+
-+
B+
*+
1++
1 " $ 7 . - B * 1+ 11 1" 1 1$ 17 1. 1- 1B
&ction
E
e
i
g
h
t

Stress
Complexity
8raining
Experience
Event /actors
&tmospheric
/actors
Fi7!2$ 0
$
+
1+
"+
+
$+
7+
.+
-+
B+
*+
1 " $ 7 . - B * 1+ 11 1" 1 1$ 17 1. 1- 1B
&ction
E
e
i
g
h
t
2an
Cver6oard
Aas ?elease
/ire @
Explosion
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