Transcript
Welcome to the Operator Training edition of Chemical Processing's Distilled Podcast. This podcast and its transcript can be found at chemicalprocessing.com. You can also download this podcast on your favorite player. I'm Traci Purdum, Editor in Chief of Chemical Processing. And joining me is Dave Strobhar, Founder and Principal Human Factors Engineer for Beville Engineering. Dave is also the founder of The Center for Operator Performance. Hey Dave, how are you?
Dave: Doing great, Traci. Doing great.
Traci: Good. You had suggested an interesting topic for this Operator Training series, fixation. And you gave me some background material so I could get my head around the subject. And I think one of the best lines from that background was this, "Fixation is like a moth that cannot escape a flame." So, with that visual in mind, let's get into this a little bit. First off, what is fixation?
What Is Fixation?
Dave: So, fixation is where we come to a solution or a concept that defies contrary evidence. We believe that this answer is correct, or we have a belief that, well, this is the way it is, and people can throw out all this contrary evidence, and it doesn't budge you. And that quote is because it's wired into us. That's how we, as human beings, tend to function. Just like visual issues we have or auditory issues, it's in there. And we can't help but get caught up in this problem of fixation. We used to call it confirmation bias, which means, obviously, once I come to a conclusion, I'm biased against it. I seek out information that supports my conclusion, and I dismiss information that goes against it. And then, before that, we used to call it tunnel vision, that, "Hey, I quit taking in new information. I am just going to use what I have right now. Don't cloud the issue with facts because I'm confident in what's going on." That's what we are calling fixation today.
Why Is Fixation – Or Confirmation Bias – A Problem?
Traci: And I think as you pointed out, we all fall into that very much so. But let's talk a little bit about why this is a problem, especially for operators and for folks in the industry here. And are there examples of it happening? I'm sure you have plenty.
Dave: Oh, yeah. So, it is definitely a major stumbling block in decision-making. Probably one of the more famous examples of fixation wasn't with process operators but the 1972 Yom Kippur War in Israel. Leading up to that war, Israel was very confident that Syria and Egypt were not going to attack them despite weeks of evidence to the contrary, there were amassing troops at the border and all sorts of things. It wasn't until the night before the attack that the Israelis finally said, "Hey, I think they're actually going to attack us." And Israel was caught off guard, and they had huge losses. And so, there's that sort of fixation. They were fixated on that, "We're not going to be attacked, and so, again, don't cloud the issue with facts, don't bring up these other things." So that certainly was the case with just human nature in general.
Process operators, when I was working at Three Mile Island, one of the causes of that particular incident where the operators were so sure that the problem did not have to do with this stuck relief valve off the pressurizer that even though more and more evidence was indicating, "Hey, that's the problem," they weren't going to take it. They're like, "No, no, no, no, that's not it. We checked it, it's not part of the problem." So, we see this numerous times where operators say, "Hey, we know what's going on. I was in one control room, and the console is showing it's a fired reboiler, and it's showing that it's really hot." And for some reason, the operators didn't believe what they were seeing on the screen. The head operator went out with a heat gun, and all of a sudden, he comes running back in, and he's going, "It's real. It's real. Cut the heat. Cut the heat."
Traci: Oh, geez.
Dave: So, we get into that, and again, it's that moth to the flame, we can't help it, but that's where we're trying to do things to not have that happen. Fortunately, they got through that; they didn't burn down the heater, but those are the sort of things that can happen because you become so tied to this one idea, this one state of affairs that, "Don't bother bringing up anything else because I'm not going to factor it in."
How To Stop Fixating
Traci: So how do we combat that? I mean, when you're stubborn, you're stubborn, right? I don't know if stubborn is the right word, but how do you unfixate, if that is a word?
Dave: Yeah. Yeah. I'm not sure, but it's a good one for this podcast, so we'll use it with it. So, just knowing it can happen helps a lot because it tends to cause you to perhaps entertain notions that maybe you wouldn't otherwise. If you know that you could potentially fixate, that alone is going to help you be open to more things, and you're not going to be as rigid.
But there are some other things that you can do. There are a couple of different tactics that you can use. One is called the two-strike rule. One anomalous situation, indication, well, that happened. I was involved in it. It was a training exercise, and we were the scenario of flow through the charge heater. And I'm thinking pump is cavitating. And then, there were these pressure spikes in the reactor, this was a cat cracker, and I ignored those pressure spikes because I really didn't know what to do with them. And I was sure it was this pump cavitation. And I was assuming everything. I was seeing everything in the pump cavitation. So even though my level looked fine, I was like, "Well, that's probably a bad transmitter. The level indication's lying to me and that we're doing it." Now, I'm getting these pressure spikes, and it's like, "Well, I don't think that's it."
But it's sort of if you're getting two pieces of data that are contrary to what you think, you try to train yourself, or you train your operators at, hey, that's probably a key to say, "Maybe I should step back and reassess this situation." That's one way to help overcome it. Another is just test some hypotheses. In other words, I thought this was a pump cavitation, maybe somebody could have thrown out, "Well, hey, what if it's water in the feed? How would that be different than your pump cavitation?" And I might've gone, "Huh! Yeah, you know what? Water in the feed wouldn't affect the level, it would flash in the heater, and it causes those flow problems, and it would cause that. Oh, hey, that's a better fit than the one I had."
And this is part of the whole what they call crew resource management or team training. This is where the team would come into play. As far as providing these alternate hypotheses, does this one fit better? If you used to watch the series House, they did this from a medical perspective, which disease better fit the symptoms with it? So if your crew can provide these alternate hypotheses, you can test them and see what's occurring.
One of the surprising ways that fixation is overcome, not intentionally sometimes, is shift change. Basically, bring in a new set of eyes who can look it over and, "Why do you think it's the pump cavitation when I see this as possibly water in the feed?" So, the shift change can be a powerful tool, or maybe it's just pulling somebody new into the assessment and see what they have to say.
The operators at Three Mile Island, when they got caught up on what was occurring, the accident actually ended when the oncoming shift came in, and the new shift supervisor said, "I want you to close the block valve off of this relief valve." And the crew that was on there said, "That's not the problem." And he says, "I don't care, close it anyway." And they did, and that's what stopped the leak. That fresh set of eyes does wonders in terms of taking you away from what you might have thought to see it in a different fashion and use that as a way to get forward.
The other thing is I try to teach people to become curious about some of these anomalies that are happening. The exercise I was going through, why is the pressure spiking in the reactor? I didn't have any answer for that, but if somebody had said, "Well, wait a minute, what would cause that in addition to what we were already seeing?" "Well, gee, if that water got back up into the reactor, it would flash there as well, and we would see these pressure spikes trying to happen." Trying to not just dismiss the negative information. "Oh, well, that's crazy," or, "Oh, that's a bad instrument," or, "Well, I don't trust what the previous crew did." Think about, "Well, maybe it is true. And let me investigate it. Let me see if I can't pull something in and use that in coming up with a different look at it."
We often hear about situational awareness, and that's a key part of fixation. That's tunnel vision that actually sort of brought us up to the issue of situational awareness. We lose the big picture. We're stressful. We're in this upset. We're in this incident. We're going to focus in on the problem at hand. We're looking at a very detailed section. Taking a look at the big picture, and that's actually a function of two different things.
One is having a good display that shows you the big picture. And that's a real problem in the industry is the operators often fail to have that big picture display so they can see what's going on. And then often it's having somebody disengaged, that isn't there trying to man the valve moves and the alarms. Whether this is a head operator or shift supervisor or somebody to step back and say, "Is this making sense in the big picture view?" and not getting caught up in the details of making it happen. This is also a way in which procedure automation, we're trying to free the operator up. So rather than having to make all these valve moves, well, let's have the DCS make them valve moves, and let's free the operator up to try to figure out what's going on and not worry about, "Did I open this valve? Did I close this particular valve?" So giving them that chance to maintain the big picture, maintain their situation awareness. To be able to say, "What I thought was happening is not what I thought was occurring."
And then finally, probably one of the main items is to listen to people on the team, again, who may be in some way presenting different views. I don't think this is right. Again, this gets back to this crew resource management or team training, somebody on the crew who feels that they can bring it up and say, "Hey, I think you're wrong. I think it's water in the feed. I don't think the pump's cavitating." If you've created an environment where they can speak freely, they're used to bringing up those things, then they can be a way to help, again, nudge you out of your fixation so that you look at things.
But if you've created this very rigid structure, "Hey, I'm the head operator and don't question me, don't talk unless you're spoken to," you're not going to get that kind of input from the crew and use it and tap their experiences to have them potentially bring up these alternate ideas that you may want to be looking at.
Diverse Work Teams
Traci: Everything that I'm thinking of when you're talking about all of this is the diverse work teams, the diverse teams, and having all of those different opinions in there, can that help or will that team become complacent over time and become fixated on the same things?
Dave: That's the environment of how the team is functioning, that if they are rewarded for bringing up alternate views and they feel there's an environment of, the term is psychological safety, that, "Nobody's going to make fun of me." We've all heard that there is no such thing as a stupid question, and we've all heard stupid questions, but if you are encouraged to like, "Hey, just bring this up. You're not going to be mocked. You're not going to be dismissed."
So, if you have a good team environment, they probably won't be brought into that sort of fixation. Somebody has to be a decision maker, and they're going to have to say, "Hey, I think it's a pump cavitation. Go out and check that pump." And even though they're like, "There's water in the feed," but it's like, "Hey, he's the boss, I'm going to go do it." So all you can do in the team thing is they need to be able to bring it up, they need to feel safe to bring it up, and hopefully, it will be used and factored in, but there's no guarantee that that's going to happen.
If the people say, "Well, I think it's water in the feed, but I'm not going to bring it up because they're going to laugh at me, or they're going to say, "That's a stupid idea," or, "Hey, we don't question the head operator here, he's in charge," then there's no hope for that new information to potentially get in and shift that fixated view that the decision maker is running into.
Fine Line Between Experience and Fixation
Traci: Well, you certainly give me psychological safety because I ask my fair share of dumb questions in our interactions, so I appreciate that. And it makes absolute sense. But here's another question for you. Is there a fine line between experience and fixation?
Dave: Well, there is because again, sometimes problems, what seems obvious may not be obvious. So, my example, I was like, "Well, level transmitter tends to plug, so I think I got a bad level indication." That can be based on actual experience, and so, I get used to, "Well, I've seen this before," and this has been a problem. This is one of the dilemmas in Cry Wolf alarms that, "Hey, I've seen this, and it's happened all these times, and it's never anything." Or the industry, we suffered a fatality a few years ago because the console was constantly getting these low oxygen alarms and in a particular area and to the point where they said, "Hey, this has happened. I've gotten 10 of these alarms and I've sent an operator in there to check it out 10 times and nothing's there, so I'm going to assume there's nothing there."
We are constantly updating these mental probabilities that we have. Is this possible? Apparently, the 11th time they send a person into an oxygen-deficient atmosphere and a fatality occurred. So experience can be a two-edged sword in that regard, in that if we've seen something a lot, it can cause us to be fixated. But at the same time, it may create a situation where, "I know what the symptoms seem to be saying, but I have also experienced this and it wasn't what we thought it was, so we need to go back and look at it at a different place."
So, you talk about fine line, it is a fine line. And again, a lot of this has to do with if you can stay open to alternatives, then hopefully, the experienced person can say, "Yes, this is a low probability," or, "Yes, I know that, well, maybe I should be looking at these symptoms," and will test out that hypothesis against their experience and say, "Oh, okay, yeah, this is really an issue that we need to be dealing with.
Resources To Eliminate Fixation
Traci: Are there any resources available to help with this sort of training?
Dave: Well, there are. The Center for Operator Performance, one of our initial projects had to do with decision-making exercises. And these were developed. They're scenario-based. You give symptoms, and then the student, the trainee is there to try to come up with, "Well, okay, what do I think is happening?" And you constantly provide these symptoms that they're going to react to, but you provide some red herrings in there too. You provide some misleading ones. And so, they have to decide, "Should I be paying attention to this?"
The example I've been giving you is, "Well, those pressure spikes, should I be paying attention to those?" Because not everything is relevant to the scenario at hand. So, these decision-making exercises, they're a way to help as you're going through the drill, "How would I find different alternatives?" And you can gear them to that. "How do I get input?" And particularly if you do it as a team rather than as an individual. So, you've got the crew, each one is coming up with their thoughts as to what's happening, and then they can kind of see how everybody's making their decisions with it. So, the decision-making exercises are a good tool for a whole range of opportunities, but fixation would be one of them. "How do I use this information?"
Traci: Well, Dave, as always, in this topic, fixation, don't cloud the issue with facts, you've helped us flip the script on that. And we always appreciate your insight to these topics.
Want to stay on top of operator training and performance? Subscribe to this free podcast via your favorite podcast platform to learn best practices and keen insight. You can also visit us at chemicalprocessing.com for more tools and resources aimed at helping you achieve success. On behalf of Dave, I'm Traci, and this is the Chemical Processing Distilled Podcast Operator Training edition. Thanks for listening. Thanks again, Dave.
Dave: Thank you, Traci.
