PTP-Global

Accident Investigations and ways to

predict, prevent and minimise human failure

Tim Southam. QCVSA, BSc, FIEHF, FIIRSM, CFIOSH

Director PTP-Global

PTP-Global

Electronics Design 8 Years

RAF Pilot 21 Years – Jaguar /

Tornado – Rae Farnborough

Human Factors Specialist -

Registered Ergonomist and

Chartered Safety Professional

Specialist in Virtual Reality

design, workload, fatigue, Human

Error, Human Factors Integration,

Human Performance. Human

Factors Engineering.

Associate Consultant with:

The Keil Centre

Abbott Risk Consulting

Marex Marine

PTP-Global

• We are very good at saying Human Error is an issue and plays a part in 80% of accidents

– Then do little about it or put it in a pigeon hole.

• We say “No harm to people, equipment and the environment.

– Then do not remove the opportunity for it to happen again or the conditions for human failure.

• We investigate accidents and incidents

– Then stop at the person and do not get to the real root causes of human error.

• What we say we do

– We often don’t

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Be Aggressive

and Pro-active!

The causes of

tomorrow’s events

exist today! Latent System Weaknesses Accumulate!

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Chronic Sense of Uneasiness

An attitude of mindfulness

regarding one’s capacity to err

and the presence of hidden threats;

preoccupation with failure

“When you stop being scared, you start making mistakes.” -- unknown

--how you perceive, think, feel, and behave toward hazards--

Organisational Alignment

Engineering Systems Behaviours

Trends Trends

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What do we do to Prevent or Reduce Human Error?

We do not diagnose the pain

• Safety Critical Task List • Predictive Human Error Analysis

(PHEA) • HAZOP including HE Guidewords • Safety Case including Human Factors

as per APOSC and legislation • Human Error Analysis in AI using

HFAT or other software

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Three Serious Concerns

1. Hardware Vs Human issues and the focus on

Engineering.

• Despite the growing awareness of HF in safety, the

focus is almost exclusively on engineering and

hardware aspects at the expense of people issues.

• When the operator moves from direct involvement to a

supervisory or monitoring role, in a complex system,

they will be less prepared to take timely and correct

action in a process abnormality. The opeator, often

under stress, may not have situational awareness or an

acurate mental model of the system state and the

actions required.

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2. Focus on Personal Safety.

• The majority of major hazard sites still tend to focus on occupational

safety rather than process safety and those sites that do consider

human factors issues rarely focus on those aspects that are

relevant to the control of major accident hazards.

• Sites consider the personal safety of those carrying out

maintenance rather than how human errors in maintenance

operations could be an initiator of major accidents.

• This imbalance runs through the safety management system, as

displayed in priorities, goals, the allocation of resources and safety

indicators

• The causes of personal injuries and health are not the same as the

precursors of MAH and are not an accurate predictor – this will lead

to complacency

• Thus the management of Human Factors in major accidents is

different to traditional safety management.

• Clearly, an SMS that is not managing the right aspects is as

effective as NO system.

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3. Focus on the Front-line Operator.

• In general most safety activities are focused on the behaviours and

actions of individual operators.

• However, operators are often ‘Set-up’ to fail by management

and organisational failures.

Rather than being the main instigators of an accident, operators tend to be

the inheritors of system defects created by oor design, incorrect installation,

faulty maintenance and bad management decisions. Their part is usually

that of adding the final garnish to a lethal brew whose ingredients have

already been long in the cooking.

James Reason (1990) “Human Error”

• Audits rarely consider management and organisational factors such

as the quality of management decision making or allocation of

resources.

• Safety culture is seen as something that operators have and that

this does not fall within management responsibility.

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If culture, understood here as mindset, is to be the key to preventing major

accidents, it is the management culture rather than that of the workforce in

general that is most relevant. What is required is a management mindset

that every major hazard will be identified and controlled and a management

commitment to make available whatever resources are necessary to ensure

that the workplace is safe.

Hopkins, Lessons from Longford

• Audits of management systems frequentlty fail to to report bad

news.

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The Problem is…… It is not impacting these

This will only succeed if we deal with

BOTH Unsafe Acts

and Unsafe Conditions

? ? ? ?

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Our Goal: Minimising Human Failure

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How we execute AIPSM in upstream

Leadership is the key enabler

HSE Case

HSE Cases per HSE Case Guide Manual of Permitted Operations (MOPO) ALARP Process Guide 5 Year Process Safety Review (PSR) Process Guide

Maintenance and Integrity Execution Safety Critical Equipment (SCE) TI Performance Standards (TIPS) Assurance Tasks for SCEs, How Work Gets Done

Operating Integrity Operating Envelopes/Windows, Alarm Management, Competence, Effective Permit to Work,

Projects and Engineering Integrity Global DEM1 DEP’s DEM2 (PSBRs) Statements of Fitness (SoF) Critical Documents/Drawings

Well Integrity Well Failure Model (WFM) eWIMS Electronic Data Manager (EDM) WIMM (Well Integrity Mngt Manual)

Bypass Register

Shift Handover Key Dwg & Docs

Technical Integrity

Verifications (TIV)

Through five global workstreams

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How the workstreams relate to the 22 requirements

HSE Case

#1 Identify and document PS hazards #2 Manage risks to ALARP #3 Manage competencies in HSSE Critical Positions #6 Supervision of HSE Critical Activities (Identify)

#12 Process Safety Reviews (PSRs)

All requirements covered via Well Integrity Management standard

Maintenance and Integrity Execution (MIE)

Operating Integrity (OI)

Well Integrity

#15 Technical Integrity of HSSE Critical Equipment #16 Maintain HSSE Critical Equipment

#7 SoF (restart of Existing Asset) #13 Work in Classified Areas #14 Operate within Operational Limits #17 Permit to Work

Projects and Engineering Integrity (PEI)

Integrity Leadership

#7 SoF – Start-up of New Assets / Modes #8 Technical Integrity in Design / Construction #9 Use of DEM 1s

#10 PSBR Requirements #11 Documentation for HSSE Critical Equipment

#22 Demonstrate Leadership in PS

Requirements handled by the five workstreams

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The Problem is……

? ? ? ?

Personal Safety

Process Safety

Everyone on the Pitch

Increased Focus and Urgency

Engineering Issues

Design, Packages,

Access, signs,

Maintenance

Layout

Alarm Handling

CCRs, Screen Config

Process Visability

Interfaces

Useability, HAZOP

HF Guide-words

Safety Critical

Task Analysis, PHEA

Procedures

Integration

Organisational Issues

Man of Change

Leadership &

Supervision

Workload / Time

Training and

Competency

Resources

Fatigue

Behaviours

People Issues

Human Failure

Accident Invest – HEA

Safety Critical

Communications

Organisational

culture

Performance

Human

Failure

Our Goal: Minimising Human Failure

PTP-Global

Safety

Case

MAH

PSM

Accident Investigation

Human Factors

MoC HF Integration

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Safety management is about:

diagnosing the symptoms,

to determine causes;

and then treat those causes or

suggest appropriate treatment to management

Not put the conclusions in a pigeon hole called “Human Error”

If we do not diagnose properly – we will never find the CAUSES

Getting to ZERO is a vision – We are Human and have a brain – that’s why we are very vulnerable.

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Principles of Human Performance

• Humans are fallible . . . Even the best people make mistakes.

•Error-Likely Situations are . . . Predictable, manageable and preventable.

•Individual behaviour is influenced by . . . Organisational processes and values.

•Behaviours are reinforced . . . People achieve higher levels of performance

•Events are avoidable . . . By understanding the reasons mistakes occur. By applying lessons learned

Ac tio nAc tio nSayingSayingBe lie fBe lie f

FilterFilter

Perceptio

ns

Perceptio

ns

AssumptionsAssumptions

ExpectationsExpectations

ValuesValues

BeliefsBeliefs

Defence MechanismDefence Mechanism

EmotionsEmotions

FilterFilter

Differentiate –

were all different

GENDER

NATIONALITY

PARENTAL LOVE

UPBRINGING

EDUCATION

CULTURE

LIFE’S EVENTS

Stress

Fatigue

Workload

Working Hours

Shifts

Logic Lists Language Analysis Linear 123456789

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1 We take in information

through our senses

2 We process the

information and make

decisions …

3 … referring to our

memory store

4 We act accordingly

in line with the decision

made

Information processing

1 We might misread

something, we might miss

something important, we

might choose to focus on

certain things rather than

others 2 We might make the

wrong connections, we may

not have all of the facts, we

might make the wrong

assumptions

3 We might forget or fail to

remember important

information

4 We might select the

wrong response, we might

set out to act in one way

but get “clumsy”

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Learning The Lessons

Yet they have not dealt with:

– ensuring adequate resources for tasks,

– reducing “initiative overload”,

– dealing with maintenance backlogs

– and long working hours,

– and have created high workloads, high

fatigue levels in the workforce.

– Stress is High

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Los Rodeos Airport, Tenerife 27th March 1977 - 583

Human factors – why bother?

The Herald of Free Enterprise 6 March 1987 - 193

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Process Safety Management

… it must be more about insights, recoveries

and adjustments.

Less about sticking to the checklist as the

plane goes down.

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Ergonomics - Make Safety Achievable

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The Management of HF

Do you have a

competent person or

access to competent

help in Human Factors

Risk Assessment

Do they apply

knowledge of HF in

identifying and

assessing risks

Management System

Is there a functioning

SMS that can assure

standards are

maintained

Design

Does design of

plant,procedures,

controls take account of

HF People

Are people involved in

the control of Major

Hazards, competent, fit,

have appropriate

supervision and control

0 = HF not addressed

1 = Some good practice

2 = Good practice + plan

3 = Good practice due to plan

4 = Best Practice due to system

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Vulnerability HSE

Financial

Reputation/ Social

Lifecycle Risk Management – Appraisal to Disposal

Co

nce

pt

Des

ign

Co

nst

ruct

Co

mm

issi

on

Op

erat

e

Res

tore

Mo

dif

y

Dis

po

sal

De-

com

mis

sio

n

Acq

uir

e

Working Environment

Task Analysis PHEA

Work Org HAZOP + HF

Management System HF in AI and HEA

PTP-Global

• Your main goal is improving safety

• A key component of improving safety is reducing

human error

Reduce the number of errors

Put defenses in place to reduce their impact

• Why use task analysis?

• Because it builds a concrete, thorough description of

what people do

Task Analysis

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• HTA is the concrete representation of the actions taken

towards user goals and the logical relationship between

those steps.

• Tasks are broken down into their sub-components,

plans describe how all the pieces fit together

• Components

Tasks (sometimes called goals or operations);

Verb/action/qualifier

Subtasks

Plans

Task details

Hierarchical Task Analysis (HTA)

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• Use the task analysis as the basis for reviewing the

human aspects of the system – for the Critical Tasks

• Develop the following task details

Performance Influencing factors

Potential error

Hazard

Potential consequences

Severity

Likelihood

Mitigation strategy

Error Reduction

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Ergonomics - Make Safety

Achievable

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Human Error Analysis

• Understand why unintentional behaviours occur

• To understand why is to be able to fix it

• Systematic method to ensure thorough analysis

– Developed for Air Traffic Control, adapted for BP

• Internal and external “performance-shaping factors"

– Linked to CLC causes

• Based on information processing model

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Error types

• Unintentional behaviour = dialling the wrong phone number from your mobile

• Perception error – Mistaking a ‘3’ for an ‘8’ on the display screen

• Memory error – Recalling 0131 667 8059 as 0131 677 8059

• Decision error – Dialling home from abroad, and getting connected to a local number

• Action error – Mis-keying two adjacent numbers

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Performance Influencing Factors • Task Factors

• Communication Factors

• Procedures and Documentation

• Ambient Environment

• Training and Experience

• Human-Machine Interaction

• Personal Factors

• Social and Team Factors

Number of tasks, Complexity, Time Pressure, Workload, non-standard activities

Communication workload, Phraseology & Standards, Language and accents, information content, method, Quality, equipment quality and reliability

Procedure availability / access / location, No of

Procedures, accuracy, correctness,

completeness, clarity, validity, format, do-ability,

suitability, compatibility

Weather, Noise, Distraction, Lighting,

Temperature, Air quality

Familiarity with Task, experience, time on job, training, quality of training, suitability of training, recency of training, competence testing, mentoring quality.

Information accuracy / correctness, info type and format, info availability / access, Quality, completeness, clarity, complexity, validity, info structure, location, position, equipment reliability, trust in equipment, allocation of tasks between person and systems, health risks, ergonomics, visual display quality,

Alertness / concentration / fatigue, emotional state, stress, anxiety, boredom, confidence, complexity, job satisfaction, Domestic issues, fitness / physical health issues, Mental health, drugs and alcohol.

Team co-ordination, quality, groupthink, handover / takeover, structure & dynamics, Team relationships and trust, Maturity, inter-team co-ordination, Age, Shift organisation, assistance and support, working methods, staff availability, allocation of responsibility

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Leve

l of

Det

ail

Error

Type Perception

Unintentionally pressed the

wrong button on a control panel

Error

Mode Selection error Unclear information

The wrong button was

pressed

Incorrect information

Error

Mechanism Other slip Human

variability

Intrusive

thoughts /

habits

Confusion

Two buttons looked

similar and were in

close proximity Distraction

Preoccupation

Memory Decision Action

Performance

Shaping Factors Clarity of information, equipment ergonomics, workload

Human Error Classification Scheme

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External Environment

Organisational Culture

Underlying Causes, Root Causes,

Systemic Failures

Maintenance Management

Ho

usekeep

ing

Hardware Training

Pro

ced

ure

s S

yste

ms

Error Enforcing

Conditions

Defences

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Accident Reporting, Analysis & Follow-Up

• Systems should be in place to:

– Determine the root cause of each incident

– Identify specific follow-up action and systems to be corrected

– Analyse all incidents to identify common root causes and to determine changes necessary to prevent future incidents by elimination of those causes

– Ensure close out of follow-up items and assess or measure the success or failure of actions taken to reduce incidents

– Encourage open and frank incident reporting by all employees through reducing emphasis on apportioning blame and emphasising the benefits of lessons learned

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Investigation Weaknesses

• No Human Error Analysis

• Focus on people and away from systems

• Failures in management systems not uncovered

• Not all facts presented

• Cover up occurs

• Reinforcement of ‘Production Must Come First’

• Repeat of incident or similar incident

• Management credibility potentially threatened

• This leads to workforce scepticism

• Likely to lead a disaster in the long term

PTP-Global

Human Error

• Is not a cause of failure. It is the effect, or symptom, of deeper trouble.

• It is not random. It is systematically connected to features of people’s tools, tasks and operating environment.

• It is not the conclusion of an investigation. It is the starting point!

PTP-Global

Human Error

Old View

• Human error is a cause

of accidents

• To explain failure you

must seek failure

• You must find people’s

inaccurate assessments,

wrong decisions, bad

judgements

New View

• Human error is a symptom of trouble deeper inside a system

• To explain failure, do not try to find where people went wrong

• Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them

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Hindsight

• Means being able to look back, from the outside, on a sequence of events that lead to an outcome you already know about;

• Gives you almost unlimited access to the true nature of the situation that surrounded people at the time (where they actually were versus where they thought they were; what state their system was in versus what they thought it was in);

• Allows you to pinpoint what people missed and shouldn’t have missed; what they didn’t do but should have done.

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We must stop and re-think

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Build commitment progressively...

A few champions trying something,

but not in the same direction

A lot of people trying to do things better,

but not always in the same direction

Everyone working together effectively,

all in the same direction

Ineffective Getting better Ideal

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Could this happen to us?

• Complacency due to our superior safety performance

• Normalizing our safety critical requirements

• Ineffective Risk Assessments of our systems

• Reversing the Burden of Proof when evaluating safety

of operations

• Employees Not Speaking Freely of their safety

concerns

• Saying were a TEAM and then blaming individuals

• Business Pressures at odds with safety priorities

• Failure to Learn and apply learnings to improving our

culture

PTP-Global

Human Error High Costs of Accidents Accident Potential Workload and Fatigue Inefficient systems and procedures Potential for Major Accidents Non-compliance with regulations Non-compliance with current guidelines

High Performance Higher Reliability Organisational Alignment HF Understanding and Awareness Proactive Risk Assessments Human Centred designs and Operations More effective Control rooms Communication and Systems Feedback More effective alarm handling Manning levels at correct level Effective Shift-work and handovers Safety Culture Workforce Interaction and Involvement Happy Regulator

COSTS

15-20%

£

PERFORMANCE

Human Factors Integration

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Conclusion Processes Need Humans

Humans are involved in processes from the outset.

Safety is maximised by optimising the human involvement, not by

minimising it.

Operators of processes need to be involved systematically with its

design.

Design Must Accommodate Human Performance… just like any

other component of the system.

Human Factors Engineering is a mature discipline that is based on

reliable, validated descriptions of human performance.

It specifies safe operational limits for human work and design

interfaces with other components.

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Let us Co-Invent the Future

PTP-Global Ltd www.ptp-global.com tim@ptp-global.com Tel: 07793018205