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© The Keil Centre 2015
1
Human factors in major hazard safety: the top 10 issues
Ronny Lardner AFIChemE Registered Psychologist
and organisational v
© The Keil Centre 2015
About your speaker
• 22 years experience as applied psychologist in high-hazard industries
• Founder of The Keil Centre Ltd
• Associate Fellow of British Psychological Society & Institution of Chemical Engineers
• Registered Psychologist in Australia
© The Keil Centre 2015
Overview • Top-ten "human and
organisational factors" most relevant to high-hazard industries
• UK oil and gas industry
experience of making improvements on these topics
• A case study
• Further reading & resources
• Questions / comments
3
© The Keil Centre 2015
Why “human factors”? • UK Health and Safety
Executive General guidance on human factors
HS(G)48 10 key human factors topics for
hazardous sites / installations
• Numerous incidents
Lost balance between major hazard & occupational safety
Many human factors causes “behavioural safety” not enough
• Client / partner expectations Developing their own expertise e.g. Woodside, Inpex, Chevron
© The Keil Centre 2015
Human factors
Reducing error and influencing behaviour
© The Keil Centre 2015
6
What do we mean by ‘human factors’ in hazardous industries?
10 Key UK HSE human & organisational factors issues
Managing human failure
Procedures Training and
competence Staffing, including
supervision Organisational change
Safety-critical communication
Human factors in design
Fatigue & shiftwork Organisational
(safety) culture Maintenance,
inspection and testing
© The Keil Centre 2015
7
Influences on human reliability & performance
Organisational (safety) culture
Usable procedures Safety-critical communication
Training and competence Human factors in design
Staffing levels, including supervision Fatigue & shiftwork
Organisational change Maintenance, inspection and testing
GOAL: Managing human reliability & failure
© The Keil Centre 2015
8
Case study: human factors analysis of five isolation incidents
• Three human errors, two violations of the control of work / isolation procedures
• This incident involved a very experienced electrical technician – a classic maintenance error
• The investigations identified a number of performance-shaping factors, which increased the likelihood of errors
• Control of work system was analysed to establish if it was “error-tolerant”
© The Keil Centre 2015
9 Human Factors Analysis Tools
Specify behaviour(s) to be understood
Behaviour intentional or unintentional?
ABC Analysis Human Error Analysis
Intentional Unintentional
Gather Evidence Identify Critical Factors
& Causes; Write recommendations
Assemble Timeline
CF 1 CF 2 CF 3
Traditional analysis
Human factors
analysis
© The Keil Centre 2015
10 Human Factors Analysis Tools
Specify behaviour(s) to be understood
Behaviour intentional or unintentional?
ABC Analysis Human Error Analysis
Intentional Unintentional
Gather Evidence Identify Critical Factors
& Causes; Write recommendations
Assemble Timeline
CF 1 CF 2 CF 3
Traditional analysis
Human factors
analysis
© The Keil Centre 2015
11 Human reliability assessment - a proactive technique for critical tasks -
Task
Probability of failure
Task of similar nature to
process isolation, with some independent checking of output
?? in 1000
Above, without independent checking of output
?? in 1000
?? in 1000
Above, plus time shortage for error detection and correction
© The Keil Centre 2015
12 Human reliability assessment - a proactive technique for critical tasks -
Task
Probability of failure
Task of similar nature to
process isolation, with some independent checking of output
3 in 1000
Above, without independent checking of output
9 in 1000
81 in 1000
Above, plus time shortage for error detection and correction
Performance-shaping factors
© The Keil Centre 2015
13
Recommendations
• Reducing isolation error rate • Early detection of isolation errors • Educate personnel on human error, and performance-shaping
factors • Share learning with other platforms, and other organizations
using same control of work software • Reducing isolation violations
• Result: 66% reduction in errors, and remaining errors are of
lower potential consequence
© The Keil Centre 2015
14
Swiss Cheese Model
Hazards H
arm &
Event
Engineering Process control system, safety devices
Management system
Behaviour & culture
Emergency response
© The Keil Centre 2015
15
Scope of COWS human factors review
Human failures during
hazardous work
ABC Ltd and
published data
COWS design
COWS training
COWS use
(12 phases)
Performance shaping factors
Recovery
Harm
& Event
© The Keil Centre 2015
16 Safety culture and human factors
• Key points
Many hazardous industries need more management focus, tools & techniques for identifying and reducing error, and performance-shaping factors
Human error includes management error
More traditional behavioural safety wont help
Strong Link to Just & Fair Culture
Maturing safety culture
Decreasing number of
unsafe acts
Unintentional (Error)
Intentional (Violation)
Capability improvement needed here?
Weak safety culture: Error obscured by focus
on more obvious violations, and blame
Strong safety culture: Cannot eliminate error; ATC = 98% error; 2% intentional
A developing
safety culture:
55% violations; 45% error
© The Keil Centre 2015
17
Summary
• A more sophisticated understanding of scope of human factors, and the many & varied influences on behaviour is required
• Increased development of internal company expertise is slowly taking place
• Integration of human factors into design, operations, maintenance and decommissioning is necessary
© The Keil Centre 2015
18 IChemE Human Factors professional development course
• Joint initiative with The Keil Centre
• 4 x 2-day modules, spread over 12 months
• Covers main “top-ten” HF topics
• Three complete Australian courses now finished 80 industry delegates
• Another East Coast course
commences May 2016
© The Keil Centre 2015
• Further reading on abstract
• Relevance?
• Questions?
• Comments?
• Thanks