Knowledge Management (KM) in Human Error (HE) in Accident Prevention

byAhmad Soyuti bin Haji Sabran

Self-Introduction

• Name:

• Background:

• Role:

• Aspiration:

جميعاأحياها فكأنما أحيا الناس ومن

Quote from the Holy Qur'an: Al-Maaida (5:32)

and whoso saveth the life of one, it shall be as if he had saved the life of all mankind.

dan sesiapa yang menjaga keselamatan hidup manusia, maka seolah-olah dia telah menjagakeselamatan hidup manusia semua

Outline• Introduction

• Background

• Problem Statement

• Aim

• Objectives

• Review

• Method

• Analysis and Findings

• Conclusion

• Further Research & Takeaway

Introduction

BP, Deepwater

Piper Alpha

Challenger

Chernobyl

Bhopal

Flixborough

Texas City

Halifax

Iroquois Theatre

Titanic

59,000Injured

6051517

200 58128

8000

4000

7 167 110

2000

4000

6000

8000

10000

1903 1912 1917 1947 1974 1984 1986 1986 1988 2010

…Top 10 major accident

that influenced the World(Krasek, 2011)

Fatality

O&G,

Petrochemical

Introduction …Top major accident

In MalaysiaYear Major Accident Impact

1991 Bright Sparklers fire and explosions 26 killed

1992 Tiram Kimia Depot Chemical explosion PD

1997 Bintulu explosion PD

1999 Refinery fire in West Malaysia PD

2002 Fire and explosion 3 killed

2003 LNG Complex Bintulu fire incident PD

2009 LNG Complex Bintulu gas leakage PD

2010 Bekok C Platform fire 6 injured

2012 Methanol tanker explosion 5 killed

2013 Hit by watertight water door 1 killed

2014 Gas pipeline explosion PD

PD – property damage

Background

… KM is the process ofcapturing, developing, sharing,and effectively usingorganisational knowledge.(Davenport ,1994)

… HE means that somethinghas been done that was "notintended by the actor; notdesired by a set of rules or anexternal observer; or that led thetask or system outside itsacceptable limits". In short, it is adeviation from intention,expectation or desirability.

(Senders et al, 1991)

… Major accident is defined inthe Regulations means anoccurrence including, in particular,a major emission, fire or explosionresulting from uncontrolleddevelopment in the course of anindustrial activity which lead toserious danger to persons, whetherimmediate or delayed or inside oroutside the installation, or to theenvironment, and involving one ormore hazardous substances.(OSHA, 1994)

… The link

… Causal factor, due

to Human Error

… 1992-2009 66 fatalities

recorded in Malaysia

(Othman, 2010)

Source: OGP Safety Performance

Indicators – 2013 Data, (2013). Report

No. 2013s

Problem Statement

Problem Statement

Major accident still

happen mostly due to

“Human Error” (HE)

Aim

… to develop KM framework and link with

HE to prevent, reduce & minimize major

accident among Malaysian’s Oil and Gas

industry players…

Objectives

1. To determine the critical success factors of KM in

preventing HE;

2. To assess the state of KM implementation in

Occupational Safety and Health (OSH);

3. To develop an integrated framework integrating KMand HE to prevent major accident.

… end result of this research –

Pertinent Question

How KM in HE can prevent major

accident?

What are the most suitable KM?

How effective is KM in offshore

installations? What is the best method of sharing the

outcome from KM in oil and gas

installations?

… Can KM help to prevent, reduce or minimize

HE for Malaysian oil and gas players?

Review

… Major accident (fatality)

vs HE …

Heinrich (1931)

Maslow's

Hierarchy of NeedsMaslow (1943)

… theories

Review

Heinrich (1931)

… theories

Ancestr

y

Fault o

f pers

on

Unsafe

act

Accid

ent

Inju

ry/loss

Bird and Loftus (1976)

Review

The HOLES are:

① Active failures*

- Directly linked to an

accident

② Latent

conditions*

- Contributory factors

that may lie dormant

for days, weeks,

months until they

contribute to the

accident

Swiss Cheese

ModelOrlandella and Reason (1990)

… causation

ReviewSOCSO (2013)

… statistics

Source: OGP Safety Performance Indicators – 2013 Data, (July 2014).

Report No. 2013s

Review … statistics

6.02

1.991.58

2.92

2.252.78

3.16

1.67

0.89

3.27

0

1

2

3

4

5

6

7

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Fatal Accident Rate (Offshore)

Offshore

Review

People TechnologyTacit and Explicit

Knowledge

KM Coordinating Group

• Assess the knowledge

• Develop vision and strategy

• Communicate KM

• Identify

initiative/programmes/projects

• Priorities and select initiatives

• Allocate resources

• Develop a technological

infrastructure

• Build a supportive/environments

• Measure and monitor performance

General Guide

• Plan

• Launch pilot/trial

• Review

• Expand

• Formalize

Initiatives/Programmes/

Projects/Activities

Create, acquire, codify,

organize, store, share and

apply knowledge others

Tools and Techniques

Hard tools

• Knowledge repositories/bases

• Knowledge maps/directories

• Collaborative tools

• Expert & intelligent systems

• Learning tools

• Others

Soft tools

• Collaborative teams

• ‘Communities of practice’

• Mentoring

• Job rotation

• Training

• Debriefing

• Others

Translate into

Wong and

Aspinwall (2004)

… framework

Review Peterson (2006)

Review

Factors

PERSONAL

WORKGROUP

JOB

MANAGEMENT

Decision-

to-errUnsafe Act Accident

Wiegmann et al (2005),

Peterson (1984),

LaDou (1994)

Twenty (20) Factors were identified and grouped

under four categories i.e. Personal, Job,

Management and Workgroup of decision-to-err

factors and their codes.

Human Error

Illustration of the Four Major Factors Contributing

to the Decision-to-err

PF-01 Laziness

PF-02 Past experience

PF-03 Being in hurry

PF-04 Showing off

PF-05 Being angry

PF-06 Being

uncomfortable

PF-07 Effects of using

drug and alcohol

PF-08 Supervisors’

acceptance

PF-09 Co-worker

acceptance

PF-10 Overconfidence

Review

PERSONAL WORKGROUPJOB MANAGEMENT

Weegmann et al

(2005), Peterson (1984),

LaDou (1994)

JF-01 Too much work

(overload)

JF-02 Too little work

(relax)

JF-03 Time pressure

MF-01 Management

pressure

MF-02 Management

support

MF-03 Supervision

MF-04 Reward

MF-05 Penalty

WF-01 Group norms

WF-02 Group

pressure

Identification of Decision-to-err Factors and Coding

• First Timer

• Complexity

• Complacency

• Empowerment

Review Peterson (1984), Anton (1989), Stranks (1994),

Simachokdee (1994), Michuah (1995),

Abdelhamid & Everett (2000) and Holt (2001)

Identification of Unsafe Acts and Coding

Coding List of Unsafe Acts

US-01 Working without authority on the job

US-02 Failure to warn or to secure members out of danger

US-03 Working at improper speeds, exceeding the prescribed speed limits, or unsafe speed actions

US-04 Improper lifting, handling or moving of objects

US-05 Improper placing and stacking of objects and materials in dangerous locations

US-06 Incorrect use of tools and equipment, hand tools, power tools and machinery

US-07 Using defective equipment and tools to work

US-08 Annoyance and horseplay in the workplace

US-09 Ignoring to wear personal protective equipment (PPE)

US-10 Removing safety guards from the workplace or equipment

US-11 Smoking creating naked flame or sparks in areas where flammable materials are stored

US-12 Leaving nails or other sharp objects protruding from timber

US-13 Throwing or accidentally dropping objects from high levels

US-14 Working under the effects of alcohol and other drugs

US-15 Improper positioning of tasks

US-16 Improper posture for tasks

US-17 Servicing equipment which is in operation

US-18 Working with lack of concentration

US-19 Working in poor physical conditions

DescriptionInitial

validateSurvey Method (Questionnaires)

Respondent (N) 143/200

(71.5%)

86/143

(49.6%)

23/40

(57.5%)

Background Ratio (Management: Employee)

25:118 14:56 8:15

Method of data

collection(Questionnaires &

Interview)

Scale 1 2 3 4 5

Frequency

performed

never rarely Occasionally Often Usually

Degree of

influence

not little moderately Strongly

Panel of offshore

safety experts(at least 10 years

experience)

20 disagree some

what

agree

moderately

agree

strongly

agree

Project Safety Managers, Safety Engineers, Senior Safety Officers

Analysis Statistical Package for Social Science (SPSS)

Methodology

Note: Kruskal-Wallis test (nonparametric technique) was applied to whether or not the several

groups of worker have similar patterns of unsafe practices. The level of significance chosen for the

study was 0.05.

WorksiteWorksite Location

(SapuraKencana 2000)

Dimensions

Total Length 120 m

Accommodation300 cabins

Main Crane

2000 MT

Pipeline Installations

6”-60” Pipe OD

05x Welding Stations

01x NDT Station

Video Clip #1 (31s)

Video Clip #2 (35s)

Main Crane

Accommodation

1278

13

52

62

28

18

0

10

20

30

40

50

60

70

80

90

100

Management Employee

Root Causes of Human Error

Overlaod Ergonomic Traps Decision to Err System Failure

Decision to Err

• Misjudgement of the risk

• Unconscious desire to err

• Logical decision based on the

situation

Description Survey

Respondent (N) 143/200

(71.5%)

Background Ratio

(Management: Employee)

25:118

Analysis and Findings

Source: SapuraKencana TL Offshore Installations Campaign – UCUX Submission, 2014

Unsafe Act 620Unsafe Condition 1,773Safe observation 553

Total 2,946

Unsafe Act, 620,

21%

Unsafe Condition, 1773, 60%

Safe Observation,

553, 15%

204

89

5844

16

PPE relatedIssues

SafetySignages

Short cut Failure tomake secure

TakingUnsafe

Position

TOP 5 Unsafe Act

114

53

23

113

Safety Glass Hand Glove Face/DustMask

Ear Plug Body Harness

PPE Related Issues

Project Overall Submission

Analysis and Findings

ConclusionThe most frequent unsafe acts committed by workers –

The workers rarely

wear PPE while doing

their jobs

The workers lift or

handle objects or

materials improperly

The workers leave

sharp objects in

dangerous locations

Correlated factors• Lack of management

support

• Group norms

• Overconfidence

• Being uncomfortable

• Past experience

• Group norms

• Overconfidence

• Management

pressure

• Group norms

• Laziness

• Overconfidence

What is the relationships between the occurrences of unsafe acts and site safety performance (major accident)?

Note: Similar result with Jaselskis and Suazo (1994), Suraji et al (2001) and

Thanet Aksorn and B.H.W. Hadikusumo (2007)

Deep water Horizon

Blowout(BOEMRE, 2011)

Further Research

• The failure of the crew to stop work on the

Deepwater Horizon after encountering

multiple hazards and warnings

• BP’s failure to document, evaluate, approve,

and communicate changes associated with

Deepwater Horizon personnel and operations

Bureau of Ocean Energy Management,

Regulation and Enforcement (BOEMRE) final

report, 2015.

This is Human Error?

Further ResearchPeterson (2006)

Major Accident

Minor Accident

Human Error that caused

System Failure

Knowledge Management Framework!

Active Failure

Latern Failure

Further Research

Plan Do

START

END

Do Do

Phase 1

Check

• Continuous Education & Competency

Program for Safety Officers;

• HSE Critical Position Renewal Competency

Program:

1. DOSH’s Registered i.e: Crane

Operators, Scaffolders, RPO, RPS,

AGT

2. Contractual Requirements

Project Mobilization

(Safety Induction/Competency Matrix)

Q1

Q1 & Q2

Q1 to Q3

• Front liners Safety Program

Phase 3

• Safety

Awareness

• Safety Meeting/

Reviews

• Pre-Exec Audit

• Management Site Visit

• Safety Promotional Program/Activities -

1. Safety Reward Program (SRP)

2. Unsafe Condition (UC) Unsafe Act (UA)

• Health Screening/UDAT

• Compliance to Safety Rules (LSR)

• STOP WORK Practice/Encouragement

• HAZID Revisit

• Learning from Incident

• Counselling

• Consequence Management & Reward

Worksite

Lesson Learnt

for Future

Project

Safety Core Procedures (HSE

Plan, ERP, Bridging etc.)

• HAZID

• Management

Intervention

Framework

Action

Phase 2 Phase 4

Sharing of

Lessons Learnt

• Site Inspections i.e

Compliance to Legal, DOSH,

DOE Requirement etc.

• Drill exercise

Compliance to Legal, Contractual Requirement & HSEMS.

OSH Standard: OHSAS 18000, ISO 14001 & MS 1722

1

2

4

3

6

7

5

8

9Q3 to Q4

10

Takeaway Framework

• Visibility

• Budget

• Intervention

• Review

• Legal & Other

Requirements

• Competency

• Safety Programs

• Rewards

• STOP Work

• Unsafe Act

• LSR

• Solutions

• Customer

Satisfaction

• Alliances &

Partners

• Compliance with

Safety Requirements

• ISM Code (IMO)

• IMCA

• Safety Plan

• Risk

Management

• Performance

Monitoring

• Audit

• Resources

• Lessons

Learnt

SUSTAINABILITY• OSH Standard

KMAccident

Prevention

System Failure

• Policy

• Standard or

Procedures

• Training and

Competency

• Correction

• Inspection

• Communication

HUMAN

ERROR

Thank you