Post on 24-Oct-2021
transcript
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
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• 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
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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
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• 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
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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!
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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
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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