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white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety
12-15th September, 2006
Development Of A Functional Model Of How Human Factors,
Safety Management Systems And Wider Organisational Issues
Fit Together
Dr. Linda Bellamy, White Queen Safety Strategies
The NetherlandsTim Geyer, ERM Risk
London, UKJohn Wilkinson, Health and Safety
ExecutiveBootle, UK
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
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HFRCS
ORG
SMSProject overview
regulates and inspects the chemical industry
assesses safety reports
Safety Case
HSE recognises
Human Factors
Human factors
Safety Management
System
A Safety Management
System
are important in
Control
Risk Control
Organisationalfactors
provides guidance
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
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HFRCS
ORG
SMSBut how do they fit together for Major Accident Prevention (MAP)?
Organisation
Human Factors
Safety Managemen
t
System
Risk Control
UNDER CONTROL
LOSS OF CONTROL
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
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HFRCS
ORG
SMSConcept: Indicating the degree of hazard associated with a chemical
• National Fire Protection Agency’s hazard diamond
• Simple
• Informative
• Underlying taxonomy
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
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HFRCS
ORG
SMSMAP WARNING Triangle “Archetype”
• Same idea as Hazard Diamond but using Major Accident Prevention (MAP)
• All elements interface the same key risk control system elements
• Want model that makes more explicit hidden HF aspects in long standing inspection approaches
• ..together with organisation and SMS
HumanFactors
KeyRisk Control
System(MAP)
Organisation
Safety Management System (SMS)
The perspectiveThe perspective
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
6
HFRCS
ORG
SMSMAP elements
• There could be many MAP elements to choose from and fit together (like Lego bricks)
• Need to make a collection of these potential MAP bricks
• And work out meaningful combinations
Risk perception
DesignLeadership
Measuring performance
Competence /expertiseHuman
Factors
Modifications
KeyRisk Control
System
Planning & implementing
SMS
Complexity
Organisation
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
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HFRCS
ORG
SMSLego Analogy
• Many bricks
• Limited meaningful combinations
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
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HFRCS
ORG
SMSMeaningful combo sub elements = Theme
Theme
Safety Management
System
Risk Control
OrganisationHuman Factors
Theme
Them
e
Theme
Safety Management
System
Risk Control
OrganisationHuman Factors
Theme
Them
e
What makes a vehicle
What makes (Loss of) Control (LOC themes)
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
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HFRCS
ORG
SMSSteps
• 1. Defined our “bricks”, a taxonomy of Major Accident Prevention (MAP) elements, from the literature, research etc.
• 2. Found meaningful combinations (themes) by seeing which ones (re-)occurred together in major accidents
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
10
HFRCS
ORG
SMSTaxonomy
• Our taxonomy comprised 850 factors
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
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HFRCS
ORG
SMSe.g. Human Factors• Task demands (physical,
mental)
• Human capacities (physical, physiological, mental)
• Behavioural outcomes (symptoms of mismatch, speed, accuracy..)
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
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HFRCS
ORG
SMSAccidents analysedAccidents analysedAlloid Colloids (UK 1992)Alloid Colloids (UK 1992)
• Fire following misclassification of chemicalsFire following misclassification of chemicals
Associated Octel (UK 1992)Associated Octel (UK 1992)• Fire due to poor awareness of risks in complex poorly maintained plantFire due to poor awareness of risks in complex poorly maintained plant
Cindu (NL 1992)Cindu (NL 1992)• Explosion due to runaway reaction in a batch processing plant. Explosion due to runaway reaction in a batch processing plant.
Flixborough (UK 1974)Flixborough (UK 1974)• Explosion due to release from a temporary bypass assembly Explosion due to release from a temporary bypass assembly
Grangemouth (UK 1987)Grangemouth (UK 1987)• Fire due to passing valve (poor design) and inadequate isolation proceduresFire due to passing valve (poor design) and inadequate isolation procedures
Hickson & Welch (UK 1992)Hickson & Welch (UK 1992)• Jet fire following runaway reaction during non routine vessel cleaning Jet fire following runaway reaction during non routine vessel cleaning
Longford (AUS 1998)Longford (AUS 1998)• Explosion and fire due to incorrect valve operation.Explosion and fire due to incorrect valve operation.
Texaco (UK 1994)Texaco (UK 1994)• Explosion and fire due to failure to recover deviationsExplosion and fire due to failure to recover deviations
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
13
HFRCS
ORG
SMSModel development – Accident contributors
• Half the taxonomy factors (around 400) occurred at least once across the 8 accidents
• A limited set appeared in all 8 accidents
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
14
HFRCS
ORG
SMSRESULTS – Main Accident contributors (1)RESULTS – Main Accident contributors (1)
• Risk control failures in:…Risk control failures in:…• OperationsOperations
- ..Detection of departures from normal..Detection of departures from normal- ..Inspection, test and maintenance of plant, equipment, ..Inspection, test and maintenance of plant, equipment,
facilitiesfacilities
• DesignDesign- ..Safety and environmental implications are identified..Safety and environmental implications are identified- ..Necessary S & E control measures defined, documented, ..Necessary S & E control measures defined, documented,
implementedimplemented
• ModificationsModifications- As design (but less cases)As design (but less cases)
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
15
HFRCS
ORG
SMSRESULTS – Main Accident contributorsRESULTS – Main Accident contributors(2)(2)
• Safety Management System failures in:Safety Management System failures in:
• ..Planning & Implementing: *Identifying ..Planning & Implementing: *Identifying hazards and assessing the riskshazards and assessing the risks
• ..Measuring: *Ongoing assessment of ..Measuring: *Ongoing assessment of compliancecompliance
• ..Organising: Providing competences ..Organising: Providing competences (specifically for MAP tasks) (specifically for MAP tasks)
• ..Organising: Communicating information ..Organising: Communicating information important to the controlimportant to the control of MA hazards
• ..Audit and review..Audit and review
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
16
HFRCS
ORG
SMSRESULTS – Main Accident contributorsRESULTS – Main Accident contributors (3)(3)
• Organisation failuresOrganisation failures• Organisational learning, memory and knowledge Organisational learning, memory and knowledge
failures dominatefailures dominate
• Personnel in job positions with key authorities and Personnel in job positions with key authorities and roles in MAP - Job allocation /provision of training roles in MAP - Job allocation /provision of training failuresfailures
• Norms and pressures Norms and pressures
• Chemical/process complexityChemical/process complexity- Actions on a single substance (drying, cooling, Actions on a single substance (drying, cooling,
heating, distillation and separation)heating, distillation and separation)
• Control complexityControl complexity
• Control InteractionsControl Interactions
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
17
HFRCS
ORG
SMSModel development – accident Model development – accident contributors (4)contributors (4)
• Human Factors failuresHuman Factors failures
• Demands :Demands :- Workload**Workload**- man-machine interfaceman-machine interface- detecting deviations and process disturbancesdetecting deviations and process disturbances- Identification and recognition (what am I dealing with here, Identification and recognition (what am I dealing with here,
what does this situation require from me)what does this situation require from me)
• Capacities :Capacities :- failures in understanding, interpretation & situational failures in understanding, interpretation & situational
awareness**awareness**- learning & knowledge failures**learning & knowledge failures**- incorrect decisions or choicesincorrect decisions or choices- selective attention, signal / pattern recognition failureselective attention, signal / pattern recognition failure- competence / expertise / skillscompetence / expertise / skills
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
18
HFRCS
ORG
SMSSymptoms of demand-capacity mismatch
• Individual symptoms of strain
• Reduced situational awareness
• Self reported feelings of strain
• Conflicts between safety and business processes
• Unsafe group (collective) practices
• Human error: deviations and omissions in doing task
• * Mistakes [8 accidents]
• Action physically impossible
• Rule violations
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
19
HFRCS
ORG
SMSThemes
• “Warning" triangle –warning themes concerning hazardous combinations of the main components found in accidents
• The warning triangle sits within a larger triangle (light blue) that shows the ‘theme’ under which the elements are linked
• The theme is the name chosen to best describe what fails
• The theme constrains the possible taxonomy elements that can appear in each of the parts of the warning triangle
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
20
HFRCS
ORG
SMSUnderstanding Major Accident Prevention
Understanding of MAP
Hazard identification
& risk assessment
MAP measures
Selection & training, roles & responsibilities
Cognition & understanding
Understanding of M
AP
Und
erst
andi
ng o
f MA
P
Understanding of MAP
Hazard identification
& risk assessment
MAP measures
Selection & training, roles & responsibilities
Cognition & understanding
Understanding of M
AP
Und
erst
andi
ng o
f MA
P
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
21
HFRCS
ORG
SMSCompetence for tasks
Competence for tasks
Competence delivery system
CompetenceSelection & training for competence
Tasks relating to MAP
measures
Com
petence for tasksC
ompe
tenc
e fo
r ta
sks
Competence for tasks
Competence delivery system
CompetenceSelection & training for competence
Tasks relating to MAP
measures
Com
petence for tasksC
ompe
tenc
e fo
r ta
sks
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
22
HFRCS
ORG
SMSPriorities, attention & conflict resolution
Priorities, attention & conflict resolution
Employee involvement &
communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionP
rior
ities
, att
entio
n &
con
flict
res
olut
ion
Priorities, attention & conflict resolution
Employee involvement &
communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionP
rior
ities
, att
entio
n &
con
flict
res
olut
ion
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
23
HFRCS
ORG
SMSAssurance
Assurance
Compliance with objectives
Goals & procedures
for MAP
Organisational knowledge &
learning
Behaviouraloutcomes
Assurance
Ass
uran
ce
Assurance
Compliance with objectives
Goals & procedures
for MAP
Organisational knowledge &
learning
Behaviouraloutcomes
Assurance
Ass
uran
ce
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
24
HFRCS
ORG
SMSPyraMAPS
• The four primary chemical major accident prevention warning triangles can be joined to make a pyramid
• The pyramid of chemical Major Accident Prevention (the PyraMAP).
• The pyramid is a 3-D representation of the four main triangles identified and is a multidimensional archetype
• It also represents the fact that the 4 triangles are linked by issues which cut across the 4 areas
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
25
HFRCS
ORG
SMSPyraMAPs
Competence for tasks
Competence delivery system
CompetenceSelection & training for competence
Tasks relating to MAP
measures
Com
petence for tasks
Com
pete
nce
for
task
s
Assurance
Compliance with objectives
Goals & procedures
for MAP
Organisational knowledge &
learning
Behaviouraloutcomes
Assurance
Ass
uran
ce
Understanding of MAP
Hazard identification
& risk assessment
MAP measures
Selection & training, roles & responsibilities
Cognition & understanding
Understanding of M
AP
Und
erst
andi
ng o
f MA
P
Priorities, attention & conflict resolution
Employee involvement & communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionPri
oriti
es, a
tten
tion
& c
onfli
ct r
esol
utio
n
Priorities, attention & conflict resolution
Employee involvement & communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionPri
oriti
es, a
tten
tion
& c
onfli
ct r
esol
utio
n
Competence for tasks
Competence delivery system
CompetenceSelection & training for competence
Tasks relating to MAP
measures
Com
petence for tasks
Com
pete
nce
for
task
s
Assurance
Compliance with objectives
Goals & procedures
for MAP
Organisational knowledge &
learning
Behaviouraloutcomes
Assurance
Ass
uran
ce
Understanding of MAP
Hazard identification
& risk assessment
MAP measures
Selection & training, roles & responsibilities
Cognition & understanding
Understanding of M
AP
Und
erst
andi
ng o
f MA
P
Priorities, attention & conflict resolution
Employee involvement & communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionPri
oriti
es, a
tten
tion
& c
onfli
ct r
esol
utio
n
Priorities, attention & conflict resolution
Employee involvement & communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionPri
oriti
es, a
tten
tion
& c
onfli
ct r
esol
utio
n
Competence for tasks
Competence delivery system
CompetenceSelection & training for competence
Tasks relating to MAP
measures
Com
petence for tasks
Com
pete
nce
for
task
s
Assurance
Compliance with objectives
Goals & procedures
for MAP
Organisational knowledge &
learning
Behaviouraloutcomes
Assurance
Ass
uran
ce
Understanding of MAP
Hazard identification
& risk assessment
MAP measures
Selection & training, roles & responsibilities
Cognition & understanding
Understanding of M
AP
Und
erst
andi
ng o
f MA
P
Priorities, attention & conflict resolution
Employee involvement & communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionPri
oriti
es, a
tten
tion
& c
onfli
ct r
esol
utio
n
Priorities, attention & conflict resolution
Employee involvement & communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionPri
oriti
es, a
tten
tion
& c
onfli
ct r
esol
utio
n
Competence for tasks
Competence delivery system
CompetenceSelection & training for competence
Tasks relating to MAP
measures
Com
petence for tasks
Com
pete
nce
for
task
s
Assurance
Compliance with objectives
Goals & procedures
for MAP
Organisational knowledge &
learning
Behaviouraloutcomes
Assurance
Ass
uran
ce
Understanding of MAP
Hazard identification
& risk assessment
MAP measures
Selection & training, roles & responsibilities
Cognition & understanding
Understanding of M
AP
Und
erst
andi
ng o
f MA
P
Priorities, attention & conflict resolution
Employee involvement & communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionPri
oriti
es, a
tten
tion
& c
onfli
ct r
esol
utio
n
Priorities, attention & conflict resolution
Employee involvement & communication
Job & equipment design for MAP
tasks
CommunicationDemand-
capacity match
Priorities, attention &
conflict resolutionPri
oriti
es, a
tten
tion
& c
onfli
ct r
esol
utio
n
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
26
HFRCS
ORG
SMSWORKING MODEL
• Run issue (s) through the PyraMAP
• A kind of HAZOP/scenario generator tool
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
27
HFRCS
ORG
SMS
Example: non-routine maintenance for Triangle 1
Understanding of MAP
Hazard identification
& risk assessment
MAP measures
Selection & training, roles & responsibilities
Cognition & understanding
Understanding of M
AP
Und
erst
andi
ng o
f MA
PUnderstanding of MAP
Hazard identification
& risk assessment
MAP measures
Selection & training, roles & responsibilities
Cognition & understanding
Understanding of M
AP
Und
erst
andi
ng o
f MA
P
2) Are there criteria & resources for including
[non-routine maintenance] and possible
consequences in a RA?
1) What risk control measures have been identified from the risk assessment to prevent a major accident resulting from [non-routine maintenance]?
4) Do people in jobs that could be related to MAP measures understand the risks of [non-routine maintenance] and the possible consequences?
3) Is selection and training used to deliver understanding of measures and effects of loss of control for MAP where [non-routine maintenance] could play a role?
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
28
HFRCS
ORG
SMSThe working model applied generally
Warning Triangle archetype + a sector
specific taxonomy for defining constraints
3) Define constraints: limit the building components to be used in the archetype=themed combinations
1) Specify inputs: issues of interest or concern/theme
4) Outputs: Issues translated into model terms
2) Resources: users' knowledge (provides building components – can update & share)
white queen
S a f e t y S t r a t e g i e s
3rd International Conference on Working on Safety12-15th September, 2006
29
HFRCS
ORG
SMSThe working model
• Stakeholders have many professionals who are knowledgeable in specialist areas
• The archetypes provide a basis for bringing this knowledge together
• Flexible for the user
• Specialist teams can generate themed instances (like the ones here for MAP)
• Stakeholders can then transform issues into archetypes based on this expertise
• The warning triangle archetype ensures that Human Factors can be integrated into major hazard activities in a meaningful way