human factors - 20 critical hse factors

7/28/2019 Human Factors - 20 Critical HSE Factors

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Patrick Hudson & Dianne Parker, Leiden and Manchester Universities

Introduction

One of the group exercises undertaken at the OGP safety workshop in March 2000 generated a lot of

interest from OGP members. The exercise built on a process begun in 1999 to develop a useable measure ofan organisation's safety culture. Westrum's (1985) three stages of organisational culture provided aframework and were extended to five levels:

1. Pathological: No-one knows or cares about safety.2. Reactive: Improvements are only made following a serious negative incident3. Calculative: Complex management systems are used to encourage and monitor safe working4. Proactive: People try to avoid problems occurring and exist in a constant state of awareness.5. Generative: Safety is integral to everything we do.

Progress through these five stages shows increasing sophistication. The exercise reported here involvedcollecting the consensus views of what constitute these levels. This was done through interviews with topmanagers with responsibility for safety, and HSE professionals, in a number of the OGP member companies.The aim was to produce a set of definitions of organisational behaviour.

The exercise did not involve the sharing of company specific information and did not therefore includedisclosure or discussion of confidential or sensitive company matters.

Detailed Descriptions

Benchmarking, Trends and Statistics

1. Compliance with statutory regulations, but the data that is collected is not used.2. Try to respond as other companies do, and worry about the cost of accidents, and their placing in the

'safety league'. Don't think about the underlying causes.3. Benchmark with respect to incidents and accidents, collect and publicly display lots of data, and

believe that measuring is fix ing. Don't look for future problems, and don't try to move beyond 'hard'

objective measures that can be summarised numerically.4. Interpret trends and extrapolate in order to prevent future loss. Define best practice and auditagainst it. Try to be the best in the industry. Don't involve all levels in the auditing process.

5. Benchmark outside the industry. Consider the human factor seriously, and therefore use a broadrange of 'hard' and 'soft' measures. Involve all levels of the organisation in identifying action pointsfor improvement

Audits and Reviews

1. Minimal regulatory requirements are met, and financial audits are carried out. Don't do HSE audits,except after a major accident.

2. Operations are audited after serious or fatal accidents. May be audited by regulators or auditcontractors, but don't usually audit themselves, and if they do, omit less risky areas. No schedule foraudits and reviews, they are seen as a punishment.

3. There is a regular, scheduled audit program, but it is superficial. It concentrates on high hazardareas. Don't willingly audit themselves, but happily audit others.

4. Extensive audit program including cross-auditing within the organisation. Audits are seen as positive.5. Search for non-obvious problems with self and cross audits. There is good follow-up of audits. There

are fewer audits of hardware and systems, more at the level of behaviours.

Incident/accident reporting, investigation and analysis

1. Cover up of incidents is common. Investigation only takes place after a serious accident. Don'tconsider human factors; don't do more than is legally required; don't look beyond protecting thecompany and its profit.

2. Define zero accidents as the desired state. Lay down a paper trail to show an investigation has takenplace. Has some informal reporting system. There is no reporting system that can get at root causes.There is no systematic follow through, and previous similar events are not considered.

3. Lots of information is collected and filed. The company has detailed investigative procedures, andmay suffer information overload. The company pays attention to root causes. There is no systematicfollow through on the findings and recommendations. The investigation and its results do not gobeyond the local workforce.

4. Reports are sent company wide in order to share information and lessons learned. There are trainedinvestigators, and a systematic follow-up to check that change has occurred and been maintained,but this is not alwa s done. There is no focus on incident otential, or lookin at the total of hazard


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reports, near misses, incidents and accidents.

5. Data is aggregated across business functions to look for trends and issues that need to be addressed.There is a systematic follow up to check that change has occurred and has been maintained and it isalways used.

Safety reports

1. There are no safety reports.2. Safety reporting is simple and factual, and tends to involve finger-pointing. The company does not

track actions after reports.

3. There are reports that follow a fixed format with considerable documentation. Body parts and hazardsare scored in detail. A tracking system is available. The company does not like blanks in forms.4. Safety reporting looks for 'why' rather than just 'what' or 'when'. Rapid submission of reports is

appreciated, and it is possible to leave blanks in the form to be filled in later.5. Senior management is routinely involved and sets reporting goals. Safety reporting is easy to

disseminate across the whole organisation, using widely accessible databases.

Who causes accidents in the eyes of management?

1. The individual is blamed, and it is believed that accidents are to be expected. The responsibility ofmanagers is not considered.

2. There are attempts to weed out 'accident-prone' individuals. It is believed that accidents are just badluck. The responsibility of managers is considered.

3. There are attempts to reduce exposure hours in order to reduce accidents. Faulty machinery, and

poor maintenance are blamed. Management has a Them, rather than Us, mentality. Managementdoes not take a systems perspective.

4. Management looks at the whole system, including processes and procedures. They acknowledge thatmanagement must take some of the blame, and that some incidents can't be prevented.

5. Management no longer sees this as a relevant question, as blame is not an issue. Management lookto themselves to assess what could be improved, and takes a broad view looking at the interaction ofsystems and people.

What happens after an accident? Is the feedback loop being closed?

1. Reports are filed to the authorities. There is no follow-up of recommendations.2. The focus is on the employee, and they are often fired. The priority is to fix the damage.3. Extensive statistics are collected. And accidents are analysed one at a time. There is no sharing of

information, and follow-up is variable.

4. Shared learning activity takes place, and action (points) are closed out.5. Top management visibly involved in public activity after an accident. Employees take accidents to

others personally.

How do safety meetings feel?

1. Meetings seem to be run by the boss, and to be a case of going through the motions. They are seenas a waste of time.

2. Meetings feel negative, and are attended reluctantly. They feel like an opportunity to point the fingerof blame, and form a stock response to a previous accident.

3. Meetings feel like textbook discussions. There is some attempt to develop interaction with attendeesThe meetings act as a forum for higher level employees to be informed about company policy.

4. Meetings feel like a genuine forum for interaction between company levels. They still feel like overkill,as there are many regular, scheduled meetings. They occur at a lower level (toolbox meetings etc.)

and are used to identify problems before they occur.5. Meetings feel like an opportunity for communication but are likely to be informal. They can be called

by any employee, and feel comfortable to all those attending.

Work planning including Permit To Work, Journey Management

1. Work planning is for the quickest, fastest, cheapest production possible. There is not much planningoverall, and no HSE planning.

2. Plans are based on what went wrong previously. They are a crude/informal process based primarilyon time taken for a job.

3. There is lots of planning with emphasis on Permit To Work. The system is an end in itself. However, itis not always consistent, and there is little or no evaluation of plan quality.

4. Planning is standard practice, and there is follow through and some evaluation of effectiveness. The

implementations are patchy.5. There is a polished planning process with anticipation and review of the work process. Employees aretrusted to do most planning. There is less paper, more thinking, and the process is well known anddisseminated.

Contractor management


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1. Contractor management is focused entirely on price, and does not take safety issues into account.The company regards the contractor as wholly responsible for their own workers' safety.

2. The company pays attention to HSE issues in contracting companies only after an accident. Theprimary selection criterion is still price, but poor safety performance has negative consequences for acontractor.

3. Contractors are expected to jump through a lot of HSE hoops, some of which may not be necessary.Pre-qualification is on the basis of previous safety record. Standards are lowered if no contractormeets requirements. No effort is made to help contractors get up to speed.

4. HSE issues are seen as a partnership. Pre-qualification is on the basis of previous safety record andhaving systems in place. The company helps with contractor training. Joint safety efforts begin to beseen.

5. Contractor and company staff are not seen as separate, but an integrated workforce. Sharedinformation leads to integration of policies, procedures and practices. Work is postponed if nocontractor meets the HSE requirements. Joint training and competency programmes are standard.

Standards setting and by whom

1. Minimum regulatory requirements are the most there are. There are no internal standards.2. There are compliance-based industry standards.3. There are regulatory and internal standards often based on incidents. The company is willing to spend

money on improvement.4. The company takes a leadership role, striving to exceed minimum standards for the industry.

Standards are set by the workforce, and approved by management.5. The company tries to influence the regulator in the setting higher standards. It is not worried about

spending money to attain higher standards. Standards are defined by the workforce.

Competency/training - are workers interested?

1. Training is in response to statutory requirements only. It is seen as a necessary evil by managementand supervisors. Workers enjoy it when they get it as it's a couple of hours off the job.

2. There is a massive training/retraining effort following an accident, and an attitude of 'now we all haveto suffer'. The training effort diminishes over time.

3. There is regular retraining, and the training department ensures all the relevant boxes can be ticked.There is no assessment for competency, as going through the training is seen as an end in itself.

4. Competency becomes an issue. The workforce understands the benefits of training and welcomes thechance to extend their skill base. Training needs start to be identified by the workforce.

5. Issues like attitudes become as important as knowledge and skills. Training is seen as a processrather than an event. Needs are identified and methods of training are suggested by the workforce,

who are seen as an integral part of the process rather than just passive receivers.

Work-site hazard management techniques

1. There are none.2. STOP is brought in after accidents, but it doesn't really get used systematically.3. STOP is cascaded to lowest levels. Some go/no-go criteria are defined. Nothing else is used, and

there is no systematic on-site hazard management.4. Job safety analysis/job safety observation with procedures in place. There is a buddy system in

place.5. Job safety analysis is revised regularly in a process. People (workers and supervisors?) are not afraid

to tell each other about hazards.

Who checks safety on a day-to-day basis?

1. Safety is checked by no one. There is no formal system, so individuals take care of themselves.2. There are site visits, but only following legal action. Cursory site checks are performed by

management when they are visiting. There is no documentation of the results.3. Safety is checked by a designated, although not senior, person. Site visits ensure minimal compliance

with procedures. There is a manual of procedures designed to ensure safe behaviour.4. Supervisors are involved, and encourage work teams to check safety for themselves. Managers

doing walk-rounds are seen as sincere, but may not be good at spotting hazards. Internal cross-audits occur, also by managers.

5. Everyone checks safety, looking out for themselves and their work-mates. Supervisor inspections areinfrequent, as they are largely unnecessary. There is no problem with demanding shutdowns (ofoperation).

Balance between safety and profitability

1. Profitability is the only concern. Safety is seen as costing money, and the only priority is to avoidextra costs.

2. Cost is important, but there is some investment in preventative maintenance. Operational factorsdominate.

3. Lip service is paid to safety. Safety and profitability are juggled rather than balanced. Safety is seen


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as a discretionary spend. If all contractors are unacceptable, the least bad is taken.4. The company tries to make safety the top priority, while making a positive connection between safety

and financial return. The company is better at juggling the two, and accepts delays to get contractorsup to standard in terms of safety. Money still counts.

5. The two are in balance, so that this becomes a non-issue that is not discussed. The company acceptsdelays to get contractors up to standard in terms of safety. Management believe that safety makesmoney.

Is management interested in informing workforce about safety issues?

1. Not interested, but sometimes management have to tell them certain things. Management is moreinterested in preventing workers causing problems. The process is top-down only.2. Management tell workers what to do in reaction to regulators requirements. The 'flavour of the

month' safety message is passed down without much enthusiasm. Any interest diminishes over timeas things get 'back to normal'.

3. Management overwhelms workers with a lot of information to take in and has frequent safetyinitiatives. There is still lots of telling and not much listening going on with little opportunity forbottom-up communication.

4. Managers realise that dialogue with the workforce is desirable and so a two-way process is in place.Asking as well as telling goes on. The emphasis is on looking out for each other (in the workplace).

5. There is a definite two-way process, in which managers get more information back than they provide.This process is transparent. It's seen as a family tragedy if someone gets hurt.

Commitment level of workforce and level of care for colleagues

1. "Who cares as long as we don't get caught?" Individuals look after themselves.2. "Look out for yourself" is still the rule. There is a voiced commitment after accidents by management

and workforce, but this is short-lived.3. There is a trickle down of management's increasing awareness of the costs of failure. People know

how to pay lip service to safety.4. There is some commitment, and pride is beginning to develop but the feeling is not universal.5. Contractors are included in care from day one. Levels of commitment and care are very high and are

driven by employees.

How do you get new/improved procedures?

1. Procedures are very rare - they only arise out of necessity.2. The procedures are only considered following an incident, when a new one is written or an existing

one changed. Managers and/or HSE staff develop procedures.3. There is a proliferation of procedures. A lot of time and effort is devoted to the development of

procedures, but they may not be good and/or appropriate. HSE staff write safety procedures andinsist they are followed.

4. There is a procedure for reviewing procedures to ensure they are up-to-date. If workers feel theyneed to work outside certain procedures, these procedures will be reviewed. They can be tailored tothe job in which they are to be used.

5. Procedures are developed by the workforce, and reviewed constantly. They can be tailored to fit thejob at the suggestion of the local workforce. Some procedures are scrapped as they are no longernecessary.

What is the purpose of procedures?

1. The company makes procedures out of necessity. Procedures are seen as limiting peoples' activities.2. The purpose is to prevent individual incidents recurring. They are not well thought out.3. There are many procedures to CYA. It is hard to separate procedures from training.4. Procedures spread best practice but are seen as inconvenient. A limited degree of non-compliance is

acceptable.5. There is trust in employees. Non-compliance goes through recognised channels. Procedures are

refined for efficiency.

What is the size/status of the HSE department?

1. There is none. If there isit is small and part of the Human Resources department.2. The HSE department is small and has little power. It is seen as a career backwater. It is on call

constantly3. HSE positions given to middle managers who can't be placed elsewhere. It is a large department with

some status and power4. HSE seen as an important job5. There isn't one because it is not needed

What are the rewards of good safety performance?

1. Sta in alive is reward enou h. There are no tan ible rewards, onl unishments for failure.


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2. There are disincentives for poor HSE performance. The understanding that positive behaviour can berewarded has not yet arrived.

3. Some lip service is paid to good safety performance. Tokens such as T-shirts are given out.Managers' bonuses are tied to LTIs.

4. There is some reward, and safety performance is considered in promotion reviews. TRCF is usedwhen calculating bonuses.

5. Recognition itself seen as high value. Tokens (e.g. baseball hats) are not given, as the workforceknow they perform well. Evaluation is process-based.

human factors - 20 critical hse factors

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