human factors in major hazard safety ronny lardner

© The Keil Centre 2015

1

Human factors in major hazard safety: the top 10 issues

Ronny Lardner AFIChemE Registered Psychologist

[email protected]

and organisational v

mailto:[email protected]


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


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


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


Human factors

Reducing error and influencing behaviour


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


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


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”


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


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


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


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


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


14

Swiss Cheese Model

Hazards H

arm &

Event

Engineering Process control system, safety devices

Management system

Behaviour & culture

Emergency response


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


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


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


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


• Further reading on abstract

• Relevance?

• Questions?

• Comments?

• Thanks

human factors in major hazard safety ronny lardner

Government & Nonprofit