repositioning human factors · • human factors; • human performance, and: • human and...
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Executive Health and Safety
Repositioning human factorsIdentifying barriers to understanding human factors in prevention of major accidents among key decision makers and managers in the industries concerned
Prepared by Greenstreet Berman Limited for the Health and Safety Executive 2009
RR758 Research Report
Executive Health and Safety
Repositioning human factorsIdentifying barriers to understanding human factors in prevention of major accidents among key decision makers and managers in the industries concerned
Greenstreet Berman Ltd Fulcrum House 5 Southern Court South Street Reading Berkshire RG1 4QS
This report, and the work it describes, explores how HSE might reposition Human Factors/Ergonomics (HF/E) so it is more central to the thinking of Key Decision Makers (KDMs); within high hazard industries belonging to the Oil and Gas, Chemical and Nuclear sector. The findings suggest that although knowledge and understanding of HF/E is penetrating through there is recognition by KDMs that they need to do more.
Possible options to help improve the application of knowledge and techniques in the prevention of error and unsafe behaviour include:
n improve knowledge and understanding of HF/E, primarily through training; n develop and promote tools and guidance to help enhance this knowledge and assist in the practical
application of this knowledge to the prevention of major accidents; and n facilitate peer review to critique safety management system and processes and to demonstrate how
particular HF/E techniques can be applied.
Improving knowledge; developing tools and guidance and facilitating peer review could be delivered in co-operation with industry associations and professional institutes. The eventual aim should be to better integrate HF/E into day-to-day management.
This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.
HSE Books
© Crown copyright 2009
First published 2009
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner.
Applications for reproduction should be made in writing to:Licensing Division, Her Majesty’s Stationery Office,St Clements House, 2-16 Colegate, Norwich NR3 1BQor by e-mail to [email protected]
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CONTENTS
1 INTRODUCTION ............................................................................................................................1
1.1 ABOUT THIS REPORT ..................................................................................................................1
1.2 BACKGROUND............................................................................................................................1
1.2.1 Health and Safety Executive (HSE) ......................................................................................1
1.2.2 Human Factors/Ergonomics (HF/E) ....................................................................................2
1.2.3 Process and nuclear safety ...................................................................................................3
1.2.4 Research rationale and project aims ....................................................................................3
2 METHOD ..........................................................................................................................................6
2.1 INTRODUCTION ..........................................................................................................................6
2.2 TASK 1 KDM PROFILE ...............................................................................................................6
2.2.1 Stakeholder Telephone Interviews ........................................................................................6
2.2.2 Desktop review of major accidents.......................................................................................7
2.3 TASK 2 CONSULT KDMS ...........................................................................................................8
2.4 ANALYSIS ..................................................................................................................................9
2.4.1 Introduction ..........................................................................................................................9
2.4.2 Self selection .........................................................................................................................9
2.4.3 Quantitative analysis ..........................................................................................................10
2.5 TASK 3 STRATEGY WORKSHOP .................................................................................................10
3 FINDINGS.......................................................................................................................................12
3.1 INTRODUCTION ........................................................................................................................12
3.2 SUMMARY OF FINDINGS ...........................................................................................................12
3.2.1 Indentifying KDMs and understanding the decision making process.................................12
3.2.2 Current application of HF/E to tackle process safety issues ..............................................13
3.2.3 The perceived value of HF/E ..............................................................................................13
3.2.4 How can the application of HF/E be improved? ................................................................13
3.3 FINDINGS FROM TASK 1 – THE PROFILE OF KDMS AND THE DECISION MAKING PROCESS .........14
3.3.1 Introduction ........................................................................................................................14
3.3.2 Identifying the Key Decision Makers (KDMs)....................................................................14
3.3.3 How decisions are made.....................................................................................................15
3.3.4 The level of collaboration in decision making about HF/E ................................................16
3.3.5 Other factors that influence on decision making ................................................................17
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3.3.6 The range of methods used to incorporate a HF approach into decision making..............17
3.4 FINDINGS FROM TASK 2 – THE EXTENT OF HF/E IN CURRENT DECISION MAKING (Q1) .............18
3.4.1 Introduction ........................................................................................................................18
3.4.2 Process safety activities......................................................................................................18
3.4.3 HF/E issues being addressed..............................................................................................19
3.4.4 Activities undertaken to address these issues .....................................................................20
3.4.5 Factors influencing Decision Making (Q1) ........................................................................22
3.5 FINDINGS FROM TASK 2 - LEARNING ABOUT HF/E & PROCESS SAFETY (Q2) ...........................23
3.5.1 Introduction ........................................................................................................................23
3.5.2 Training ..............................................................................................................................24
3.5.3 On the job learning.............................................................................................................24
3.5.4 Internal safety department..................................................................................................25
3.5.5 Internal accident/incident reporting...................................................................................25
3.5.6 Conferences ........................................................................................................................25
3.5.7 Safety qualifications ...........................................................................................................26
3.5.8 Guidance and standards.....................................................................................................26
3.5.9 Accident/incident reporting ................................................................................................26
3.5.10 HSE inspectors...............................................................................................................27
3.5.11 Peer review ....................................................................................................................27
3.5.12 External consultants ......................................................................................................27
3.6 FINDINGS FROM TASK 2 WHAT MAKES LEARNING COMPELLING (Q2B).....................................28
3.6.1 Introduction ........................................................................................................................28
3.6.2 Practical .............................................................................................................................28
3.6.3 Industry specific..................................................................................................................28
3.6.4 Powerful message ...............................................................................................................29
3.6.5 Benefits clearly stated.........................................................................................................29
3.6.6 Sector/job differences .........................................................................................................29
3.7 FINDINGS FROM TASK 2 - HF/E TECHNIQUES AND APPROACHES USED (Q3A) ...........................29
3.7.1 Introduction ........................................................................................................................29
3.7.2 Analysis techniques.............................................................................................................30
3.7.3 Organisational approaches ................................................................................................31
3.7.4 Competence management approach...................................................................................31
3.8 FINDINGS FROM TASK 2 - WHAT ARE THE PROMPTS TO APPLY HF/E TECHNIQUES AND
APPROACHES? (Q3B AND C)...................................................................................................................31
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3.8.1 Introduction ........................................................................................................................31
3.8.2 External ..............................................................................................................................32
3.8.3 Organisational....................................................................................................................32
3.8.4 Individual............................................................................................................................33
3.9 UNDERSTANDING AND ATTITUDE TOWARDS HF/E (Q6Q7)......................................................33
3.9.1 Introduction ........................................................................................................................33
3.9.2 Overall Findings.................................................................................................................34
3.9.3 Sector differences in understanding and attitude ...............................................................35
3.9.4 Job type differences in understanding and attitude ............................................................36
3.10 OVERALL SECTOR DIFFERENCES ...............................................................................................37
3.11 OVERALL JOB ROLE DIFFERENCES ............................................................................................37
3.12 BARRIERS TO THE UPTAKE OF HF/E .........................................................................................38
3.12.1 Inconsistent message......................................................................................................39
3.12.2 Complex poorly bounded topic ......................................................................................39
3.12.3 Uncertainty about training quality ................................................................................39
3.12.4 Diverse and varied audience .........................................................................................40
3.12.5 Guidance........................................................................................................................40
3.12.6 Conflicting commercial pressures .................................................................................41
3.12.7 HF/E not fully integrated ...............................................................................................41
3.13 CURRENT GOOD PRACTICE .......................................................................................................42
3.13.1 Introduction ...................................................................................................................42
3.13.2 Sharing knowledge with peers .......................................................................................42
3.13.3 Learning from past accidents.........................................................................................43
3.13.4 Leadership .....................................................................................................................43
3.13.5 Workforce engagement ..................................................................................................44
4 FUTURE OPTIONS FOR IMPROVING THE UPTAKE AND APPLICATION OF HF/E...45
4.1 INTRODUCTION ........................................................................................................................45
4.2 IMPROVE KNOWLEDGE OF HF/E...............................................................................................47
4.3 INTEGRATE HF/E .....................................................................................................................48
4.4 INDUSTRY ASSOCIATION LED ACTIVITIES .................................................................................49
4.5 AWARENESS RAISING COMMUNICATIONS CAMPAIGN ...............................................................51
4.6 THE CONCEPT OF HF/E.............................................................................................................52
4.7 BRANDED INITIATIVES .............................................................................................................54
4.8 INCREASE ENFORCEMENT.........................................................................................................55
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5 OVERALL CONCLUSION...........................................................................................................57
6 RECOMMENDATIONS................................................................................................................61
6.1 SUMMARY................................................................................................................................61
6.2 INTRODUCTION ........................................................................................................................61
6.3 TRAINING AND CONTINUING PROFESSIONAL DEVELOPMENT (CPD) .........................................61
6.4 GUIDANCE................................................................................................................................62
6.5 PARTNERSHIP WORKING...........................................................................................................62
6.6 COMMUNICATIONS STRATEGY.................................................................................................65
6.6.1 Audience .............................................................................................................................66
6.6.2 Messages.............................................................................................................................67
6.6.3 Approach ............................................................................................................................67
6.6.4 Branding .............................................................................................................................67
6.6.5 Style ....................................................................................................................................68
6.7 HSE INFLUENCE.......................................................................................................................68
6.8 PEER REVIEW ...........................................................................................................................69
6.9 CONCLUDING STATEMENT .......................................................................................................70
7 REFERENCE..................................................................................................................................71
8 APPENDIX I – STAKEHOLDER RESPONSES ........................................................................72
9 APPENDIX II – KEY DECISION MAKER RESPONSES ........................................................79
10 APPENDIX III – STAKEHOLDER INTERVIEW PROFORMA...........................................106
11 APPENDIX IV –KDM INTERVIEW PROFORMA.................................................................113
12 APPENDIX V – FINDINGS FROM DESKTOP REVIEW OF MAJOR ACCIDENTS .......121
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1 INTRODUCTION 1.1 ABOUT THIS REPORT
This report is intended to assist Health and Safety Executive (HSE) with its aim of helping high hazard industries (Nuclear, Oil & Gas and Chemical) better manage and prevent the risk of major accident hazards.
It aims to do this by considering the extent to which influential people, within high hazard industries, take account of Human Factors and Ergonomics (HF/E) when making decisions about ‘process safety’.
This report provides the Background to the research, the historical context and rationale for why the promulgation of HF/E (principles, knowledge and techniques) remains a priority area for HSE.
The document also provides a brief outline of the Method used to collect information on key decision making and the tasks that were undertaken to inform the findings.
The document also presents the overall Findings with a more detailed exploration of the following key themes:
• The key decision makers (KDM);
• How decisions are made and the role of HF/E within this process;
• Current understanding and attitude to HF/E
• The barriers to HF/E.
Finally the document includes possible Future options for improving the uptake and application of HF/E and recommendations for how these might be achieved.
Additional information, such as the analysis of interviewee responses and interview proforma are also provided in the Appendix.
1.2 BACKGROUND
1.2.1 Health and Safety Executive (HSE)
The mission of the Health and Safety Executive (HSE) is to protect people's health and safety by helping to ensure risks in the workplace are properly controlled. They do this through undertaking a number of activities, for example: conducting research; providing advice; promoting training; devising new or revising regulations and codes of practice and finally carrying out inspection, investigation and enforcement.
HSE also considers itself a leader and opinion former and seeks to promote and influence the uptake of health and safety good practice. One aspect of this promotional activity, is to encourage proper consideration of Human Factors/Ergonomics (HF/E) in the management of health and safety. This is consistent to views expressed by many other respected organisations and associations concerned with the reduction of risks in the workplace.
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The types of activities undertaken by HSE to promote HF/E include, for example:
• A suite of guidance material on, for example, human error; manual handling and shiftwork;
• An "operationalised" list of key HF/E topics (for hazardous industries) with briefing sheets and extracts from an inspectors toolkit and other useful resources;
• Practical tools (Fatigue Risk Index and the Manual Handling Assessment Chart).
HSE have also recruited specialist inspectors and provide training on HF/E for health and safety field inspectors. The role of these inspectors is further supported by a dedicated unit and formalised guidance to be used in conjunction with The Control of Major Accident Hazards Regulations (COMAH) 1999 and Nuclear Safety Assessment Principles (SAP).
1.2.2 Human Factors/Ergonomics (HF/E)
HSE has defined Human Factors also known as Ergonomics as: The environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work.” [4]
On the HSE website (http://www.hse.gov.uk/humanfactors/index.htm), the following terms are used to describe this topic area:
• Human factors/ergonomics;
• Human factors;
• Human performance, and:
• Human and organisational factors.
The high hazard industries commonly use the term Human Factors. Human performance, in addition to the term Human Factors, tends also to be used within the nuclear sector. For the purposes of this report, however, it will be described as Human Factors/Ergonomics or the abbreviated term HF/E.
Every job, to some extent, is dependant on people. When accidents do happen, they are very often a result of the errors that people make. Careful consideration of HF/E can improve health and safety by reducing the number of accidents and also the causes of ill-health at work.
There are two principal areas where HSE’s HF/E efforts are focused:
• Preventing major accidents (major hazards);
• Protecting personal health & safety (preventing personal injury/ill-health).
More information on Human Factors/Ergonomics (HF/E) is provided on the HSE website: http://www.hse.gov.uk/humanfactors/
This report is focused on HF/E in the prevention of major accidents and the application of HF/E to improve Process and nuclear safety.
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1.2.3 Process and nuclear safety
The unintentional release of chemicals, energy, or other potentially dangerous substances (including radioactive material and steam) poses risks (fires and explosions) to workers and members of the public nearby.
Process safety is a way to identify and assess the hazards posed by these dangerous substances at work and consider ways to prevent unintentional release from occurring, for example, leaks, spills, equipment malfunctions, over-pressures, excessive temperatures and other similar conditions.
Process safety, however, is not just concerned with the quality of pipe-work and/or valves and the effects of corrosion, and metal fatigue. It is also concerned with HF/E issues and the types of factors that could lead to errors and influence people’s behaviour and similarly lead to an unintentional release of dangerous substances.
1.2.4 Research rationale and project aims
HSE believe they have made progress in engaging with industry and in increasing understanding and uptake of this topic. HSE are also aware, however, that, although successful in communicating with safety specialists, knowledge about HF/E does not always penetrate through to Key Decision Makers (such as senior managers, site managers, operational managers, engineers etc).
Anecdotal evidence generated through HSE contact with duty holders as part of their advisory and inspection function, also suggests that awareness and application of HF/E is not consistently applied by organisations.
A consequence of this may be that some KDMs may still tend not to take HF/E adequately into account in the way they manage their work. Some evidence for this view is provided by the occurrence of major accidents, for example:
• On March 23rd, 2005, the BP Texas City refinery experienced a catastrophic process accident. It was one of the most serious U.S. workplace disasters of the past two decades, resulting in 15 deaths and more than 170 injuries. Two reports that investigated this accident identified issues concerning safety culture, leadership and Process Safety management and also a number of more technical Human Factors issues.
• On 20th April, 2005, a leak of highly radioactive product liquor occurred inside a cell of the THORP plant at Sellafield. HSE’s investigation identified a range of issues, including management of change, alarm handling, culture, procedural violations, roles and responsibilities, supervision and management oversight.
• In May, 2004, nine workers were killed in Glasgow following an explosion at the ICL/Stockline plastic factory. The blast happened after petroleum gas ignited in a pipe which had been corroding over the years. A public inquiry revealed a failure of risk assessments or checks carried out on pipe-work when a new gas tank was fitted.
Earlier research [7] also commented that although “duty holders appear to be a willing audience they lack a consistent understanding of Human Factors, often relying on intuitive
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Nice to Have
Essential a must have
High awareness
Low awareness
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presumptions of what is meant by Human Factors”. The full report of this research is available on the HSE website (http://www.hse.gov.uk/research/rrhtm/rr149.htm).
The report further identified that different decision makers are likely to have a range of different pre-existing attitudes towards HF/E. This may alter how receptive they are towards messages about HF/E and the extent to which they apply it to their business. It raised the concept of Human Factors as a brand and stated that the challenge is to reposition this brand so it: “conveys what HSE wish to express about Human Factors in the context of major accident prevention”
In this context repositioning, therefore, concerns how to alter the relative position of Human Factors so that KDMs, and not just safety personnel, have an improved awareness and understanding of HF/E and see it as more essential to their business needs. This concept is illustrated by the figures presented below.
HSE, therefore, want a clearer vision of how they can reposition HF/E so that it is better understood and more valued by Key Decision Makers (KDMs). They want to identify what HSE can reasonably do to achieve a shift from position (1) – low awareness and value of HF/E ‘now’ to a future (position 2) where there is high awareness and every organisation within the high hazard sector considers it essential to major accident prevention. The research, therefore, seeks to further explore these issues; verify these beliefs and identify strategies that HSE could adopt to help achieve this change.
Figure 1 Awareness of HF/E
High awareness
2. Future
Well bounded
Fuzzy
1. Now
Low awareness
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Figure 2 Value and understanding of the importance of HF/E
Essential
2. Future
Personal safety Major accident preventions
1. Now
Nice to have
The overall aim of the research is to seek to understand how to make HF/E more central to the thinking of KDMs and improve awareness and understanding. To achieve this aim the objectives of the work are to:
• Clarify who the KDMs actually are;
• Explore how KDMs make decisions about process safety;
• Identify the key factors that may have influenced whether HF/E is central to the decision making process;
• Investigate what possible barriers might prevent or inhibit a broader uptake of HF/E in decisions which affect process safety;
• Understand current attitudes towards HF/E;
• Explore future strategies for improving the uptake of HF/E;
• Provide recommendations that HSE can adopt to help overcome these barriers or more generally improve the uptake of Human Factors amongst KDMs.
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2 METHOD
2.1 INTRODUCTION
To help achieve the project aims and objectives three key research activities were undertaken by Greenstreet Berman Ltd:
• Task 1 (Profile Key Decision Makers) – conducted 20 interviews with stakeholders to identify KDMs and improve understanding of the decision making process;
• Task 2 (Consult Key Decision Makers) – conducted 60 interviews with KDMs to discuss their involvement in decision making about process safety, how they have learnt about process safety; what techniques they might have applied to address issues concerning human error and what would help them to apply such techniques in the future;
• Task 3 (Strategy Workshop) - discuss with KDMs and stakeholders future strategies to help reposition HF/E.
Each of these research activities are discussed in more detail under the following relevant headings. The outcomes from these tasks are presented together in the next section Findings.
2.2 TASK 1 KDM PROFILE
2.2.1 Stakeholder Telephone Interviews
Telephone interviews were conducted with a range of stakeholders who were identified as having knowledge and experience of HF/E and/or safety and who could talk about issues concerning decision making on behalf of their industry.
In total, responses were provided by 20 stakeholders, from a range of sectors and specialism’s, for example: representatives from the high hazard industries concerned (onshore oil and gas, offshore oil and gas, nuclear and chemical); energy specialists; HF/E specialist; general safety specialists and process safety specialists.
The key questions asked during the interview were:
• Who do you think makes the key decisions that take account of and seek to influence human performance (reducing errors and controlling unsafe behaviour)?
• What are the different types of issues that these decision makers deal with?
• How do these decision makers improve performance, prevent error and control unsafe behaviours?
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In addition to these general questions, the interviewees were also asked to consider a similar set of questions but relating specifically to the HSE operationalised HF topic list1. Interviewees were asked to consider the following questions for each topic:
• Where does the decision occur?(at what level within the organisation?);
• And/or within which Department?;
• Do formal decisions take place and, if so, can you briefly say how these might occur? (for example: corporate policy, in isolation, collaboratively?);
• How is HF incorporated into tackling these topics? (What methods/strategies are used?).
A copy of the interview proforma is provided in Appendix III Stakeholder Interview Proforma.
2.2.2 Desktop review of major accidents
In addition to the interviews a desktop review was conducted to identify relevant literature on key decision making in high hazard industries. Specifically a number of recent major accidents in the chemical, nuclear, oil and gas industries were reviewed to see if decision making is a contributory factor in major accidents and identify key decision makers by job role or title. The following incidents were considered:
1. Humberside Refinery (2001) - A fire and explosion incident occurred at the Humberside Refinery following the catastrophic failure of an overhead gas pipe;
2. Thorp reprocessing plant (2005) - 83,000 litres of radioactive waste was discovered to have leaked in the Thorp reprocessing plant from a cracked pipe into a huge stainless steel-lined concrete sump chamber built to contain leaks;
3. Glasgow - ICL/Stockline (2004) - Nine workers died following an explosion;
4. Houston - Philips Petroleum (2000) - One worker died in the explosion and 69 others were injured (six-month investigation concluded that failure to train workers properly was a key factor in the explosion and fire);
5. Tokairmura (1999) - Criticality event - two workers hospitalised due to radiation sickness (plant workers were not properly trained and safety procedures were routinely violated);
6. Paks (2003) - Plant closed after increased radiation levels, poor cleaning tank design, combined with a weak safety analysis and inadequate operational oversight, contributed to the incident;
7. Grangemouth (2000) - Three safety incidents - power distribution failure (29th May), the medium pressure (MP) steam main rupture (7th June) and the Fluidised Catalytic Cracker Unit (FCCU) fire (10th June);
8. Texas City Oil refinery (2005) - The startup of the Isomerization (ISOM) unit (after a temporary downtime) led to an explosion, which killed 15 and harmed over 170 people;
9. Buncefield (2005) - A massive explosion led to a large fire which engulfed a high proportion of the site and over 40 people were injured (investigation still on-going).
1 Details of the HSE operationalised HF topic list can be found at: http://www.hse.gov.uk/humanfactors/majorhazard/index.htm
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The brief summary of findings from this review are provided in 12 Appendix V – Findings from desktop review of major accidents
2.3 TASK 2 CONSULT KDMS
Following completion of the profiling of KDMs, participants were recruited to match the different job types and roles identified during the earlier interviews e.g.: senior management; site managers; front line managers and health and safety personnel and from the following high hazard industries sectors: Chemical; Onshore Oil and Gas; Offshore Oil and Gas; and Nuclear;
A contacts database was then generated from new and existing contacts and participants were invited to take part in the research. Each interview took approximately 45 minutes to complete.
The proposed sample size was 60 persons. This was because experience suggests that this provides an adequate sample for this type of qualitative research and gives a sufficiently diverse range of different attitudes and positions towards HF/E. The following Table 1 provides the summary of the participants actually recruited for interview, segmented by job profile and sector.
Table 1: KDM recruited for interview
Key Decision Makers Profile
Sectors Chemicals Onshore Oil
& Gas Offshore Oil & Gas Nuclear Total
Senior Manager 2 2 4 3 11
Site Managers 6 5 2 3 16
Front Line Manager 5 6 3 5 19
H&S Personnel 1 6 5 1 13 Total 14 19 14 12 59
Information was then gathered about each KDM participating in the research and their views towards HF/E. In summary the key topics discussed during this interview were:
• Examples of personal involvement with a decision, development activity or assessment process that directly or indirectly influenced process safety;
• Examples of learning about process safety and ways of improving it;
• Examples of applying approaches, principles or techniques to assess error, manage human performance or influence behaviour;
• Consideration of future options for further supporting process safety decision making.
In addition to help understand if awareness and attitudes toward HF/E affected responses KDMs were also asked to rate:
• Awareness of Human Factors;
• Awareness of Ergonomics;
• Understanding of Human Factors;
• The importance which you place on Human Factors for your business;
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• The relevance of Human Factors to major accident prevention.
And to rate their level of agreement with the following questions:
• I seek advice from others when making decisions about preventing error and improving human performance;
• I have used guidance on Human Factors when considering process safety;
• Past events or incidents have prompted me into finding out more about Human Factors or applying a Human Factors approach.
A copy of the interview proforma is provided in Appendix iV –KDM interview proforma
2.4 ANALYSIS
2.4.1 Introduction
The analysis of the results from the interviews is provided in a series of tables presented in Appendix i – stakeholder responses and Appendix ii – key decision maker responses
These tables were developed using thematic analysis which is a technique used in the social sciences to analyse information derived from interviews usually by studying transcripts. It should be noted that for this work, interviews were not recorded and therefore the research required the accurate reporting of information by the interviewers – supported by an interview proforma.
The key feature of thematic analysis, used in this research, was to identify key themes or concepts within the interviews and then to code interview responses against these key themes. For example, to identify the types of HF/E issues recently being tackled by KDMs, their responses were coded against the HSE HF/E key topic list. The tables were reviewed to look for trends or differences in the interview responses. This provides insight into, for example:
• The types of issues currently being tackled;
• What method or approaches are being used to address these issues;
• In what way have KDMs learnt more about HF/E and process safety;
• What if anything had led them to find out more about HF/E and process safety.
The thematic analysis was further supported by looking in more detail at the responses from interviewees and what was actually said. In addition and where applicable, statements from the interviews have been included in the findings section to help illustrate the areas of interest identified from the analysis.
2.4.2 Self selection
The main KDM interviews took place over a four month period from June to September 2008. Interviewees were selected to fulfil the KDM profiles developed from task 1, such that a range of views and opinions were captured. Potential participants were identified through a number of methods:
• Contacts from industry associations such as the Energy Institute;
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• Existing Greenstreet Berman Ltd contacts within the high hazard industries;
• Referrals from KDMs taking part in the research;
• And to a lesser extent, direct referrals from HSE.
Potential participants were sent information explaining the background to the work; what the work entailed and were then invited to take part.
It is recognised that because KDMs were self selecting, it is possible that the decision to participate may have influenced KDM responses. For example, those choosing to take part may have a more positive attitude towards both HSE and HF/E. It should be noted, however, that all those taking part were assured anonymity and confidentiality.
2.4.3 Quantitative analysis
The majority of questions asked during the interviews were open questions where KDMs were asked to express their view on a topic area, such as, the types of techniques and approaches they used to tackle human performance issues. Some questions, however, also asked KDMs to rank their answer on a 5 point Linkert rating scale. In total 58 of the 60 respondents provided a quantitative rating from 1-5 when asked to rate their:
1. Awareness of Human Factors (with a score of 1 being poor and 5 being good);
2. Awareness of Ergonomics (with a score of 1 being poor and 5 being good);
3. Understanding of Human Factors (with a score of 1 being poor and 5 being good);
4. Importance which you place on Human Factors for your business (with a score of 1 being not essential and 5 being essential);
5. Relevance of Human Factors to major accident prevention (with a score of 1 being not essential and 5 being essential);
6. Seeking advice from others when making decisions about preventing error and improving human performance (with a score of 1 being not essential and 5 being essential);
7. Using guidance on Human Factors when considering process safety (with a score of 1 strongly disagree and 5 strongly agree);
8. Past events or incidents have prompted me into finding out more about Human Factors or applying a Human Factors approach (with a score of 1 strongly disagree and 5 strongly agree).
It should be noted, however, that the small sample size means that responses provide only a broad indication rather than a more robust measure of true attitude and understanding towards HF/E. This is particularly the case when segmenting responses to assess job type or sector differences.
2.5 TASK 3 STRATEGY WORKSHOP
The final task was a ½ day strategy workshop.
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17 stakeholders attended the event, representing views and opinions from different sectors, professions, institutions and organisations:
• Associations (2);
• Institutions (1);
• Industry Groups (2);
• Societies (1);
• Academic Institutions (1);
• Firms in the Nuclear Sector (1);
• Firms in the Onshore Oil & Gas sector (2);
• Firms in the Offshore Oil & Gas sector (1);
• Firms in the Chemical sector (1);
• Unions (1);
• Regulator (4).
They overall aim of the workshop was to consider possible future cost effective strategies to help achieve the goal of repositioning HF/E.
Participants were organised into three groups and were then asked to discuss:
• To what extent is there a need to tackle human performance issues (reduce errors and unsafe behaviour) in the high hazard industries?
• What needs to be done to increase the knowledge and application of Human Factors to address these issues?
• What are the best strategies for achieving this?
• To what extent are these strategies already available to you and/or your industry?
• What can be done to better deliver these strategies and what role can industry and associations play?
Each group appointed a note taker to write up views and opinions on a flip chart. After each topic was discussed within each group; views and opinions were shared and ideas were discussed collectively.
The outcomes from the workshop was be used to enhance and refine the Conclusion and Recommendations section of this report.
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3 FINDINGS
3.1 INTRODUCTION
This section provides the overall findings. A more thorough discussion on what these findings might mean, in terms of seeking to increase the uptake of HF/E, takes place in the conclusion and recommendations section of this report.
The findings are summarised and then specific key topics are discussed under the following headings:
• Identifying the Key Decision Makers and Understanding the Decision Making Process;
• The current extent of HF/E in decision making;
• Learning about HF/E and process safety;
• HF/E techniques and approaches currently in use;
• Understanding and Attitudes towards HF/E;
• How do sectors differ in their approach to HF/E;
• How do job types differ in their approach to HF/E;
• The barriers to the uptake of HF/E;
• Current good practice.
3.2 SUMMARY OF FINDINGS
The summary of the findings are as follows:
3.2.1 Indentifying KDMs and understanding the decision making process
Key decision makers were identified to be: senior, site and front line managers as well as H&S Personnel. Other named decision makers were Operation Personnel and Board and Committees Members. Less frequently cited groups, who are likely to support and influence the decision making process rather than actually make the key decisions, included: Trade Unions; Financial department (agreeing resources, allocating funds etc); Human resources and Contractors.
Decision making on process safety, that takes account of HF/E, is frequently collaborative and can be complex and varied. Those involved in the decision making process will change depending on the type of decision being made. Certain HF/E topics are tackled by specialist roles with close links to that area of work.
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3.2.2 Current application of HF/E to tackle process safety issues
The findings indicate that often a range of familiar and accepted HF/E techniques were frequently cited as a way to tackle issues impacting on process safety. In particular KDMs cited that they frequently consulted workers and also used a number of different analytic techniques to improve understanding of a problem area. It was less clear whether worker consultation and analysis were applied in a systematic and consistent way.
3.2.3 The perceived value of HF/E
KDMs recognise the need to consider and manage human error and performance - as per previous research. The findings indicate that the value of HF/E is understood and KDMs recognise that there is a need to do more and that HF/E should be better integrated into wider professional development and safety management decision making. KDMs, however, were less clear about how to apply HF/E to their work place.
3.2.4 How can the application of HF/E be improved?
KDMs need more help to improve the application of HF/E within the high hazard industries and cited the following as possible ways that this might be achieved:
• More training on HF/E (relevant/practical/certificated);
• More practical support in tackling HF/E issues (tools/guidance);
• Developing partnerships with industry associations and professional institutions to help deliver training, practical guidance and peer review;
• Peer review is a very valuable method for learning and improving;
• HSE should seek to take the lead on HF/E and develop an agenda and strategy to communicate on it more effectively.
There are little discernible job or sector differences in terms of these broad requirements, although the findings indicate that formal peer review is used more widely within the nuclear sector.
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3.3 FINDINGS FROM TASK 1 – THE PROFILE OF KDMS AND THE DECISION MAKING PROCESS
3.3.1 Introduction
This section explores who is making the key decisions regarding process safety and HF/E and how decisions are made. It provides insight into who HSE should seek to communicate with and influence to both increase understanding and application of HF/E.
The following key topics are discussed in the section:
• Identifying the Key Decision Makers;
• How decisions are made;
• Factors influencing decision making;
• Job differences.
3.3.2 Identifying the Key Decision Makers (KDMs)
The findings from the initial interviews, with 20 stakeholders, largely confirmed current thinking on decision making – see Table 13 Appendix I. There were four main role types, most cited by interviewees, as making decisions that take account of HF/E issues (influencing human error, performance and behaviour) namely:
• Senior Management (site director, managing director, senior executive);
• Site Managers (facility, installation or refinery managers - those leading day-to-day plant operation);
• Front Line Managers (operations managers, production managers, project managers, design managers, safety assurance managers, maintenance managers);
• Health and safety Personnel (HSE department, safety director, safety manager, safety case authors, incident investigators, process safety specialists etc).
The other main decision makers frequently cited were Operation Personnel and Board and Committees Members - respondents believed that multi national companies may have different decision making but only at the most senior level e.g. (Board, CEO and President).
Other decision makers also named included: Trade Unions; Financial department (agreeing resources, allocating funds etc); Human Resources and Contractors. The latter, less frequently cited groups are more likely to support and influence the decision making process rather than actually make key decisions.
The Baker report [1] also provided information about the hierarchy of decision making and accountability for process safety performance. At the time of the Texas City explosion BP refineries authority was viewed as a line running from:
• The Group Chief Executive; • The Chief Executive, Refining and Marketing;
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• The Group Vice-President, Refining - the most Senior Manager of the refining business;
• The Refining Vice President—North America; • The individual refinery plant managers; • Operating personnel at the refineries.
This different and varied audience is a potential problem for the communication of HF/E. This is because the appropriate message must first get to its intended audience; be applicable and then be understood. This issue is explored in the sections: Awareness raising communications campaign and Communications Strategy.
The findings indicated not discernable difference in KDMs between sectors.
3.3.3 How decisions are made
Those involved in the decision making process appear to vary depending on the type of decision being made – again see Table 13 Appendix I. Certain HF/E topics are tackled very much by specialist roles with close links to that area of work, for example:
• Corporate level (President CEO) - Organisational change and organisational culture;
• Training department – Training and competence;
• Design department – HF in design, Alarm handling;
• Engineering – Alarm handling, Interfaces;
• Technical – Procedures;
• Production and Quality – Procedures.
The findings indicate that there is a diverse range of people and departments involved in making decisions about HF/E. This supports the point that HF/E is a wide ranging topic relevant to many aspects of managing and operating a company within the high hazard industries. Key decisions about HF/E not only occur across different departments but also through the hierarchy of the organisation. For example, individuals at a very senior level are making decisions on topics like organisational change and culture (which can have an impact company wide) yet HF/E is also relevant to those making decisions about matters concerning day to day operation, for example, alarm handling.
A number of respondents also indicated that they felt the level (position within the company) of those involved in key decision making will vary depending on the size of the business: “In small/medium sized organisations the owners would make the key decisions.”
The findings, from the main interviews, also indicated that workers were frequently consulted when the KDM was involved in a development activity or assessment process that directly or indirectly influenced process safety – see Table 17 Appendix II. There was less evidence, however, that workers were participating in the decision making process or actually involved in helping to resolve HF/E issues.
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The findings indicated that decisions on HF/E are made in different ways. The most frequently cited method – see Table 14 Appendix I was a top down approach with decision making driven by company policy; corporate standards or programmes or initiatives. “Board members and their direct reports (senior leadership team)- these individuals set the culture and strategy, and hold the purse strings. From our experience, if you can get their attention and commitment to an issue it will happen. HF (and other disciplines) often doesn’t get the exposure to and sponsorship by, senior leadership.”
Decision making that may take into account process safety and HF/E can, however, also be driven bottom up with the initiative taken at a departmental level: ”Decisions may be made at an individual or department level which is networked and progressed to more senior level, if successful, maybe adopted as policy more widely.”
To make the picture even more complex respondents also believed decisions occurred at the site manager level. “Key decisions start with the refinery leaders.” For the nuclear sector the World Association of Nuclear Operators (WANO) themed the first world wide Plant Managers’ Conference (Nov 2006) with the title: ‘Effective operational decision making to improve plant safety and reliability’. This also tends to suggest that site managers are seen as key decision makers regarding safety and by extension also HF/E.
Overall, however, the majority of respondents believed decision making that takes account of HF/E should be driven by corporate policy and senior management. This might be focused by using a programme of work or branded initiative. The Baker report, for example, also raised the potential risks inherent in not clearly defining expectation when delegating decision making on, process safety: “…its decentralised management system and entrepreneurial culture have delegated substantial discretion to U.S. refinery plant managers without clearly defining process safety expectations, responsibilities, or accountabilities.”
The way decisions are made is similar for each sector. This is probably because despite the variety in the type of work they undertake, the HSE topics will be relevant for all. How they tackle each of these topics might be different but the findings tend to suggest that overall decisions about HF/E tend to be tackled by similar job roles across each sector.
3.3.4 The level of collaboration in decision making about HF/E
Responses from stakeholders – see Table 14 Appendix I would tend to indicate that decisions are often made in collaboration rather than by individuals or departments in isolation. This is supported by individual comments which described a number of different teams of people making decisions about HF/E, for example:
• Refinery Management Team - Refinery Manager, Process manager, Mechanical Manager, Technical manager;
• Personal Safety Team/SHE team - Site manager or OIM, engineering manager (work force such as Trade Unions would help to influence decisions in safety meetings etc);
• Process safety/Safety and Operations Team - Human Factors Advisor, Director of Personal Safety, Behavioural Safety Advisors, Incident Investigation Advisor;
• Design team - HF specialists, process designers, senior management and other specialists.
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Decisions were not, however, always reached collaboratively but could, when special circumstance dictated, also occur at an individual or departmental level. For example, in the offshore sector it was only the diving teams who made decisions regarding the purchase of Remotely Operated Vehicles (ROVs).
3.3.5 Other factors that influence on decision making
Table 14 in Appendix I, provides examples of a number of external factors that were cited by interviewees as likely to influence or direct decision making, for example: Legislation - HSE inspectors; Safety Case demand; Standards and guidance.
Surprisingly, however, no interviewee directly identified any advisory bodies, which might provide advice or information through websites, and telephone help lines etc. A number of interviewees also stated that they felt there was less support than desirable to help address HF/E in certain areas, for example: Procedures and Managing Organisation Change: “Very few companies have guidance / standards on how to write a procedure, who to involve, and how to make sure they are followed. There is very little accessible guidance on this subject, even for the HF professional” and “Many companies have MOC (management of change) procedures, but great variation exists in how well they are applied. Much advice on MOC does not explicitly tackle the human factor.”
No interviewee cited location, such as being an offshore facility or remote site as a factor that might influence decision making.
3.3.6 The range of methods used to incorporate a HF approach into decision making.
A diverse range of methods are used to incorporate a HF/E approach into decision making – see Table 15 Appendix I. This again might reflect how HF/E is applicable to many different topic areas, which all require slightly different approaches.
Risk assessment [20] was the most widely cited method incorporating HF/E into decision making followed by external consultants [16]. Although risk assessment is not normally classified as a HF/E technique, it is used to consider issues concerning human error.
No interviewee cited a specialist in house HF capability, however, there were a number of analytical methods cited as being used to support decision making, for example:
• Task Analysis (7);
• Gap analysis (7);
• Workplace mapping (6);
• Root cause fault tree analysis (5);
• Error analysis (SHERPA HEART HRA) (4);
• Workload analysis (3);
• Job safety analysis (1).
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Table 15 also reveals that consultation or worker involvement, through workshops and interviews, was only seldom cited by stakeholders as a method for incorporating HF/E into decision making. This contrasts with findings from the main interviews with KDMs which indicated that consultation was a commonly cited risk control for managing human error. Findings from Task 2, the interviews with KDMs, are explored next.
3.4 FINDINGS FROM TASK 2 – THE EXTENT OF HF/E IN CURRENT DECISION MAKING (Q1)
3.4.1 Introduction
This section explores unprompted responses by KDMs concerning their involvement in a decision making on process safety issues. KDMs were asked to respond to the following question: “Please think of a recent example of where you have been personally involved in a decision, or development activity or assessment process that directly or indirectly influenced process safety. For example, a review of staffing levels on a site, introduction of a new control room, re-design of a control panel, development of operator training standards, revision of a permit to work system and so on”.
The aim of this question was to steer the KDM into considering a potential issue or topic related to process safety to see, if unprompted, they discussed HF/E issues. The overall objective of this question was to reveal whether HF/E is central to the thinking of KDMs when addressing process safety problems.
3.4.2 Process safety activities
Of the 59 respondents 57 KDMs cited process safety activities where they had personally been involved.
The most commonly cited activities were:
• General review of safety or process safety (13);
• Manning (8);
• Plant design (8);
• Organisational change (4);
• Systems upgrade (3);
• Safety culture (3);
• Training and competence (3);
• Control room (3);
• Emergency shutdown (2).
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The remaining 10 KDMs cited other process safety activities cited, such as: maintenance; permit to work, communication; decision making; leadership; performance; procedures, fatigue management and shift patterns.
The majority of KDMs tended to give an account of a broad area, such as a general review of safety. The key areas of concern were manning or staffing levels or a need to consider process safety because of plant design or systems upgrades. A smaller number of KDMs, focused on a specific topic area such as reviewing procedures or looking at communication issues.
The review of responses to this question also considered whether unprompted, KDMs discussed HF/E issues were more directly concerned with human performance issues (error and behaviour). This is explored under the next heading: 3.4.3 HF/E issues being addressed.
3.4.3 HF/E issues being addressed
The key issues identified were classified using the HSE HF/E operationalised topic list2. This was because an initial consideration of the responses indicated that issues could be easily described in this way. Earlier research had, also indicated that HSE topic list was an appropriate reflection of the types of issues commonly tackled by high hazard industries.
Of the 57 KDMs responding to this question 37 cited an issue that could be classified using the HSE HF/E operationalised topic list – see Table 16 Appendix II. These are again listed by frequency:
• Training & Competence (16);
• Procedures (8);
• Communication (3);
• Staffing levels and workload – manning (2);
• Organisational change (2);
• Behavioural Safety (2);
• Alarm Handling (2);
• Human Factors in Design (1);
• Interfaces - usability (1);
• Safety & organisational culture (1);
• Accident investigation - integration of HF into RA/investigation (1);
• Fatigue (1);
• Supervision (1);
• Managing human failure Safety & safety management process safety (0).
These findings indicate that KDMs are addressing a spectrum of issues across a range of HF/E topics, with the primary focus on training & competence and procedures. It also indicates that
2 Details of the HSE operationalised HF topic list can be found at: http://www.hse.gov.uk/humanfactors/majorhazard/index.htm
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20 KDMs did not mention or discuss an issue that could be classified using the topic list but rather focused on the more physical or material aspects of process safety i.e. not related to HF/E. This is illustrated by the following comments: “A design issue came from a formal process hazards analysis involving several sets of pumps across the refinery. There was a risk found with a particular set of pumps. There was a priority to modify the cost involved to see if these were justified; selected pumps were modified at the next turnaround cycle.”
The analysis of the findings also considered whether those that had cited an HF/E issue went on to describe a number of further issues concerning ways to address error, behaviour or performance issues. This could be judged to be an indication that HF/E was more central to their thinking. Of the 37 respondents, a further 23 mentioned other or additional HF/E issues they had tackled.
The following response reveals a KDM where HF/E appears more central to their thinking: “We looked at the refinery and took it through a ladder assessment. The ladder assessment included looking at working patterns, situation awareness, working hours, shift patterns, fatigue, training and development, management of operations and procedures, management of change. The review of procedures ensured that the procedures were understood by operators. The results were an eye-opener, some areas were good and some not so good. We looked at the detail to see how to address these issues. We will move forward by - identifying forward actions against risk, and complexity of addressing the issue; - shift supervisor, process engineer, operations manager will progress this and then present to senior managers”.
The results indicate that although many KDMs are considering HF/E issues in terms of process safety and some have a well developed understanding of its benefits; there are still a number who are less familiar with using such an approach.
This would tend to confirm HSE initial belief that full awareness and understanding of HF/E does not always penetrate through to all KDMs.
3.4.4 Activities undertaken to address these issues
The thematic analysis – see Table 17 Appendix II, also considered the types of activities that KDMs were undertaking to address these issues. They were asked: “What sort of risk controls did you consider for prevention or management of human error?”
The most commonly cited activities were:
• Consultation and interviews with employees such as contractors, front line staff, maintainers etc (19) “Consult with maintainers and contractors to revise maintenance instructions e.g. add diagrams photographs etc”;
• Risk analysis and assessment (16) – “Risk analysis were carried out to assess these changes which included the impact on process safety.”;
• HAZOPs (11) “The risk and impact assessment uses HAZOPs, HAZIPs and fault trees to identify risk, impact, control. Risk assessment looks to integrate HF with physical risks.”;
• External consultants (8) “For this, consultants conducted a study for quantitative risk analysis in order to determine if there is any significant change in numerical risk.”
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The least commonly cited were:
• Standards (4);
• Internal HF Champions (2);
• Guidance (1);
These activities cited are again broadly inline with the findings from the stakeholder interviews from Task 1. KDM responses, however, indicate that there is less use of: standards; guidance or formal HF/E tools and analytical techniques. This may provide an insight into why many KDMs, when later asked what future ways the HSE might improve the uptake of HF/E, suggested they could benefit from practical help and guidance to assist then in better integrating HF/E into the way they manage safety.
In addition, the analysis of the KDM interviews suggested there was no clear pattern between activities and issues. For example, when the two most frequently cited issues, training and competency and procedures were reviewed, no one particular activity was used:
• Training and competence (risk assessment, root cause analysis, task analysis, toolbox talks, consultation/interviews and external consultants);
• Procedures (audits, modelling, risk assessment, job safety analysis, workload analysis, consultation/interviews).
The following descriptions of the activities undertaken to improve the emergency shut down of hydrochloric alkylation unit, helps to illustrate the range and diversity of accepted HF/E approaches being used: “Key considerations included identifying hazards, initiating events and current protection. The SEQ manager looked at quantified RA of the unit. Potential causes included loss of containment through corrosion. We used fault tree and event tree analysis. People involved in the review/decision process included technicians; control and instrument department; operations team; process support group; and inspection department. Consultation occurred face-to-face. Inspection was also carried out by an HF specialist to consider the HF elements. They completed an RA, which went very well. Risk controls included new procedures, guidelines, training and cameras looking at the process.
A positive finding from the interviews was the frequency with which KDMs cited that they had engaged with workers through consultation and involvement. The following examples help to illustrate this: “We recently undertook a commissioning process to ensure operability of the terminal. This includes fitting and updating the control room. For example replacing VDUs and making systems more user friendly, simplifying complex logic and reducing numbers of redundant alarms. Set up a review team to conduct facilitated discussions including: platform owner, original designer, operators and the new software developers.”
There were no notable differences between sectors and job roles in terms of activities or approaches to tackle the issues impacting on process safety. For example, external consultants are used across all sectors and were cited by a range of job types. Comments made by stakeholders in the nuclear sector suggest that there is greater use of internal HF/E specialists within their industry. Findings from the thematic analysis tend to support this claim; however, the sample is too small to state this with confidence.
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3.4.5 Factors influencing Decision Making (Q1)
During the Task 2 interviews, KDMs were also asked to consider not only their involvement in a recent decision but also to discuss what had influenced them to consider human performance issues: “What prompted you to consider managing human error and human performance in this way”?
The key factors influencing the decision to address a particular issue were identified to be:
• Design or upgrade (change to facility or work process/system) [14];
• Findings from an organisational review process, risk assessment/analysis [13];
• On site incident/accident [8];
• Own decision to address the issue or non specified [8];
• External incident/accident [4];
• Recommendation from HSE inspector [4];
• Enforcement [3];
• Corporate directive or company policy [3];
• Guidance, standards [3].
These findings are similar to the responses from the interviews carried out in Task 1 (with stakeholders) who also identified safety case demands and standards, as well as corporate policy as a key influencing factor on the decision making process.
The findings are encouraging because they indicate that decisions to tackle process safety issues are largely driven by an ongoing and regular internal review process. This is probably part of the organisation’s overall safety management system and safety case requirements. The other key factor influencing decisions was simply that a system or facility needed to be upgraded, for example, fitting and updating the control room; or re-writing maintenance instructions following a change of power supply. The findings also suggest that KDMs are responding to events such as onsite incidents and accidents.
A number of KDMs were also prompted into tackling an issue because of influence from HSE. This influence could either occur through regular HSE inspector visits, because organisations were top tier COMAH sites or because a formal notice had been raised on their organisation because of a perceived non-compliance with health and safety regulation. The influence of HSE is illustrated by the following statements: “An improvement notice led to a review of safe systems of work and a re-classification of operations.”
The direct interaction of HSE, with individual sites, has undoubtedly been effective at influencing decision making. It is also largely welcomed by KDMs. This way of working, however, places a potentially high workload on HSE inspectors (stretching an already limited resource) and seems a less efficient way of getting change than influencing decision making at a more corporate level.
It should be noted that when KDMs were asked to discuss effective ways to achieve greater consideration of human error and how to prevent it, they did not indicate that influencing corporate decision making would be effective. There was, however, recognition that
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understanding and knowledge of HF/E needed to be improved and HF/E principles embedded more within organisational processes. This issue is discussed in more detail in the section Future options for improving the uptake and application of HF/E.
3.5 FINDINGS FROM TASK 2 - LEARNING ABOUT HF/E & PROCESS SAFETY (Q2)
3.5.1 Introduction
This section explores how KDMs learn and acquire knowledge about issues that can impact on safe operations of a facility. Question 2 asked them to: “think of a good example of where you have learnt about process safety and ways of improving process safety, something that you found useful”. The aim of this question was to provide a lead on how similarly HSE might seek to promote learning about HF/E.
The following key learning techniques (presented in Table 18 Appendix II and listed below) were identified from the interviews, as an example of how the KDM had learnt more about process safety:
• Training (32);
o In house internally provided [17];
o Externally provided company training [11];
o External attended accredited course [4].
• On the job learning [19];
• Internals safety teams [15];
• Accident investigation [11]
• Conferences [12];
• Safety qualification or member of a safety association [7]
• Peer review informal and formal [7];
• Guidance and industry documentation [6];
• HSE inspectors [4];
• External consultants [3].
Theses results indicate that unsurprisingly training was the most popular way for learning about process safety. The findings, however, also indicate that a broad range of other techniques were used by KDMs.
Overall, the responses indicated that there were only limited differences in responses relating to job position although senior managers were the lowest group citing training as a mechanism for learning. Senior managers may have less opportunity for training or it may be an attitudinal issue, where senior managers may believe they do not need training in this area. In contrast to this view, however, other respondents felt that it was important to ensure senior managers were provided and encouraged to take part in training and industry events, to help them understand the importance of process safety.
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In terms of sector differences, the nuclear sector favoured the use of formal peer learning, while respondents from the onshore and offshore sector cited learning from incidents and guidance more that any other sector. However, learning from such accidents was a widely accepted method mainly because industries tackled the same types of issues and these accidents were universal and provided learning opportunities applicable to many different industries.
These techniques are explored and discussed in more detail under the following relevant headings.
3.5.2 Training
The most frequently cited example of training was internal training arranged through the KDMs organisation. Types of internal training reported were: general company safety courses; safety training on process and chemical hazards; learning about analysis techniques (HAZOP and QRA); behavioural training and internal process safety presentations.
Fewer KDMs had attended external process safety training courses, which are run through safety organisations such as the Chemical Industry Association (CIA); Institute of Occupational Safety and Health (IOSH) or the Ergonomics Society. Types of external training included for example: Human Factors process safety Course run by the Ergonomics Society, a Root Cause Analysis run by the CIA, and IOSH Management Safety Courses. The KDMs who had attended external training did, however, report a positive experience: “The human element training was very effective at getting the message across by using simple analogies (stress bucket) and personal and industrial examples. Found it very interesting because it was interactive and engaging.”
Attending external training was also seen as beneficial because it provided networking opportunities and learning from shared experience, illustrated by the following comment: “Undertaken process safety training which provides an underpinning of knowledge but shared experience (briefings on events etc) is the best way of gaining knowledge”
Overall training was considered to be more effective when it was practical rather than a formal presentation or “chalk and talk”.
A number of KDMs also expressed the view that external training might be less useful because it was less industry specific in comparison to in-house training arranged through their own organisation. “In-house training focused on what process safety is, what can happen and recent examples. Case studies were then used for individuals to work through and identify key issues, causes and how the incident could be avoided.”
There was little evidence that formal processes were used to identify training requirements particularly for senior managers and site managers. “It is challenging, however, for site managers and senior executives to assess their own training requirements particularly in terms of addressing process safety. There is less access to a peer group to bounce ideas off and to discuss own training requirements.”
3.5.3 On the job learning
On the job training was the second most frequently cited method, with three different forms described:
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• Learning through work experience;
• Being part of an assessment team;
• Undertaking workplace of work practice re-design.
On the job learning can be effective but is often informal and no respondents provided evidence that formal processes were used to identify training requirements.
Learning from experience and on the job activity is likely to be unplanned and therefore less likely to be robust and meet all safety management requirements. Unlike external training, KDMs did not report that on the job learning was a notably positive way of finding out more about process safety. This may help explain why KDMs rated enhancing knowledge of HF/E, through training and professional development, as the most effective option for improving the uptake of HF/E – see section 4.2 Improve knowledge of HF/E.
3.5.4 Internal safety department
Learning through the information disseminated from an organisation’s safety department or team was cited by a number of KDMs. This way of learning focused around safety teams sharing information about process safety issues through: the intranet; safety bulletins, internal SHE alerts; presentations etc.
Some safety teams also provide practical help on tackling process safety, which also provided a learning opportunity: “HSEQ leads on process safety and is carried to site level by process safety managers and process risk assessors. They conduct formal assessments that inform the company internally”.
3.5.5 Internal accident/incident reporting
Learning from investigations into internal accident/incidents, was also seen as a good learning opportunity. A number of different learning methods were reported:
• Sharing incidents and near misses through documentation: “All incidents/near misses are recorded online and these are then picked up by the corporate officer and sent out in a safety bulletin”;
• Sharing information through verbal communication such as site visits or toolbox talks: “Group terminals each liaise and communicate with each other to pass on plant problems. Safety managers include accident/incident data in safety meetings and toolbox meetings”;
• Desktop reviews of incidents: “Event reviews of incidents consist of 4/5 hours desk top exercise to explore why an event has happened.”
It is unclear from the interviews which method was most popular and most effective. However, it is likely that being part of a team that explores an event would be an effective method for learning more about process safety.
3.5.6 Conferences
Attending conferences was also frequently given as a good learning opportunity. Conferences were considered more beneficial when focused on learning from incidents and experiences and
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applying practical lessons. This supports the view that learning from accidents and applying lessons is a good way of improving understanding of process safety issues and understanding how to address them: “Conferences focused around learning from disasters in process safety helps to think about impact on organisation and what the organisation should do”.
3.5.7 Safety qualifications
A small number of KDMs stated that they had either a degree or safety qualifications (NEBOSH; MSc in process safety from Sheffield University) that encompassed process safety or were a chartered member of a professional body such as IOSH. One KDM also stated that their degree as a chemical engineer had included academic training on process safety.
3.5.8 Guidance and standards
The use of guidance, industry documentation and standards were cited by six KDMs as a method for learning about process safety and HF/E. The two documents actually named were: HSG 65 – “Safety Management” and HSG 254 – “Developing Process Safety indicators”.
Two International Standards were also cited by one KDM: IC61508 (overall standard) and IC 61511 (applies to the Chemical Industry). They commented that: “the principles involved in this standard are very good and structured. However it is not easy to apply the standard and it is very long and very general.”
The above comment might explain why guidance is less frequently cited than other techniques for learning more about process safety.
Several respondents also commented on the HSE website. The perception was that although the HSE website contains a large amount of useful information the site was difficult to navigate and hence difficult to find relevant information. “HSE website is a ‘gold mine’ but is very difficult to navigate. The site could be easier to follow and find information using a road map and better referenced material.”
3.5.9 Accident/incident reporting
KDMs used reports into major high profile accidents, for example Texas City and Buncefield, to learn more about process safety and the role of HF/E in accident causation.
Responses highlighted three different methods for exploring and applying relevant knowledge to the workplace:
1. Reading the reports and then seeing how lessons can be applied: “process safety was a major failure for this disaster (Piper Alpha disaster). The isolation control process has been improved and is operated to a high standard.”
2. Conducting a more thorough review of the accident e.g.: contacting those directly involved with the incident: “Reading reports of recent process safety incidents such as Texas or Buncefield. Using their contacts in the industry to talk to relevant people from the companies where the incident took place to understand the root causes and then consider the application to their business.”
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3. Undertaking scenarios that act out the accident to better understand the key issues that led to the event: “Use a formalised procedure called OFFSITE INCIDENT PROCESS to investigate an incident elsewhere (Texas City and Buncefield) as if it had occurred on their site.”
One KDM indicated how they believed that HSE might be able to enhance this type of learning: “Help to make the link between major accidents and human error more explicit and simple, with Buncefield for example indicate that human error (HF issues) played a key part”.
3.5.10 HSE inspectors
The general view was that support and advice provided from HSE was good particularly from visiting inspectors.
KDMs (who cited HSE inspectors as a way of finding out more about process safety) did, however, express the view that inspectors were good at identifying where an organisation might need to improve but did not always provide sufficient guidance on how that organisation might actually address a particular issue or signpost where they could go for assistance.
3.5.11 Peer review
Peer review was not commonly cited (7 KDMs) but those who did, considered it to be a very effective way of enhancing understanding of process safety and the role of HF/E.
Peer review involves inviting people from other organisations to assess a management system and/or processes at a particular site. Reviewers are often experts in a particular field and provide critical feedback on relevant safety issues. The peer review process is either informally developed through contacts or arranged formally through an industry association.
Formal peer review was cited only by respondents in the nuclear industry facilitated by World Association of Nuclear Operations (WANO): “Visits from WANO technical support mission conduct peer review site visits - they spend several weeks to immerse themselves in a topic (manning) and then spell out what is wrong and present the evidence. In terms of operational experience and feedback they are leading the industry”.
Peer reviews were popular because they were carried out by peers rather than external consultants. KDMs trusted peers and felt the reviewers understood their industry and the constraints and problems they faced: “The WANO technical support mission is compelling. You respect your peers because they come from the same industry and understand the issues; not a consultant looking for more work”.
3.5.12 External consultants
The use of external consultants was one of the least frequently cited ways to learn more about Process safety although the earlier findings suggests they were used quite commonly used to help tackle issues affecting process safety. This suggests the external training providers are not widely used to provide bespoke training on process safety to industries and this subject is more likely to be provided from within the organisation.
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3.6 FINDINGS FROM TASK 2 WHAT MAKES LEARNING COMPELLING (Q2B)
3.6.1 Introduction
This section explores what makes learning compelling by asking KDMs to consider: “What was it about this ‘information’ that was useful and influential/compelling? Why was it useful?”
The aim of the question was to identify which were the most effective ways of finding out more about process safety and what encouraged them to actually apply knowledge about process safety to their workplace.
The analysis of the responses, presented in Table 19 Appendix II, indicated four main factors that make learning compelling:
• Practical learning [26];
• Industry specific [22];
• Powerful message, often highlighting the human cost of poor safety [12];
• Easy to understand and benefits of action clearly explained [7].
These techniques are explored and discussed under the following relevant headings.
3.6.2 Practical
Learning was more compelling when it was practical and helped KDMs to understand an issue and see how it related to their organisation: “The most useful thing is the lessons learnt from reports such as the Baker Report. You can then apply these lessons to your own facility.”
KDMs also stated that being involved in techniques such as: HAZOPs; risk assessment; walkthroughs and accident investigation provided practical learning opportunities that enhance understanding of relevant process safety issues. These techniques are also likely to be cited more frequently, because they are more commonly used and understood.
Overall, practical learning was believed to enhance training effectiveness: “These forms of training were good because they were practical; they got the messages across, could be applied in practice and were not like COMAH in that they did not provide reams of paperwork. Training has to be PRACTICAL!!”
3.6.3 Industry specific
Information was considered to be more compelling when its relevant to industry. This may explain why learning techniques such as on-the-job learning and formal peer review were popular ways of learning more about process safety: “The major incident report information came from a real incident and described the philosophy across oil refineries. It was directly applicable to us and we could see our own issues in the document.”
KDMs also commented that learning from other industry events is compelling if it is focused around similar issues and provides transferable learning. This may explain why the Texas City and Buncefield accidents were both cited as key learning aids by KDMs in both the Chemical
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and Nuclear sector. The information is not industry specific but the issues that led up to the incident and subsequent learning actions are transferable.
3.6.4 Powerful message
Learning from accidents was also seen as compelling when it provided a powerful message in terms of the damage and suffering that can be caused by process safety failures: “Accidents are a constant reminder of the impact. It reminds you of the need to deal with the issues. Most issues are dealt with on a day-to-day basis and are relatively minor, so major accidents remind of the reason you're doing the work”
Moreover KDMs commented that the use of videos, images etc helped reinforce messages and subsequent learning: “High impact video was used to illustrate how task performance issues led to a process safety accident.”
3.6.5 Benefits clearly stated
Information can be more compelling when it is easy to understand and clearly states organisational benefits. This was, however, the least frequently cited reason for using a particular learning method. This may be because the argument for applying HF/E methods and tackling process safety is already made and therefore it is not necessary to sell the benefits.
3.6.6 Sector/job differences
The factors that made learning more compelling did not differ between job types or sector.
3.7 FINDINGS FROM TASK 2 - HF/E TECHNIQUES AND APPROACHES USED (Q3A)
3.7.1 Introduction
This section briefly explores the particular approaches, principles or techniques that KDMs may have used to assess and manage error, human performance and influence behaviour. KDMs we asked “Can you recall any examples of where you have applied particular approaches, principles or techniques to assess error, manage human performance or influence behaviour”.
Respondents were prompted if they were unable to think of a relevant example.
Respondents cited a range of different techniques – see Table 20 Appendix II.
As with previous findings there was no clear distinction between sector or job role to the approaches used.
The following techniques and approaches were identified:
1. Analysis techniques [62]:
• Safety related (Risk assessment; Root Cause Analysis, Risk analysis, Process Safety Review and analysis and HAZOP);
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• HF techniques (Task analysis, gap analysis, HF analysis technique not specified) Predictive human error analysis/PHA;
• Engineering related (FMEA, Fault tress analysis).
2. Organisational approaches [21]:
• Safety culture/culture management (step change/hearts and minds);
• Behavioural safety;
• Standards and Audits;
• Incentives and performance indicators.
3. Competence management approach [19]:
• Competence assessment/management e.g. performance reviews PTW;
• Training needs analysis;
• Supervision arrangements/briefings etc;
• Training.
These techniques are explored and discussed under the following relevant headings.
3.7.2 Analysis techniques
Safety techniques such as Risk Assessment, Risk Analysis and HAZOP were the most commonly cited approaches by KDMs to assess error and manage behaviour etc. This is similar to the findings from Task 1 and interviews with stakeholders. Although these techniques are not commonly considered to be HF/E approaches they do include consideration of human error.
Root Cause Analysis, in particular, was a key technique cited to improve understanding of human error in incident causation. This may be because this is an area that has received a greater focus of attention in recent years: “There was a lack of understanding of events. Of 700 people, only 70 understood the root cause of events. The same mistakes were reoccurring as we were not learning from events and not understanding how we could reduce accidents. Root cause and the behavioural safety initiatives have helped people understand this better and it also helps engage the workforce”.
A number of KDMs also indicated that their view of incident causation had changed. In the past there may have been a greater tendency to focus on the role of the individual when investigating an accident. Nowadays, however, attention appears to be more focused on the range of performance shaping factors that influence safety.
Analytical techniques more associated with HF/E were also cited as approaches used to understand and address human error, for example, task analysis and error analysis methods such as HEART: “Task analysis is used for many activities. There is a competency programme across the refinery and we also use external consultants. We have looked at each job to identify safety critical tasks. We look at operations criteria and criticality.”
HF/E was also seen as a specialist area and a number of KDMs commented that they would not expect to be knowledgeable about such approaches: You need the experience and background to
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apply these techniques. There is a danger of using your own interpretation to suit your view. It should be left to the experts”.
3.7.3 Organisational approaches
Organisational approaches were also cited as ways to address issues concerning the management of error and behaviour. These largely concerned techniques such as safety culture assessment; behavioural assessments and the use of audits and performance incentives. Similar to the findings from task 1, No KDMs directly mentioned workforce involvement or consultation as ways to tackle human error.
This may indicate that consultation is used to improve understanding, as suggested by the response to Question 1, but that there is less active participation of workers in finding solutions to tackle an issue or problem area.
There may, however be several other reasons why KDMs did not cite workforce involvement or consultation. For example, the wording of the question did not include consultation as a prompt. It may also reflect the perceptions of KDMs that they would carry out consultation as a matter of course; rather than being seen as a specialist approach to tackle human error.
3.7.4 Competence management approach
Another area for tackling error and behaviour was through competence management.
Interestedly only four KDMs stated that they a used Training Needs Analysis (TNA), which may mean that outcomes from training are less effective than desired.
This could explain why, when asked to consider future options, KDMs, cited training more frequently then any other option.
3.8 FINDINGS FROM TASK 2 - WHAT ARE THE PROMPTS TO APPLY HF/E TECHNIQUES AND APPROACHES? (Q3B AND C)
3.8.1 Introduction
This section explores the prompts that encourage the application of HF/E techniques and approaches. Following on from Question 3, KDMs were asked: “Please describe what prompted this?”
The responses – presented in Table 21 Appendix II indicated a range of prompts to apply of HF/E techniques and as before, there were no discernable sector differences or job preferences.
The main prompts were themed or grouped into three main areas:
1. External influence [52]:
• Peer groups/forums/benchmarking [21
• HSE inspector and/or external regulator [20];
• External accident and/or incidents [5];
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• Industry information [6];
2. Organisational influence [36]:
• Company policy and strategy [19];
• Internal Incident/accident [14];
• Culture change and/or improvement program [3].
3. Individual decision [18]:
• Methodology relevant and easy to apply [8];
• Perceived as valuable [6].
• Personal area of interest [4];
These are explored in more detail under the following relevant headings.
3.8.2 External
External influencers were the most frequently cited prompt to use tools and techniques to assess and manage human error, performance and behaviour.
Peer learning opportunities were cited as a key prompt and appears to provide a valuable opportunity for individuals to share and exchange information. Peer learning was a popular method and this may be because it provides an opportunity to, not only learn about a technique, but also see how in practice it is used and applied. Learning from peers was also seen as a way to get advice on using a particular technique.
Benchmarking was also seen as a way to check what other organisations were doing and take onboard the approaches and techniques used elsewhere: “Benchmarking might help to prompt the use of other tools, or evidence that shows there are better tools available.”
HSE inspector visits and regulation were also cited as a key reason for using a particular method or technique. It also helps to illustrate, not surprisingly, the strong influence that the regulator has on decision making with industry.
Only a few respondents cited external incidents as prompting them to actually use techniques and approaches, even though these incidents were cited as key reason for learning more about process safety. This may be because external accidents/incidents provide lessons about how an incident or accident happened but are unlikely to provide detailed information on how to use a certain technique to actually prevent such an event from occurring.
3.8.3 Organisational
Organisational factors were the second most cited prompt for influencing the use of techniques. Of these factors, company policy and strategy were the most cited, while internal incidents and accidents was also a key influence: “The use of DUPONT was prompted by a factory having 2 people every year in hospital and around 40-50 minor injuries”.
KDMs often cited that they applied techniques retrospectively after an event had occurred. However, a small number of KDMs also stated that they used a proactive approach, such as
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audits, as a prompt to applying a particular approach or method. “Prompted through Information from SHE audits talking to people about safety and asking them to think about their job.”
Analysis of responses did not, however, reveal a direct link between a particular prompt and the use of a certain technique or method.
A future option, to help KDMs tackle HF/E and apply relevant tools and techniques, might be to provide more guidance on ways to proactively identify issues and which also gives additional advice on how to help select appropriate methods for addressing these issues.
3.8.4 Individual
Individual prompts related to those factors that are specific to the individual’s interest or perception: “I instigated this as I felt that it was the right thing to, I felt that we needed assurance of what the guys on the ground are doing.”
This was the least frequently given prompt although surprisingly still cited by 18 respondents. It indicates that there is still, to some extent, reliance on individual HF/E champions, to promote HF/E, rather than it being applied systematically.
3.9 UNDERSTANDING AND ATTITUDE TOWARDS HF/E (Q6Q7)
3.9.1 Introduction
This section provides information on the KDM understanding and attitude toward HF/E. In total 58 of the 60 respondents provided a quantitative rating from 1-5, when asked to rate their:
1. Awareness of Human Factors;
2. Awareness of Ergonomics;
3. Understanding of Human Factors;
4. Importance which you place on Human Factors for your business;
5. Relevance of Human Factors to major accident prevention;
6. Seeking advice from others when making decisions about preventing error and improving human performance;
7. Having used guidance on Human Factors when considering process safety;
8. Past events or incidents have prompted me into finding out more about Human Factors or applying a Human Factors approach.
Overall, responses to this question were considered, as well as any differences that might emerge due to sector and/or job type. It should be noted, however, that the small sample size means that responses provide a broad indication rather than a more robust measure of true attitude and understanding.
The detail analysis of these questions is presented in Table 24-27 in Appendix II.
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3.9.2 Overall Findings
The findings, in Table 2, show that KDMs believe HF/E is relevant to accident prevention (88%) and also important for their business (91%).
KDMs indicated that they had good awareness of HF/E (64%) but only 36% stated they had a good or very good understanding. The findings suggest that KDMs, at present, know HF/E is important but believe they do not have an adequate understanding of the topic.
In contrast, only 38% of KDMs indicated they had a good or very good awareness of Ergonomics. The reason for this difference was not explored but it is somewhat surprising because both these disciplines are concerned with similar issues. The difference in responses probably indicates that the term: ‘Human Factors’ is more widely used in high hazard industries. It also, however, highlights the problem of having different definitions and descriptions of HF/E and the implications this has for effective communication.
The majority of KDMs (88%) indicated they seek advice from others and use guidance to learn about and apply HF/E. This supports early findings, from Task 1, that show decisions involving HF/E tend to made collaboratively. It also suggests that KDMs recognise the need for support in this area and again may reflect that understanding of this topic needs to be improved. The findings also indicate that 76% of KDMs were prompted to find out more about HF/E following an event such as an incidents and/or accidents. This is consistent with the qualitative findings that showed that often KDMs were prompted by incidents to find out more.
Table 2: Overall findings for understanding and attitude towards HF/E
Question 6 (58 respondents) % respondents good or v. good (4 and 5)
% respondents poor or v .poor (1 and 2)
1) Awareness of HF 64% 2%
2) Awareness of ergonomics 38% 20%
3) Understanding of HF 36% 14%
4) Relevance to major accident 88% prevention
5) Importance of HF to your 91% business
Question 7 (58 respondents) % of respondents agree or % respondents poor or v .poor strongly agree (1 and 2)
6) Seek advice from others about 88% H/FE
7) Use guidance on HF/E 79%
8) Prompted by past events to find 76% out more about HF/E
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3.9.3 Sector differences in understanding and attitude
The findings indicate that understanding of HF was similar across all sectors with some variation in awareness, for example between Onshore Oil and Gas and Nuclear. The small sample size, however, means it is difficult to draw any significant conclusions from this difference.
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Similarly there was little variation in the use of guidance; seeking advice or being prompted by past events.
Table 3: Sector difference for understanding and attitude towards HF/E
Sector Questions and % of respondents Awareness of Understanding Seek advice Use guidance Prompted HF? of HF from others on HF/E by past
about H/FE events
Chemical (n =14) 64 36 71 79 71
Oil and gas onshore (n=19)
53 37 89 89 79
Offshore oil and 69 31 92 69 77 gas (n=13)
Nuclear (n=12) 75 42 100 75 75
3.9.4 Job type differences in understanding and attitude
In terms of job type differences, senior managers seemed to have the lowest level of awareness of HF/E, potentially indicating that they may miss out learning opportunities. This is consistent with the qualitative findings. Senior managers were also less likely to seek advice from others and use guidance when making decisions. This may be related to their lower awareness of HF/E, in that, if senior managers are not aware of HF/E they are unlikely to seek advice or use related guidance to make decisions. These results, again, are not statistically significant due to the small sample size.
Table 4: Job difference for understanding and attitude towards HF/E
Sector Questions and % of respondents Awareness Understanding Seek advice Use Prompted of HF of HF from others guidance on by past
about H/FE HF/E events
Senior Manager (n=9)
44 30 70 70 70
Site Manager (n=16) 69 24 94 82 71
Front Line Manager 79 53 89 84 74 (n=19)
H&S Manager (n=12) 58 33 92 75 92
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3.10 OVERALL SECTOR DIFFERENCES
The findings suggest that overall there is little difference between high hazard industry sectors in terms of the: issues being addressed; methods for tackling them, understanding and awareness of HF/E. This would suggest that HSE does not necessarily need to tailor its approach or present information by sector.
There were also no notable sector differences in terms of learning about HF/E and process safety or the factors that make learning more compelling. The different sectors also used similar techniques and methods to address HF/E issues or the use of external consultants.
Some sector differences were, however, apparent between the nuclear and other sectors. Within the nuclear sector formal peer review facilitated through WANO was cited quite frequently by a number of different respondents.
One respondent in the nuclear sector believed that their industry was more open to sharing knowledge, because there was a vested interest in co-operation. If a serious accident occurred then the whole industry suffered. “Nuclear industry good at sharing knowledge they all suffer if something goes wrong so there is a vested interest in co-operation unlike the other high hazard industries who might be more guarded.”
This knowledge sharing approach, however, was also cited by other sectors although not to the same extent. It was also conducted in a less formalised way and instead developed through ad hoc contacts within their industry. This demonstrates that this peer review approach is well regarded but it may be more challenging for certain sectors.
Comments made by stakeholders suggest that there may be greater use of internal HF/E specialists within the nuclear sector. Findings from the thematic analysis does support this claim, however, the sample is so small it is difficult to say with any confidence whether this is the case.
The other sector difference was in terms of the offshore sector, which has a stronger preference for sector specific information. This may reflect the unique nature of the work environment.
3.11 OVERALL JOB ROLE DIFFERENCES
Similar to sector differences there were little notable differences between the different job types. The one exception is that senior managers seem to have lower levels of awareness of HF/E and are less likely to refer to others for advice or guidance on HF/E. They may also have less exposure to learning opportunities to finding out more about HF/E and process safety.
If senior managers had gained their experience and knowledge during an earlier time when HF/E was seen as a less critical or important discipline, then they may simply not have the same level of awareness as other more junior managers. Senior managers may also get less exposure to HF/E issues at the sharp end and may also be more likely to defer expertise to others within the organisation.
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The findings from the stakeholder interviews in Task 1 also suggested that those involved in the decision making process appear to vary depending on the type of decision being made. It may, therefore, be appropriate for HSE to identify particular job roles and tailor information when communicating on more specific HF/E issues.
3.12 BARRIERS TO THE UPTAKE OF HF/E
The research provides evidence that there is good awareness of the benefits that HF/E can bring. There also seems to be a desire for industry to apply the principles and techniques to better understand and tackle human error and behavioural issues that can impact on process safety.
KDM responses to Question 1, however, also suggest that some Key Decision Makers may not always take HF/E adequately into account when tackling process safety. Evidence for this also comes from the fact that KDM also later commented, when exploring options of integrating HF/E, that it was often seen as an add-on and not fully embedded in safety management. “This approach helps to build the ideas into engineers way of thinking rather than being an add on concept.” This is also consistent with the findings from the previous research which commented: “Duty holders appear to be a willing audience but lack a consistent understanding of human factors” [7].
There was also only limited use of guidance and standards, as well as recognised HF/E techniques to tackle issues concerning human performance; error and behaviour. This implies that there are potential barriers which might affect the use of supporting documentation and tools.
This section explores these potential barriers and discusses the reasons why these barriers might exist. Improved understanding of these barriers is likely to help HSE communicate more effectively to high hazard industries on this topic.
Form the comments made by KDMs in response to Questions 4, 5 and 8 (concerning effective ways to promote greater consideration of human error) the following barriers were identified:
• Inconsistent messages - sometimes different, confusing or conflicting messages from different sources;
• Complex and poorly bounded topic;
• Uncertainty about training quality;
• Diverse and varied audience;
• Guidance not widely used – lack of awareness of guidance not always relevant or practical;
• Conflicting pressures e.g.: commercial drivers;
• HF/E still seen as an add-on, still not fully integrated.
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3.12.1 Inconsistent message
Interviewees cited a number of examples where inconsistency was a problem in both their understanding and application of HF/E. “There is lots of inconsistency in approaches and application of HF/E. This needs to be consolidated and the approach simplified. We need a steer from the HSE in order to do this. Will the HSE listen to industry? Not all guidance is applicable to every site”
One interviewee stated that outside HF/E specialists, that had been brought in to assist them tackle a particular issue and had used different and contrary techniques to those advocated by HSE. Inconsistency also extended to the experience of HSE inspectors who might themselves have different levels of understanding of HF/E. “Need to bring local inspectors up to speed on HF and give industry more access to HSE HF specialists.”
The inconsistency that decision makers comment upon is indicative of a problem that exists within the discipline of HF/E. There are many techniques and applications originating from different fields of research and industry and within different sectors. Tools and techniques are also often adapted or altered to a new area. This is illustrated by the many different techniques for determining error probabilities.
3.12.2 Complex poorly bounded topic
HF/E poses some significant issues to non specialist and, some would rightly claim, specialist as well. It often comes across as a woolly or fuzzy topic that seems far removed from the more concrete and technical issues that engineers and business people deal with on a day-to-day basis. (HSE Research Report 149, 2003).
The discipline of HF/E is also very diverse. This can be a weakness because with such a broad spectrum it can be difficult to: define what HF/E is; what it represents and where its boundaries begin and end (Salas, Eduardo 2008).
A number of KDMs also stated that they found the topic of HF/E confusing: “HF as a whole is not clearly or accurately defined. You can often find different definitions depending on where you go. This can be baffling for smaller organisations particularly.” and “Definition is not that helpful. Need to know where the boundaries of HF are. Need more practical advice on what HF is and why we need to use it”.
This also means that training on HF/E can cover a great many different areas some of which may be relevant to the attendee but others might not – this issue is explored under the next heading.
3.12.3 Uncertainty about training quality
During the interviews, a number of respondents stated that a barrier to improving knowledge and understanding was that there was a lack of formal or accredited training on offer: "Important to build understanding through education but with formal qualifications”.
KDMs were also uncertain as to the quality of the training and how it was viewed by respected organisations, for example, did it provide measureable professional development.
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Some KDMs had also had a bad experience of attending training courses in the past, finding that the training was either not relevant to them or their organisation and was simply of a poor quality: “Courses tend to feel very remote and separate. They don’t directly apply to the rest of the work done in industry.”
As cited previously, part of the problem might be that because HF/E is such a varied subject it can offer many different topic areas. Not all of these will be relevant to the person attending the training. If an analysis of training needs is not conducted appropriately, then a manager might find themselves attending a HF/E course that does not cover the topics of interest or relevance to their particular circumstance.
3.12.4 Diverse and varied audience
The audience for communication, as cited by stakeholders (Table 13 Appendix I) is highly diverse.
The findings also show that decisions are often reached collaboratively with different combinations of KDMs involved in reaching a decision. Decisions may also be further supported by others within an organisation, from functions as varied as: human resources unions and board members etc.
HSE may not need to use a different communication strategy for the different sectors but they will need to consider how to present different messages to different audience members. Alternatively they will need to consider what single very simple message might be meaningful and easily understood by the majority of the audience. This issue is explored further in section: 6.6 Communications Strategy.
3.12.5 Guidance
The general view from KDMs was that support and advice provided from HSE was good, particularly from visiting inspectors.
A commonly expressed view, however, was that inspectors were good at identifying where an organisation was less well developed, in terms of HF/E, but did not provide sufficient guidance on how that organisation might actually improve. “Make expectation clear and in a form that can be used and understood by industry.” “More guidance on HF, and how best to use it to address issues in the work place.”
In addition the use of written guidance and information provided on the HSE website was seldom cited as a method for gaining a greater understanding of HF/E. This is despite one KDM stating the wealth of information that was available: “HSE website is a gold mine but is very difficult to navigate. The site should be easier to follow and find info, using road maps and better references to material.”
These comments and the fact that guidance was not widely cited as a source of information may indicate that:
• Sources of guidance and information are not widely known about;
• The guidance provided is not comprehensive;
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• The guidance does not provide the desired information, help or support.
This was illustrated by one respondent stating that there was no HSE guidance on HF/E despite the existence of HSG 48 – ‘Reducing error and influencing behaviour.’
In addition to guidance HSE provide three tools on the HF/E website to help KDMs tackle HF/E related problems. These concern fatigue management: manual handing and stress. These are undoubtedly highly effective methods but do not cover a comprehensive range of the issues that might be impacting on high hazard industries. For example, the response to Question 1, during the Task 2 interviews, indicated that priority area for KDMs were assessing training and competence and writing procedures.
Finally the majority of comments about guidance stated that it would better if it provided practical advice on how to tackle an issue, rather than talking academically about the subject: “Want more practical rather than theoretical guidance. Use working forums to do this. Don't baffle people with the science/theory!” One way to do this might be to use case studies that explore an incident. This could include a description of a method or tool that could have helped to identify and address the problem with an explanation of how the method was applied.
3.12.6 Conflicting commercial pressures
One interviewee also stated that it was sometimes difficult to resist the conflicting commercial pressures that might adversely influence day-to-day operations and this was a challenge to the greater uptake of HF/E. To overcome this, they had tried to separate out the different functions of the organisations to reduce the impact that commercial pressures might have on process safety: “It is important to understand and control the commercial drivers that impact on day-to-day operations. Use a "Chinese wall" to separate these two and avoid a conflict of interests.”
Another KDM stated: “One of the major hurdles was selling this to the senior managers of each refinery. We used a presentation to sell it and to explain the benefits.”
3.12.7 HF/E not fully integrated
A problem, discussed earlier, is that HF/E is often not fully integrated into how organisations manage their business. This means, for example the HF/E might be applied late in the design process. This means that even though HF/E identifies an issue affecting performance, the cost of addressing this later on might be prohibitive or delay delivery. This can challenge the commercial drivers such as delivering a project to time and cost.
It may also mean that the experiences of engineers, designers and site managers etc have a negative view of HF/E. This might cause them to be resistant to bring HF/E in their area of work.
The importance of integrating HF/E with day-to-day management was recognised by KDMs. The option of how to better integrate HF/E along with a number of other future strategies are explored in the section: 4 Future options for improving the uptake and application of HF/E.
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3.13 CURRENT GOOD PRACTICE
3.13.1 Introduction
In addition to identifying some of the barriers, the research has also provided insight into the more effective ways that industry has developed its understanding of HF/E. This section explores the unprompted examples of good practice that high hazard industries currently employ to improve or enhance the uptake and understanding of HF/E. This section also includes additional input from the strategy workshop
Effective ways identified to develop understanding and of HF/E were:
• Sharing knowledge with peers;
• Learning from past incidents;
• Leadership across the organisation;
• Engaging with the workforce.
3.13.2 Sharing knowledge with peers
The strongest message emerging from the interviews was that the preferred way to gain a greater insight into the benefits of HF/E was through sharing experiences and knowledge with peers.
The nuclear industry, in particular, used ‘peer review programmes’ facilitated by the World Association of Nuclear Operators (WANO). This involved visits from technical experts who spend several weeks immersing themselves in a specific topic. At the end of the review they discuss issues they have identified and present the evidence for their conclusions. One KDM in the nuclear industry believed that the nuclear sector was leading the way in terms of deriving knowledge from operational experience and feedback.
The peer review approach was considered to be a highly effective and particularly compelling way of communicating on HF/E. Peers were more trusted and had better insight. “WANO technical support mission is compelling. You respect your peers because they are from same industry and understand the issues, not just a consultant looking for more work.”
The peer review team, as well as identifying problem areas, could also share the industry’s good practice and provide details of their own experiences of addressing the identified issues.
A number of KDMs in the nuclear sector were very complimentary about the benefits that their associations brought to their sector: “Very fortunate in nuclear sector as we have WANO and INPO who produce materials and courses. Other Major hazard industries could do with more sharing of information in this way.”
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HSE might consider ways to try and replicate this approach by helping to create partnerships with similar bodies such as: Energy Institute and Chemical Industries Association, across other sectors. Stakeholders taking part in the strategy workshop believed, however, that even though HSE might facilitate peer review, it is important that they are ‘hands-off’ and are not directly involved in the process itself. This is because peer review encourages the sharing of potentially sensitive information and they may be reticent in doing so if they think HSE are closely involved. For this reason, it was also acknowledged, that it may also be more difficult for organisations to take part in peer review in more competitive sectors.
3.13.3 Learning from past accidents
The other method widely cited by interviewees for gaining greater insight into HF/E and process safety was through learning from high profile accidents, for example: Texas City, Buncefield and Longford.
Often KDMs would read the detailed investigations into these accidents and see if they could draw out any appropriate lessons for their own organisation.
This was often done systematically for example: “Operational experience feedback engineers extract relevant info and provide learning about process safety - extract relevant issues from recent events and feed back to the facility and info that may be applicable e.g. Texas City was Design flaws.”
Similar to the peer review process, this was a very compelling way of understanding an issue. If the incident could happen to a well known and respected international organisation then it was applicable to anyone.
Significant, high profile accidents also focuses the attention of organisations. There is a coming together as industries seek together to understand events and why they occurred and to seek ways to prevent them from happening again: Peer learning -- reading reports of recent process safety incidents such as Texas City or Buncefield and then using their contacts in the industry to talk to relevant people from the companies where the incident took place to understand the root causes and then consider the application to their business.
3.13.4 Leadership
A number of stakeholders, in the strategy workshop, believed that being more successful at tacking HF/E issues was linked to strong leadership. Leadership is a key component of health and safety management particularly in shaping behaviours and attitudes at work.
Demonstrating leadership was considered to be important not only at more senior levels of management but also across the organisation as a whole, for example, supervisors and team leaders.
This issue is linked to developing knowledge and understanding. If key personnel throughout the organisation support and facilitate the application of HF/E, and the principles it espouses, then it is more likely that it will be effective and lead to better outcomes.
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3.13.5 Workforce engagement
In addition to good leadership, it was also believed that it was important for the workforce to be engaged and buy into the basic principles of HF/E. This helps to ensure that HF/E is sustained and embedded within the company. It means that if key supporters of HF/E move on or change position within the organisation, then momentum is not lost and HF/E good practice continues to be applied.
One way to achieve greater workforce engagement on HF/E is through initiatives that enhance awareness and understanding across the organisation as a whole. In the nuclear industry they have undertaken: ‘Human Performance Initiatives’ that seek to “get the message through to the troops on the ground”. This does mean “dumbing down” or over simplifying the message but it does mean making it relevant and getting the language right. For example, not using technical jargon, like Performance Shaping Factors (PSF).
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4 FUTURE OPTIONS FOR IMPROVING THE UPTAKE AND APPLICATION OF HF/E
4.1 INTRODUCTION
The research also asked KDMs to consider and rate seven different options for improving the uptake of HF/E knowledge and application. These covered areas, such as:
• Improving the definition of HF/E;
• More enforcement;
• Better integration;
• Increasing HF/E knowledge;
• Better communication;
• More initiatives;
• HF/E led by industry associations.
Respondents were asked to rank (1 being not effective, to 5 very effective) and comment on how effective such an option would be for improving the application of knowledge, techniques and principles for the prevention of error and unsafe behaviour, and improvement of human performance.
The range of views expressed by KDMs suggests there is no panacea or one single future option for improving the application of knowledge, techniques and principles of HF/E. In fact the views of some future options, such as: branded initiatives and integration of HF/E were diametrically opposed. Even increasing enforcement, considered by many to be the most undesirable of the future options still had its supporters.
Despite this diversity, the results do show some broad themes emerging from the interviews. Overall, KDMs believed it was important to enhance their knowledge of HF/E, primarily, in the form of training. They also wanted more advice; guidance and tools to help develop this knowledge further and then practically apply HF/E to their work.
KDMs believed that such support could also feasibly be delivered in co-operation with industry associations and professional institutes but led by HSE. The eventual aim should be to better integrate HF/E in day-to-day management. This, however, would be likely to occur overtime rather than as a result of direct intervention by HSE.
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Many KDMs saw the benefit of raising awareness of HF/E through a communication campaign. This was, however, seen as a potentially difficult option to get right because of:
• The complexity of the subject matter;
• The historical legacy and the many pre-existing terms for HF/E;
• The varied audience;
• The need for HSE to develop and present a clear message.
It is important, therefore, that HSE are aware of these potential pitfalls and have committed sufficient time and resource to get the message right. If they do not, this could increase industry confusion.
The seven options are discussed in turn. The following table summarises all the options and provides a percentage of respondents who rated each option as being effective or very effective (scored 4 or 5). These options are then ranked with 1 being the highest percentage score and considered to be the most effective option.
Table 5: Options for improving the application of HF/E
Future Options Percentage rating the option 4 or 5
rank
Improve knowledge of Human Factors through the provision of training and professional development programmes.
74% 1
Integrate Human Factors to build knowledge, techniques and requirements IMPLICITLY into standards.
67% 2
A programme of activity led by industry associations and professional institutes, with HSE support.
64% 3
HSE to develop a communications campaign to raise awareness and understanding of Human Factors.
54% 4
HSE to better explain the concept of Human Factors and provide a clearer definition of what it is.
54% 5
The provision of more branded initiatives, such as Step Change or Hearts and Minds.
43% 6
HSE to increase enforcement of Human Factors as part of safety case and related inspection processes.
33% 7
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4.2 IMPROVE KNOWLEDGE OF HF/E
Respondents were asked to rate the effectiveness of an approach to improve knowledge of HF/E through training and professional development programmes.
This option was ranked as the number 1 preferred option; with 74% of respondents saying improving knowledge of HF/E would be an effective method for improving the application of knowledge, techniques and principles for the prevention of error and unsafe behaviour.
Table 6: Future option 2 – Improve knowledge of HF/E
Effectiveness Score Improve knowledge of Human Factors amongst people like you through the provision of training and professional development programmes, such as part of the Continuing Professional Development offered by professional institutes.
Not very effective 1 0%
2 10%
3 16%
4 45%
Very effective 5 29%
4 + 5 74%
Ranked in comparison to other
options where 1 is most preferred 1
This finding is somewhat self evident. Increasing knowledge of a given subject will build awareness and in turn this is likely to increase its application.
Despite this, the result helps to illustrate that there is a strong belief that despite the relative maturity of HF/E there is still a significant requirement to continue to build knowledge of HF/E amongst KDMs in high hazard industries. This is illustrated by the following statement: “Greater knowledge and visibility of HF will improve its uptake and it is obviously a good thing to improve understanding.” “Until you have undertaken HF training, the whole subject can feel woolly and you have little appreciation of what can be done. This would be great”.
Respondents indicated, through response to this future option, that the main method for building knowledge was through external training and continuous professional development courses, for example: “Best way to achieve increased understanding knowledge is through professional training (ICHEME) and graduate & under graduate courses.” “Important to build understanding through education, which is not currently out there at the moment. Currently people pick it up as they go along unlike a formal qualification like NEBOSH.”
It was important that training is effective and leads to a change of understanding and that this understanding is sustained: “Need to make HF sustainable and embedded in front line managers.”
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Very few respondents commented on other ways of improving knowledge such as: internal company training; HF/E written guidance; information provided on websites; attending conferences etc, despite the fact that these are the ways that they learn about process safety at the moment. This might suggest that current ways of developing knowledge are less effective than desired. This is consistent with the view that the way knowledge is currently developed is somewhat ad hoc; rather than following a systematic process to identify gaps in understanding, for example, using training needs analysis.
KDMs also cited a number of the barriers, to learning more about HF/E, for example:
• Finding the time to attend external courses, particularly for senior managers;
• Knowledge is compartmentalised – specialised knowledge of HF/E still resides with certain individuals rather than being understood across the organisation as a whole;
• Only the better organisations will send employees on training courses;
• Current courses are often too academic and not practical or directly applicable to work;
• Courses are too generic and not tailored to specific industry requirements;
• Need to ensure the right people attend the training and that learning is backed up within the organisation;
• Availability of courses is limited;
• Courses need to be certified similar to NEBOSH for Occupational health and safety, so it is easier to know who will provide good training.
Evidence from the interviews would suggest there is both a requirement and desire to attend external training but there are certain challenges that make this more difficult for KDMs. A key role for HSE might, therefore, be to help overcome these challenges.
4.3 INTEGRATE HF/E
KDMs often described HF/E as an “add-on” concept and not integrated directly with day-to-day decision making. “Integrating HF helps to build HF into an engineer’s way of thinking rather than it being an add-on concept”.
A criticism sometimes levelled at HF/E, particularly concerning input into design, is that it occurs too late in the design process to be truly effective. The result of this is that it is often seen to disrupt or delay project delivery rather than leading to tangible improvements. (Soekkha,1997).
To be effective HF/E should be an integral part of all facets of plant or facility operation. In terms of design, HF/E input should occur earlier even during design concept. One way to help ensure this is to build HF/E methods and principles implicitly into all company standards such as: engineering standards; safety case requirements; best practice approaches to training etc.
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Respondents were asked to rate the effectiveness of helping to better integrate HF/E knowledge and techniques. KDMs rated it the second most preferred option.
Table 7: Future option 3 – Integrate HF/E
Effectiveness Score Rather than present and promote Human Factors as separate ‘discipline’ in its own right, HSE to build Human Factors knowledge, techniques and requirements IMPLICITLY into standards (e.g. engineering standards, safety case requirements, best practice approaches to training etc, without attempting to define this as Human Factors).
Not very effective 1 4%
2 7%
3 23%
4 42%
Very effective 5 25%
4 + 5 67%
Ranked in comparison to other
options where 1 is most preferred 2
This shows recognition of the need to integrate HF/E more effectively, illustrated by the following comments: “Human Factors should not be seen as separate and should be seen as normal business, being carried out every day and part of the culture of the business. The goal is to have Human Factors completely integrated.”
A number of respondents also commented, however that although it should be part-and-parcel of daily operation, HF/E still needed to retain its identity and be seen as a separate concept: “HF is a specialism and it is very important it is retained as a separate discipline in its own right. A danger is that HF specialists are replaced by a tick box.”
4.4 INDUSTRY ASSOCIATION LED ACTIVITIES
There are many potential benefits for industry, industry associates and HSE for working in partnership together.
It can lead to a more effective use of resources with knowledge and materials being shared and it reduces the potential for a duplication of effort. It can also lead to more networking opportunities and greater openness between those within the partnership.
This option explored whether industry, rather than HSE, should lead on initiatives to promote HF/E. The rational for this is that associations have a better understanding and appreciation of their member’s requirements and therefore are better placed to provide tailored and appropriate information, tools and techniques. Together, they may also have greater resources than HSE to provide guidance and support to their members.
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This was the third preferred option with 64% of respondents indicating that they thought this would be an effective way of improving the uptake of HF/E.
Table 8 - Future option 4 - Industry associations led activities
Effectiveness Score A programme of activity led by industry associations and professional institutes, with HSE support (for example: production of guidance, agreement of best practice, identification of top Human Factor priorities, % of companies with Human Factors champion within the company, or with access to specialist Human Factors advice).
Not very effective 1 2%
2 11%
3 24%
4 42%
Very effective 5 22%
4+ 5 64%
Ranked in comparison to other
options where 1 is most preferred 3
When comments were reviewed in detail, however, it was clear that the preference was not simply for a programme of initiatives led by industry. Instead comments pointed towards three key aspects that were believed to be important in making this option effective:
1. HSE, because of the role as regulator and opinion former, should still lead on the promotion of HF/E to help ensure a consistent and unified message;
2. HSE should work more closely in collaboration with associations and industry;
3. Associations should provide the practical tailored guidance, knowledge and tools to industry supported, in this endeavour, by HSE.
The following quotes illustrate these three aspects.
“Need one body leading on HF and then everyone else falls into line”. “Led by HSE initially and when industry better understands it they will take it up themselves”. “Not a key issue but seems better for HSE to lead with close involvement and participation from industry.”
“Need industry bodies to link with HSE strategy”. “One thing I would criticise about the HSE in the past. The HSE has not been good at passing on good practice to industry.” “The partnership approach is good - the HSE would give a point of focus but there would also be a practical point of view from the industry.”
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“Need specific examples and collaboration. This will enhance the relevance of the campaign”. “Other industries and institutes can be very very strong on HF. If all get together and produce stuff and agree on what is the best way to tackle.” “This means guidance is more tailored and focused”
Despite the apparent benefits of working more closely with industry associates there is still evidence that this is not always successfully achieved. For example, associations are producing their own guidance on HF/E sometimes using different terminology; language and approaches. In addition, HSE produces guidance but does not always encourage associations to adapt and tailor them to their industries.
4.5 AWARENESS RAISING COMMUNICATIONS CAMPAIGN
A criticism sometime levelled at the discipline of HF/E and HSE’s approach to HF/E is that it does not always provide a consistent message. This can make the discipline complex and difficult to understand. “Need a consistent message from HSE.”
Previous research undertaken by HSE recommended that a possible way to promote HF/E in the onshore and offshore hazardous industries was to develop a communications strategy to raise awareness in the form of simple and consistent messages through a number of media (Michael Wright et al. 2003). This option explores the benefits of HSE developing a communications campaign to raise awareness and understanding.
This option was ranked 4th with 54% of all respondents believing this would be an effective method.
Table 9 - Future option 2 – Awareness raising communications campaign
Effectiveness Score HSE to develop a communications campaign to raise awareness and understanding of Human Factors (for example: conveying the same message through joint conferences, publications, articles on websites and in journals).
Not very effective 1 2%
2 18%
3 27%
4 38%
Very effective 5 16%
4+ 5 54%
Ranked in comparison to other
options where 1 is most preferred 4
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Developing a communications campaign was considered to be sometimes an effective approach but it was considered difficult to get right. The following comment taken from the interview, illustrates the complexity of this option, for example: “Weakness = competing with other campaigns going on at the same time. Strength = the more people see it, the more it will sink in. However it does need to be presented well and have enough time dedicated to it.”
The key issue is that although a communication campaign would be effective it is difficult to get right. “It must be a well designed set of materials in order to be utilised e.g. short and easy to understand.”
To be effective the message must be sustained and this requires a long term commitment: “This would get everyone talking about it within industry; however it has a very limited lifeline and would need to change regularly.”
The difficulty with HF/E is how to produce a simple communicable message on a subject that can be and nebulous and difficult to grasp. The very diverse nature of HF/E makes communicating on it problematic. This contrasts with government campaigns from the past that have been successful in addressing societal issues because of the clarity and simplicity of the message. For example: “Clunk Click Every Trip” concerning the wearing of seat belts, was widely acknowledged to be a successful campaign.
One possible option for HSE might be to focus on a single clear well bounded HF/E message. One respondent made the following comment: “Campaigns have been effective - especially posters in the workplace - these have been simply, blunt messages which caught peoples attention.”
4.6 THE CONCEPT OF HF/E
One of the problems with HF/E is that it is a nebulous and ill defined concept. Earlier research conducted by HSE [7] commented on HF/E as a brand: “On the one hand respondents believe the term Human Factors is useful but on the other hand, find it fuzzy.”
This hazy perception of what HF/E may inhibit understanding and become a barrier to its wider uptake. One future option may, therefore, be to better explain the concept of HF/E and provide a clearer definition of what it is. This option was ranked 5th.
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Table 10 - HSE to better explain the concept of Human Factors
Effectiveness Score HSE to better explain the concept of Human Factors and provide a clearer definition of what it is.
Not very effective 1 4%
2 18%
3 25%
4 42%
Effective 5 12%
4+ 5 54%
Rank in comparison to other options where 1 is most preferred
5
When supporting comments are reviewed the overall response across all sectors and role types is that HF/E is already well explained as a concept. “It is explained fairly well. It’s the how to get there that’s important.”
Obviously there were exceptions to this view, however, the predominant response was that improving clarity would help, but it was a “nice to have” rather than a priority area. This is again illustrated by the following comment: “Nice to know what regulatory body thinks but don’t see as encouraging good practice.”
The comments also however, provide some interesting insights into how HSE might consider improving the concept of HF/E and some subtleties to this issue that might need to be explored further, for example:
• Different definitions, exist from different organisations and this can be confusing;
• Is the current definition applicable to frontline workers? (operators, staff etc);
• Clearer idea of where the boundaries are for the topic of HF/E;
• The topic is vague unlike engineering which is black and white, this means it is difficult to know whether the desired outcomes have been achieved;
• Improve the structure of the HF/E website;
• HSE to develop its HF/E expertise further seek to be more consistency with advice, increase resource and improve its own understanding.
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4.7 BRANDED INITIATIVES
Another option that respondents were asked to consider concerned the use of branded initiatives. This is a popular approach often used to promulgate a particular idea or concept. Using a brand name helps to make issues seem more relevant or applicable to an organisation. A good example is “Hearts and Minds” which is a behavioural safety initiative that encourages employees (managers and workers) to think about their safe behaviour at work.
This option was ranked 6th with only 43% of respondents believing it to be effective.
Different respondents had different experiences with some stating that they thought they were very effective: “Really like this kind of thing as they have been developed for industry, by industry. Materials provided are very good. More of the same would be good, though the effectiveness of these are entirely dependant on take-up by orgs.” Other respondents, however, had a more negative opinion of branded initiatives: “Don’t like them, initiative overload. Do one for some time and then in 3 months it’s another initiative. HF should be part of the way you think and act.”
Table 11 - Future option - branded initiatives
Effectiveness Score The provision of more branded initiatives, such as Step Change or Hearts and Minds, which include a range of industry specific activities and programmes aimed at reducing error and unsafe behaviour (which are based on Human Factors principles but branded and presented as an industry specific initiative rather than as a Human Factors initiative).
Not very effective 1 9%
2 20%
3 29%
4 36%
Very effective 5 7%
4+ 5 43%
Rank in comparison to other
options where 1 is most preferred 6
One perspective was that although branded initiatives can be successful they were less well suited to the general concept of HF/E. This is because initiative tends to have a short term objective to raise the profile of a particular issue but this is not sustained in the long term. The concept of HF/E, however, needs to be embedded. This is illustrated by the following comment: “The term "initiatives" implies that it will only last or run for a certain amount of time. HF needs to be embedded in process and strategy. So HF strategies for industry are needed not initiatives.”
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A second issue with branded initiatives can be employed without appropriate planning. For example, to tackle repeat occurrences of injuries, an organisation may use behavioural safety without actually considering if such an initiative addresses the true root cause of the incidents.
Branded initiatives if employed incorrectly or without full commitment can actually make things worse rather than better and even affect the future application of other HF/E methods.
The issues surrounding their application of branded initiatives and the clear division in attitudes towards them; make this a potentially emotive and controversial area. HSE should therefore think carefully before providing advice on the use of such initiatives for improving the uptake of HF/E. “There are already too many initiatives. Need to focus on the good ones and get them accepted”.
4.8 INCREASE ENFORCEMENT
In addition to providing advice and guidance the other key role of HSE is to enforce against regulation. Enforcement includes: penalty fines; notices of improvement or in some instances even prohibiting a business from trading until it has resolved the issue under investigation.
To some extent HSE can already enforce on HF/E through application of good practice and other regulatory instruments. This option concerns increasing enforcement powers to include HF/E as part of a safety case and related inspection processes.
This option of increasing enforcement was the least preferred method for improving the application of knowledge, techniques and principles for the prevention of error and unsafe behaviour, and improvement of human performance. This is despite the findings that suggest that HSE was a strong influence on the uptake of the application of HF/E.
Table 12: Future option 2 – Increase enforcement
Effectiveness Score HSE to increase enforcement of Human Factors as part of safety case and related inspection processes.
Not very effective 1 16%
2 21%
3 31%
4 28%
Effective 5 5%
4+ 5 33%
Rank in comparison to other
options where 1 is most preferred 7
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The main objection was that although enforcement is an effective option for getting people to take notice of an issue, it is better to convince people of the benefits of HF/E so they adopt it by choice. This is illustrated by the following comment: “Enforcement shouldn’t be the driver. Would be effective in galvanising interest in HF, but better to get them to embrace the concept because it is good for their business.”
The fear of enforcement is likely to trigger some KDMs into action. A number of respondents believed, however, that there are some significant issues regarding enforcement of HF/E, for example:
• Enforcement may encourage organisations to hide information and divulge less to the inspectorate;
• Only effective if the standard and regulatory frameworks are in place and these are clearly understood;
• It focuses interest on certain issues and these might not be what is actually directly relevant or important to a particular organisation;
• Will have only a short term impact.
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5 OVERALL CONCLUSION
Key decision makers were identified to be: senior, site and front line managers, as well as H&S personnel. Other named decision makers were Operation Personnel and Board and Committees Members.
Consideration of how KDMs are tackling process safety, reveal that they are tackling a broad spectrum of issues and to some extent apply a range of recognized HF/E related techniques and approaches. Consultation with workers was frequently cited but there was less use of guidance or standards.
Comments made during the strategy workshop suggest that there is variation in how well HF/E issues are tackled. There were a number of reasons given for why this was the case:
• More or better guidance is available on certain topics (alarm handling) in comparison to others (organisational change);
• The topic area is discreet e.g. easily identifiable as a separate entity not impacting directly on other parts of the business (e.g. control room interface design as opposed to staffing levels);
• The topic area is tangible and easy to evaluate so measurable change of success could be demonstrated (e.g. training & competence);
• “Big bangs drive behaviour” – past incidents have focused attention on a particular issue;
• The issue is underpinned by clear regulation (e.g. organisational change in the nuclear sector);
• The issue has a high profile and their interest from industry bodies and institutions to promulgate knowledge on a particular issue (e.g. safety culture).
The variation in how issues were addressed was also hampered because even though KDMs may know about safety culture and may conduct safety culture surveys, they are still not always applying the recommendations emerging from these surveys. This echo’s the comments made by KDMs that a key problem is not simply aware and understand of HF/E but also knowing how to apply HF/E knowledge effectively to their business.
Decisions to tackle an issue or apply a particular approach were often driven corporately or as part of the safety management and safety case demands but they could also be influenced by external factors. For example, one organisation received significant input into the business after the company had hit serious financial difficulties. External experts identified why the business was failing and set out a programme of work to address the problems. These were largely centred on human performance and behavioural issues.
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The direct interaction of HSE with individual sites has been undoubtedly effective at influencing decision making. It is also largely welcomed by KDMs. This way of working, however, places a potentially high workload on HSE inspectors (stretching an already limited resource) and seems a less efficient way of getting change than influencing decision making at a more corporate level and through the more senior levels of management. These senior managers have an important role in setting the business agenda and licensing resource but the findings suggest they may get less exposure to HF/E principles and techniques than other KDMs within an organisation.
There is repeated reference to the benefits of learning from courses and training, and that the provision of further (more practical and specific support) would help people advance the management of human error. Currently KDMs tend to learn about HF/E through on the job training or ad hoc attendance of external training courses, rather than through more formal training needs analysis.
KDMs also learn about HF/E and process safety by reviewing investigative reports from high profile accidents, such as the Baker report into the Texas City explosion. Peer review, used primarily in the nuclear sector, was considered to be very effective in enhancing understanding of process safety and HF/E. Peer reviews were popular because they were carried out by peers rather than external consultants or other industry personnel. KDMs trusted peers and felt the reviewers understood their industry and the constraints and problems they faced: “The WANO technical support mission is compelling. You respect your peers because they come from the same industry and understand the issues; not a consultant looking for more work”.
Improvements in the availability; quality and accreditation of training; along with more practical guidance and peer review could feasibly be delivered in co-operation with industry associations and professional institutes, but led by HSE. Working in partnership in this way can also lead to a more effective use of resources with knowledge and materials being shared, reducing the potential for a duplication of effort. It can also lead to more networking opportunities and greater openness between those within the partnership.
There are a number of barriers which were likely to affect the greater uptake of HF/E in decision making. Some of these were concerned with the nature of the subject area which is difficult to change. Others barriers, however, appear easier to overcome such as: uncertainty about training quality and a perceived lack of practical and comprehensive guidance. Identifying ways to help address these barriers might be one way HSE might usefully help to achieve a greater uptake of HF/E.
The majority of KDMs indicated a high awareness of HF/E and overall, it is implicit within the responses that people recognise the need to consider and manage human error and human performance. This is in line with previous research that found that there was significant value placed on HF/E in controlling the factors that contribute to accidents. “Nearly all respondents agree that Human Factors is an essential part of major accident prevention.” [Wright et al 2003]
There was also little reference for a need to demonstrate the business case for this, or that costs concerns significantly inhibit this aspect of safety management. There is because there is a common desire, for not only the regulator but also industry to seek ways to reduce error and enhance behaviour.
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A key issue emerging from the findings regards the application of HF/E. Overall comments made during the main interviews, particularly responses to Question 4, indicate that KDMs want more help to better apply HF/E to their workplaces. Improving the application of HF/E would also help to widen knowledge and understanding of this topic across the organisation. It will also help to better integrate HF/E into day-to-day management.
The way HF/E is applied, now and in the future, can be illustrated by adapting the diagrams used in the introduction. These were originally used to show the path of development for awareness and understanding of HF/E – see Figure 1 Awareness of HF/E and Figure 2 Value and understanding of the importance of HF/E.
Figure 3, below, shows a possible current vision of how HF/E is currently applied. For example, position (1), shows that HF/E is not integrated and relatively unplanned. Position (2) shows a future vision, where it is fully integrated into safety management and applied systematically.
Figure 3 Application of HF/E
Consistent Planned/Systematic
2. Future
Not integrated or Integrated regularly applied & applied
regularly
1. Now
Inconsistent Unplanned/ unsystematic
Simplistically we can, therefore, say that there is a natural progression in the development of how central HF/E is to the thinking of KDMs. First there is awareness; then understanding and then effective application.
The developmental stages can be described as follows:
• Stage 1 - Awareness and a willingness to find out more;
• Stage 2 - Understanding of the relevance of HF/E to major accident prevention;
• Stage 3 – Improved practical application of HF/E to address issues impacting safety.
In the current climate it is unlikely that stage 1 and stage 2 have been universally achieved by all those participating in the interviews. HSE might, therefore, continue to seek to communicate more effectively to reposition awareness and understanding of HF/E.
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It is also likely that progress in stage 3 will be more difficult to obtain without achieving the desired state/goal for stage 1 and 2. Finally, the gaps between these stages are unlikely to be uniform and some KDMs may progress at different rates, there may also be interim stages not identified here. It is judged, however, that it is important to move through each of these stages in turn. The application of HF/E, without a well formed understanding of its value or benefit, will be less likely to achieve the desired outcomes (e.g. enhanced human performance; reduced error and improved behaviour).
The findings suggest (at least for the KDMs, interviewed as part of this research) that they are ready for more support to achieve better application of HF/E. Due to KDMs being possibly less developed in this respect, they could potentially be greater wins to be made for HSE in achieving improvements to the management of major hazards. Therefore, if HSE was to focus more of its efforts in facilitating the practical application of HF/E, it might support its long term strategy for work workplace Health and Safety in Great Britain to 2010 and beyond.
The details of how the better application of HF/E might be facilitated, along with the further development of awareness and understanding of HF/E are discussed in the next section: Recommendations.
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6 RECOMMENDATIONS
6.1 SUMMARY
It is recommended for HSE to seek to develop a more formal communications strategy to continue to raise awareness and understanding of HF/E. To begin with, this could be targeted primarily at senior managers who are likely to have the most significant influence in terms of promoting and embedding HF/E within their organisations.
HSE should also seek to provide additional support that showcases how different techniques and approaches can be applied. This will help KDMs tackle human performance issues (reduce error and control unsafe behaviour) affecting their workplace.
HSE can use its influence to establish partnerships and set the agenda to aid the development of: appropriate guidance materials; accredited training and to facilitate peer review.
The objective of HSE is to strive to ensure that HF/E is applied in a planned and systematic way and so that it eventually becomes embedded within everyday management systems and processes.
6.2 INTRODUCTION
There is a desire from both HSE and industry, to seek to integrate HF/E into wider safety management decision making. The section explores a number of methods that HSE, with support from industry associations and professional institutions, might seek to help the industry to achieve this. These methods are explored under the following key themes:
• Developing training;
• Providing practical guidance;
• Partnership working;
• Developing a communications strategy;
• More effective targeting of HSE influence;
• Facilitating formal peer review.
6.3 TRAINING AND CONTINUING PROFESSIONAL DEVELOPMENT (CPD)
The findings indicate that KDMs want to increase their knowledge and understanding of HF/E. Yet comments suggest that there are a number of barriers that exist which may prevent or inhibit increasing this knowledge.
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It is recommended that HSE seeks to overcome these barriers by implementing some of the following initiatives:
• Help HF/E champions (or those with a more developed understanding of HF/E) to promote HF/E within their organisation (by adapting HSE provided materials and promote these via key information hubs);
• Create incentives for attendance at HF/E training courses (counts towards safety performance score or CPD);
• Help to ensure the right people attend the training by promoting the use of applying techniques such as training needs analysis;
• Help to develop short courses (1-day) for senior managers that extol the fundamental principles and underlying philosophy of HF/E;
• Help to develop specific 1 day modules that expand upon the basics of HF/E (potential topics might include: understanding error, open reporting culture, workforce involvement, task analysis etc)
• Work in partnership with associations to develop a suite of appropriate and certified HF/E training that are:
o Practical rather academic;
o Directly applicable to high hazard industries;
o Tailored to specific industry requirements;
o Regularly scheduled.
6.4 GUIDANCE
HSE might also advance the breadth and depth of HF/E understanding by developing guidance that provides practical advice on tackling HF/E. These might show the way in which operational and engineering problems were solved through the application of HF/E knowledge and techniques. Examples, like high profile accident reporting, could also help to illustrate what can happen if there is an inadequate appreciation of HF/E issues. Guidance, supported with examples and case studies could be developed in partnership with industry associations and professional institutions.
6.5 PARTNERSHIP WORKING
There are a number of benefits to working in partnership with industry associations and professional institutions. This can be illustrated by looking at how partnership working can improve the development of guidance, for example:
• It helps to ensure guidance is more consistent with that being provided by HSE;
• Guidance can be tailored to a particular agenda, message or communication strategy;
• It helps to ensure guidance is more practical and suited to a particular industry or sector;
62
• It helps to ensure effort is not being duplicated by HSE and industry associations to produce guidance on the same themes
A key advantage of partnership working is that it can utilize resources more effectively by sharing work load. This is important to HSE who have a limited number of specialist inspectors with HF/E knowledge within high hazard industries. The partnership approach can, however, also help in other ways, for example:
• Helping to develop appropriate and agreed training programmes, as well as promoting accredited providers;
• Working in partnership can build trust between different organisations;
• Members of associations agree to leadership commitments statements on HF/E;
• Encourage associations to build HF/E into existing engagement initiatives and programmes of work (e.g. process safety leadership forum);
• Share incident data to enhance sector understanding on the issues impacting their industry;
• Facilitate peer review.
HSE are already collaborating, to a limited extent, with industry associations/institutes, such as, the Energy Institute, who have developed guidance materials based on the HSE HF/E topic list. It is recommended that HSE seek ways to develop this relationship further and also strive to develop and strengthen new partnerships with other organisations. A first step might, therefore, be to identify organisations who have already expressed an interest in collaborating more with HSE, for example: Chemical Industries Association (CIA); Ergonomics Society; Step Change and Institute of Occupational Safety and Health (IOSH)
Successfully developing partnerships can be made more likely, by using a more formal approach to cross industry collaboration. This is important because “one size does not fit all” and it is likely that different potential partners will have different needs, expectations, constraints and capacity. For example, institutes (more commonly made up of private members rather than organisations) will have less leverage or influence over their members than associations.
It is also likely that these different partners will provide different avenues and routes to help deliver greater uptake of HF/E. For example: the Chemical Industries Association promotes the Responsible Care Management System. This seeks to achieve higher standards of performance by focusing on 7 key areas: community awareness and emergency response; security; distribution; employee health and safety; pollution prevention; process safety; and product stewardship. Organisations are audited against these 7 key areas and awarded certification in recognition of their efforts. Closer collaboration between the CIA and HSE may help to build HF/E principles into this management system.
It is, therefore, advisable that the first step in developing partnerships is to begin to assess and understand more about prospective partners. The type of work they do and how HSE might collaborate with them to create more HF/E development opportunities.
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HSE might also seek to formalise the partnership by:
1. Securing commitment;
2. Scoping an agreement programme of collaboration and priorities (e.g. development of guidance materials);
3. Reviewing and monitoring progress against the agreed programme (e.g. were the guidance materials developed).
In addition to developing partnerships where HSE are aware that the institutes or associations has already expressed an interest in collaborating more closely; it would also be advisable to approach other institutes or associations where an informal relationship is less established. HSE may decide to formalise their approach to developing new potential partners and develop a framework or matrix that identifies:
• The associations, professional bodies, institutions and unions who may be willing to work in partnership with HSE (Nuclear Industry Association, UK Petroleum Industry Association, Institution of Mechanical Engineers, Trade Union Congress etc);
• Key contacts within these associations;
• The industries the associations support or work with;
• The areas where associations are already developing HF/E relevant information (training, guidance, posters etc);
• Opportunities to build HF/E principles into existing programmes of work e.g. broaden process safety leadership initiatives to focus not just on issues like equipment but HF/E concerns like fatigue;
• Other specialist HF/E groups residing within professional bodies and associations (e.g. IMECHE WG4 Human Factors IN Safety and Reliability);
• Programmes of work (research areas, guidance being reviewed or updated etc).
This matrix can also be used to ensure that HSE efficiently targets a cross section of associations/professional bodies that cover the full range of organisations working in the high hazard industries.
The central role of HSE in helping to develop partnerships is believed to be very important. A recent report, published in 2008, that reviewed the success of targeted initiatives in the manufacturing sector [11] identified the role of the HSE as essential in providing support by helping to:
• Secure industry commitment;
• Identify key issues;
• Encourage partners to engage;
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• Design and scope partnership schemes.
Findings from this same review also identified that working jointly with HSE generated greater respect and authority for the scheme (e.g. documentation with HSE logo and branding carrying more weight in the eyes of some participating organisations). HSE also monitored the initiative and helped to ensure that momentum was sustained. Stakeholders during the strategy workshop did, however, comment that there were some issues concerning close collaboration between HSE and industry associations primarily because of its dual role as regulator. For example guidance developed in collaboration with industry might be used as Approved Codes of Practice (ACOPs), which are later used to assess and regulate industry. HSE should, therefore, be cautious, setting ground rules for engagement and letting partnership mature and develop naturally over time.
6.6 COMMUNICATIONS STRATEGY
The findings suggest that despite improvements in awareness and a developing understanding of HF/E there is still some confusion over the terminology used to describe HF/E “Human Factors can be known as human performance or error reduction” and where the boundaries of HF/E begin and end. “People really struggle with the concept of HF it’s a very woolly subject for practical people. Need greater clarity and information”.
Stakeholders, during the strategy workshop, also indicated that the HSE was compartmentalised on HF/E with different departments providing slightly: differing messages; definitions and materials which was sometimes confusing. They also believed that industry would benefit from a clearer description of HF/E with one delegate suggesting the term; “Improving Human Performance.”
There is, therefore, an argument for developing a more clearly thought out and presented communications strategy, however, such an approach was believed to be difficult to get right “Very difficult to do campaigns. They are often only posters, emails, websites etc which are not very good at explaining the link between the campaign and the job undertaken.”
The aims of any communications strategy are to be (a) very clear and (b) present a consistent message through a number of media channels over at least a reasonable period of time. A campaign strategy should seek to ensure KDMs want to improve and deepen their understanding of HF/E rather than simply raising awareness.
A starting point for HSE would be to agree a single term for HF/E and a generic definition. This should then be presented consistently via the website and on publications. There is obviously a potential cost associated with this in terms of re-issuing publications such as HSG 48 ‘reducing error and influencing behaviour’.
The findings also suggest that HF/E is likely to have a different meaning to different people within an organisation. For example, senior managers may be dealing with different issues concerned with overall corporate policy in contrast to engineers; trainers or frontline managers who may be more concerned with issues more specific to their roles. Communications must, therefore, consider the audience and the need to reach a specific job role on particular issues.
One option is to use different approaches, for example, a fixed generic message and a secondary level message adapting to a more diverse audience. These messages should be linked to a strong
65
brand and style so the generic and secondary level messages are linked to an overarching umbrella campaign. Individuals can then see how all the different messages are in fact all bounded as HF/E. The messages contained within the campaign should also be easily understandable and accessible.
The generic message should lead KDMs towards a ‘moment of enlightenment’ i.e. HF/E is perceived as having value to them and their organisation, thus engendering the desire to either learn and/or apply HF/E more thoroughly.
The secondary message should encourage others within the organisation to find out more about specific topics of relevance to them and their job role; so that they can establish how to improve (reducing the impact/instances of human failure). This would help to drive HF/E knowledge and application bottom up, as well as through the more senior decision makers.
A successful communications strategy should consider the following issues:
• Audience;
• Message;
• Approach;
• Branding;
• Style.
6.6.1 Audience
The strategy should consider the diverse nature of the audience (KDMs), for example: senior management (site director, managing director, senior executive); site managers (facility, installation or refinery managers - those leading day-to-day plant operation); front line managers (operations managers, production managers, project managers, design managers, safety assurance managers, maintenance managers) and health and safety personnel (HSE department, safety director, safety manager, safety case authors, incident investigators, process safety specialists etc).
It is also important to consider the other people involved in the decision making process, such as: operation personnel; board and committees members; trade unions; financial department (agreeing resources, allocating funds etc); human resources and contractors. For such a diverse audience the message will need to be different because it is unlikely that board members and operational personnel will share the same issues and concerns.
A starting point might, therefore, be the development of a communication matrix that describes each of the audience types and the types of messages that might be relevant or important to them.
The matrix would be used to help identify the different types of messages that are appropriate for the different audience members. This matrix will be then used to inform the chosen approach.
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6.6.2 Messages
Once the audience has been better identified and understood it is important to select a message that is of equal value and easily understood by all. This will need to be highly generic and very simple in its design. Alternatively it will be necessary to select an audience type and target key messages at that group.
In light of earlier recommendations, it might be advisable to begin with senior management because of their perceived influence over the rest of the organisation.
The messages embraced within this campaign have to be very clear, consistent, and repeated with regularity.
The exact set of messages per audience/sector needs to be established through discussions between HSE (HF/E and communications specialists) and key stakeholders.
6.6.3 Approach
The recommended approach, therefore, would be to deliver an overarching umbrella campaign that carries two messages:
1. A top level generic message aimed at a wide audience used to raise overall understanding of HF/E;
2. A secondary more sophisticated message aimed at senior management that communicates on a particular theme, for example, developing proactive process methods that take account of HF/E.
Both messages could be developed in partnership with key industry organisations. This will help to ensure the messages are consistent with the same information about HF/E being provided by different associations. The two messages should also be written in the same language with a similar style and with common branding.
The messages could be further supported by using Social Network Analysis. This identifies the key information hubs in each organisation. These hubs can be used to distribute additional relevant materials or provide additional information about where to find out more about a particular topic, e.g. the HSE website.
The campaign should be planned to run over several years. This will help to ensure the key messages become embedded and all the relevant audiences are reached.
6.6.4 Branding
A brand needs to be developed. Initial ideas should be developed within HSE to identify the factual and emotive triggers to action. The branding could be re-enforced with a campaign logo and strap-line.
The brand should be built on the perception of the HSE as a key source of highly regarded, relevant information about all aspects of health and safety (of which HF/E is part).
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Branding should be developed in collaboration with key industry sector stakeholders but it would still need to work well with the established HSE branding and treatment. The brand (logo and strap-line) could be linked into other HF/E relevant information, such as, practical guidance (e.g. case studies, practical examples) and also relevant HF/E tools and techniques.
6.6.5 Style
The style has to be easily accessible, quick to understand, and strong, without coming across as dry, heavy-handed or remotely regulatory. A narrative style has been found to be effective in spreading HF/E learning.
It needs to build on the HSE’s position as the leader in provision of information about all aspects of health & safety.
6.7 HSE INFLUENCE
The findings from the interviews indicate that HSE has a strong influence on the decisions that KDMs make within the high hazard industries. This is partly through their role as an advisory body but also through their function as regulator and in accordance with The Control of Major Accident Hazards Regulations (COMAH) 1999 and Nuclear Safety Assessment Principles (SAP).
Top tier COMAH sites will receive regular visits from HSE inspectors. During these visits inspectors will review and discuss safety activities and principles to ensure that necessary measures are taken to prevent major accidents and to limit the consequences of such events to people and the environment.
Statements made by KDMs suggest that the direct engagement with HSE inspectors is welcome; perceived as often beneficial but also highly influential on the decision making process. “The key driver was a HSE intervention following an accident related to insufficient labelling of plant equipment - HSE told them to include a HF view/approach.” Following input from HSE they identified the top 5 areas which presented a safety risk due to human error, for example alarm handling and procedures. In addition KDMs are also influenced by other external drivers such as investigations into accident that have occurred elsewhere and by knowledge developed at conferences and through peer interaction.
The most efficient and reliable method for leading decisions is, however, internal corporate safety management systems that gather comprehensive and appropriate safety information. It is important that HF/E principles are embedded within these safety management systems.
For those organisations, where such systems are still developing, HSE influence maybe more effective at the higher echelons of senior management and aimed at the people who set organisational policy. This is likely to be a more efficient way of influencing decision making rather than providing advice directly to organisations during regular inspection visits. Feedback from HSE suggests that there are challenged in terms of their high hazard industry specialist HF/E resource. It is therefore important that they make the best use of this resource and seek the most efficient way to influence decision making.
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Many KDMs commented on how recently they had become better at classifying events in terms of HF/E. The comments also revealed that they now had a better understanding of why incidents occur and how their organisations were better at learning more from these types of events.
Improvements to how safety information is gathered often require a fundamental change in organisational culture. Such changes may, therefore, illustrate how HSE and other external agents have influenced corporate policy. Learning from past accidents, however, is reactive and is only one component of a comprehensive safety information system. Much can also be learnt from proactively gathering information through audits, as well as surveys and consultation with workers. The aviation industry is recognised to be one of the leaders in this area.
Few KDMs, however, discussed the use of proactive measures to identify HF/E issues impacting on their organisation, despite the fact that this type of information gathering is a key facet of an HF/E approach. This, therefore, might be an area that the high hazard industries might improve upon.
It is, therefore, recommended that HSE use their influence in a more directed way at senior management and those that set corporate policy. A starting point could be the development of a strategy to communicate on the benefits of developing proactive process measures that take account of HF/E.
During the strategy workshop it was also revealed that the industry benefited from clear expectation and a steer to help them focus on the areas considered to be important. Currently HSE provide an operationalised list of key HF/E topics but this has not been recently updated and may benefit from review. They might also consider providing a broad generic HF/E topic list and then more specific topics tailored to particular sectors.
For each topic HSE may want to consider, how they provide information that supports each of the three stages of awareness, understanding and application discussed in the conclusion. For example:
• Enhance awareness - brief information on each topic area, that raise awareness and demonstrates how not considering a particular topic area led to a costly accident or incident;
• Enhance understanding - more detailed guidance on each topic and case studies and examples that\demonstrates how problems were solved using HF/E;
• Enhance application - practical tools to help inform decision making on each topic and help organisations proactively tackle the issues impacting on their business.
HSE might also seek to set clear expectations on what industries should be achieving in terms of HF/E. For example, HSE states that it requires all organisations with the high hazard sectors, of a certain size, to conduct a Safety Culture Survey once per year or employ an individual with a qualification or training on HF/E.
6.8 PEER REVIEW
Comments made by KDMs within the nuclear sector suggest that peer review is a particularly effective and compelling way of increasing knowledge and understanding of HF/E.
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It also provides an opportunity for visiting peers, with a recognized expertise in a particular field to show how particular HF/E techniques can be applied.
This approach is used quite widely in the nuclear sector where formal peer reviews are facilitated by WANO. Currently the Institute of Occupational Safety and Health (IOSH) Hazardous Industries Group, is seeking to promote a peer review model (developed in the nuclear industry) to other industries in the Onshore Oil and Gas sector.
It is likely that this model will need to be refined and adapted and potentially HSE could play a role providing input into this process. HSE might also seek to facilitate formal peer review more widely across other sectors, such as the Chemical industry either directly or in partnership with industry associations.
It would be important: however, that HSE does not seek to be directly involved in the peer review process. This is because it might inhibit organisations from sharing potentially sensitive information.
6.9 CONCLUDING STATEMENT
The recommendations provided in this section provide a vision and way forward for how HSE might seek to reposition HF/E so that it is better understood and more valued by Key Decision Makers (KDMs). For example: develop a more formal communications strategy; advocate accredited training; provide practical guidance and support wider use of peer review.
It is clear, however, that this places a burden on HSE specialist within the high hazard industries who are already challenged by demands on their time to fulfil their inspectorate role and commitment to COMAH and SAP.
One way to help implement these recommendations is to work in partnership with: industry associations; organisations and professional bodies, many of whom have expressed a willingness to work in collaboration with HSE.
To ensure a greater likelihood of successful outcomes, from such collaboration, these potential partnerships should be more formalised. Support to do this might be provided by other functions within HSE, such as the HF/E Corporate Topic Group.
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7 REFERENCE
[1] Baker, J et al. 2007 Independent Safety Review Panel, the report of the BP U.S. refineries.
[2] Salas, Eduardo. 2008, At the Turn of the 21st Century: Reflections on Our Science, Human Factors 50 351-353
[3] HSE. 1997, Successful Health and Safety management, HSG 65, (HSE Books)
[4] HSE. 1999, Reducing error and influencing behaviour, HSG48, (HSE Books).
[5] HSE. Research Report 149 2003 - The promotion of Human Factors in the onshore and offshore hazardous industries (HSE Books)
[6] HSE. 2003, Development of Human Factors methods and associated standards for major hazard industries, RR081, (HSE Books)
[7] HSE. 2003, The promotion of Human Factors in the onshore and offshore hazardous industries, RR149, (HSE Books).
[8] HSE. 2004, Human Factors assessment model validation study, RR194, (HSE Books).
[9] HSE. 2004, Human Factors guidance for selecting appropriate maintenance strategies for safety in the offshore oil and gas industry, RR213, (HSE Books).
[10] HSE. 2007, Development of a working model of how Human Factors, safety management systems and wider organisational issues fit together, RR543, (HSE Books).
[11] HSE. 2008 Review of targeted initiatives in the manufacturing sector, RR620, (HSE Books).
[12] Moray, Neville. 2008, The Good, the Bad, and the Future: On the Archaeology of Ergonomics, Human Factors 50 411-417
[13] James Reason and Alan Hobbs. 2003, Managing maintenance error - a practical guide, (Ashgate Publishing).
[14] Hans Soekkha. 1997, Aviation Safety Human Factors, System Engineering, Flight Operations, Economics, Strategies, Management (Published by VSP)
[15] William B et al. 1997, The Case for Human Factors industry and government: Report of a Workshop (Published by National Academies Press)
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8 APPENDIX I – STAKEHOLDER RESPONSES
Table 13 - Identifying key decision makers per HSE HF/E topic
Topic – Decision area
Corporate level President/C
hief E
xecutive
Board
Com
mittee (N
uclear Safety C
hange managem
ent)
Site Director/senior executives
Senior Manager
Health &
Safety (HSE
Q SH
E)
Site Manager or m
anagement
team
(Installation ,Facility R
efinery)
Front line M
anager (project, operations/shift/ production, m
aintenance)
Operations (general staff,
personnel, technician control room
)
Supervisors
Union
Technical
Engineering
Maintenance
Design
Contractors
Production + Quality
Training department
Hum
an resources (personnel)
Business &
Finance
In house HF
expertise
External consultant
Alarm handling 3 3 4 4 3 1 2 2 1
Interfaces 1 4 2 2 4 4 2 1 1
Safety critical communications 1 4 7 3 5 2 1 1 1 1
Supervision 1 1 3 1 5 2 1 1
Behavioural safety 2 3 6 4 2 1
Procedures 1 2 5 4 2 2 1 2 1 1 2
72
Topic – Decision area
Corporate level President/C
hief Executive
Board
Com
mittee (N
uclear Safety C
hange managem
ent)
Site Director/senior executives
Senior Manager
Health &
Safety (RA HSEQ
SHE)
Site Manager or m
anagement team
(Installation ,Facility Refinery)
Front line Manager (project,
operations/shift/ production, m
aintenance)
Operations (general staff,
personnel, technician control room
)
Supervisors
Union
Technical
Engineering
Maintenance
Design
Contractors
Production + Q
uality
Training department
Hum
an resources (personnel)
Business & Finance
In house HF expertise
External consultant
Training and competence 4 6 1 5
Organisational change 7 1 2 3 2 1 1 1
Staffing levels and workload 1 2 1 5 4 1 1
Managing human failures 1 4 1 6 2 1 1 1
Fatigue (shift work/overtime) 1 1 4 2 1 1 1 1 1
Organisational culture 6 3 4 1 2 1 1 1
73
Topic – Decision area
Corporate level President/C
hief Executive
Board
Com
mittee (N
uclear Safety C
hange managem
ent)
Site Director/senior executives
Senior Manager
Health &
Safety (RA HSEQ
SHE)
Site Manager or m
anagement team
(Installation ,Facility Refinery)
Front line Manager (project,
operations/shift/ production, m
aintenance)
Operations (general staff,
personnel, technician control room
)
Supervisors
Union
Technical
Engineering
Maintenance
Design
Contractors
Production + Q
uality
Training department
Hum
an resources (personnel)
Business & Finance
In house HF expertise
External consultant
Integration of HF into RA/investigation
1 4 3 1 1 1
Design 1 4 1 4 3 2 2 1 1 5 1 1 2
Total 15 7 9 30 47 37 44 16 2 1 4 8 1 10 9 9 6 2 3 0 3
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Table 14 – How are decisions made (the decision making process considered by HSE HF/E topic)
Topic
Manner External influence Top Down How Bottom up Other
Form
al
Informal
HSE
inspectors
Safety Case
demands
Standards
Guidance
Advisory bodies
Corporate
decision
Com
pany Policy
Programm
e or initiative C
AR
E
SUSA
B-M
od
Collaboratively
(comm
itteereview
panel)review
team
Individually or by departm
ent in isolation
Response to
Incident or incident analysis
Worker
Consultation
External
Consultant
Alarm handling 2 1 3 1 1 1 1 1 3
Interfaces 2 1 1 1 1 1 1
Safety critical communications 1 1 1 2 1 1 1
Supervision 2 1 1 1 2 2
Behavioural safety 3 1 8 1 1 1 1
Procedures 4 1 1 1 3 2
Training and competence 2 1 2 1
Organisational change 3 1 1 2 3
Staffing levels and workload 1 3 1
75
Topic
Manner External influence Top Down How Bottom up Other
Form
al
Informal
HSE
inspectors
Safety Case
demands
Standards
Guidance
Advisory bodies
Corporate
decision
Com
pany Policy
Programm
e or initiative C
AR
E
SUSA
B-M
od
Collaboratively
(comm
itteereview
panel)review
team
Individually or by departm
ent in isolation
Response to
Incident or incident analysis
Worker
Consultation
External
Consultant
Managing human failures 1 1 1 2 1
Fatigue from shift work and overtime 1 1 1 1 1 2 3
Organisational culture 2 1 3 1
Fatigue from shift work and overtime 1 1 1 1 1 2 3
Organisational culture 2 1 3 1
Integration of HF into RA/investigation 1 2 1 1 1
Design 1 2 1 1 1
Total 17 3 2 7 9 2 0 12 5 14 22 9 8 7
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Table 15 Incorporating HF into decision making per HSE HF/E topic
Topic
Policy Governance Analytical methods Consultation Specialist
Legislation/Regulations
Standards
Guidance
Industry good practice
Corporate standards or
process
Com
pany experience Internal reports
Tools Org M
odels process or system
s
Risk assessm
ent
HA
ZOP
Audits
Workload analysis
Task Analysis
Gap analysis TN
A
Job safety analysis
Workplace m
apping
analysis R
oot cause fault tree
Error analysis SH
ER
PA
HE
AR
T HR
A
3D V
irtual reality
Workshop Toolbox talks
Consultation interview
s
HF
Cham
pions
External C
onsultants
Alarm handling 1 2 1 4 2 3 1 4
Interfaces 1 1 4 1 1 1 1 1
Safety critical communications 2 2 1 1 1 1
Supervision 1 2 1 1
Behavioural safety 1 1 1 1 1 1 1 3
Procedures 1 1 1 1 1 2 1
Training and competence 1 1 1
Organisational
Change 1 2
77
Topic
Policy Governance Analytical methods Consultation Specialist
Legislation/Regulations
Standards
Guidance
Industry good practice
Corporate standards or
process
Com
pany experience Internal reports
Tools Org M
odels process or system
s
Risk assessm
ent
HA
ZOP
Audits
Workload analysis
Task Analysis
Gap analysis TN
A
Job safety analysis
Workplace m
apping
Root cause fault tree analysis
Error analysis SH
ER
PA
HE
AR
T HR
A
3D V
irtual reality
Workshop Toolbox talks
Consultation interview
s
HF
Cham
pions
External C
onsultants
Staffing 2 1 2 1 1
Managing human failures 2 4 2 2
Fatigue 1 1 1 2 1
Integration of HF into RA/investigation
1 3 3 1 1 1 2 1
Design 2 1 1 2 4 4 1 3
Other
Total 4 6 6 3 4 5 12 20 9 1 3 7 7 1 6 5 4 1 2 6 1 16
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9 APPENDIX II – KEY DECISION MAKER RESPONSES
Table 16 Summary table of Issues by Sector (Q1)
Sector Position
Organisation Individual Job General safety
Organisational C
hange
Safety & O
rganisational C
ulture
Com
munication
Behavioural safety
Staffing levels and w
orkload (Manning)
Training & C
ompetence
(permit to w
ork)
Fatigue
Supervision
Docum
entation &
procedures
Design
Interfaces (Control room
)
Alarm
handling
Accident investigation
(integration of HF
into R
A/investigation)
Managing hum
an failure safety m
anagement and
process safety
Senior 1
Site 1 2 1 1 1
Chemicals Front Line 1 1 1
H&S 1
Onshore
Senior 1
Site 2 1 1
Front Line 1 1 1 1
H&S 3
79
Sector Position
Organisation Individual Job General safety
Organisational C
hange
Safety & O
rganisational C
ulture
Com
munication
Behavioural safety
Staffing levels and w
orkload (Manning)
Training & C
ompetence
(permit to w
ork)
Fatigue
Supervision
Docum
entation &
procedures
Design
Interfaces (Control room
)
Alarm
handling
Accident investigation
(integration of HF
into R
A/investigation)
Managing hum
an failure safety m
anagement and
process safety
Offshore
Senior 1 1 1
Site 1 Front Line
1
H&S 1 1 2
Nuclear
Senior 1
Site 1 2
Front Line 1 1 3
H&S 1
Total 2 1 3 2 2 16 1 1 8 1 2 2 1
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Table 17 Summary table of activities undertaken to address HF/E issues affecting process safety (Q1)
Topic
Policy Governance Analytical methods Consultation Specialist
Regulation
Standards
Guidance
Industry good practice
Corporate standards or
process
Audits
Com
pany experience Internal reports
Tools Org M
odels
Risk assessm
ent
Job safety analysis
HA
ZOP
Root cause analysis
Workplace m
apping
Gap analysis TN
A
Workload analysis
Task Analysis
Error analysis SH
ER
PA
HE
AR
T
3D V
irtual reality
Workshop Toolbox talks
Consultation
(interviews)
HF
internal (HF
team
SME
, performance
specialist)
External C
onsultants
Alarm handling
Interfaces
Safety critical communications
1 1 2 1 1 1 1 1
Supervision
Behavioural safety
1 1 1 1
Procedures 1 1 3 2 1 3 1 2
Training and competence
1 1 1 2 1 4 1
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Topic
Policy Governance Analytical methods Consultation Specialist
Regulation
Standards
Guidance
Industry good practice
Corporate standards or
process
Audits
Com
pany experience Internal reports
Tools Org M
odels
Risk assessm
ent
Job safety analysis
HA
ZOP
Root cause analysis
Workplace m
apping
Gap analysis TN
A
Workload analysis
Task Analysis
Error analysis SH
ER
PA
HE
AR
T
3D V
irtual reality
Workshop Toolbox talks
Consultation
(interviews)
HF
internal (HF
team
SME
, performance
specialist)
External C
onsultants
Organisational Change
1 1 2 2 1 1 1 3
Staffing 2 1 1 1 1 4
Managing human failures & safety management Process Safety
1 1 1 2 1
Fatigue
Organisational culture
Integration of HF into RA / investigation
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Topic
Policy Governance Analytical methods Consultation Specialist
Regulation
Standards
Guidance
Industry good practice
Corporate standards or
process
Audits
Com
pany experience Internal reports
Tools Org M
odels
Risk assessm
ent
Job safety analysis
HA
ZOP
Root cause analysis
Workplace m
apping
Gap analysis TN
A
Workload analysis
Task Analysis
Error analysis SH
ER
PA
HE
AR
T
3D V
irtual reality
Workshop Toolbox talks
Consultation
(interviews)
HF
internal (HF
team
SME
, performance
specialist)
External C
onsultants
Design 1 1 1 1 8 4 1 2 5
Other 1 1
Total 3 3 1 5 0 6 1 2 16 1 11 4 0 1 2 3 1 0 3 19 2 8
83
Table 18 Examples of techniques to learn about process safety (Q2)
Sector Job Role
Degree / academ
ic qualification
Safety qualification
HSE
, external society / association course
Internal company
training
Externally provided
company training
On the job learning
Guidance and
industry docum
entation
accident reports
Peer review inform
al
Peer review form
al
Conferences
Internal safety team
disseminating
knowledge
External consultants
Che
mic
als
Senior manager
1 1 1 1
Site manager 1 2 1 3 2 1 1 1 1 3 1
Front Line manager
1 2 1 3 1 2 1
H&S manager
1
Sub total 1 2 2 3 2 7 3 2 1 1 4 3 2
Ons
hore
Oil
and
Gas
Senior manager
2 2
Site manager 1 1 1 1 1 1 2 Front Line manager
1 1 1 2 1 2
H&S manager
1 1 2 1 2 2 1 2
Sub total 1 3 1 4 3 3 2 5 1 0 3 6 0
84
Sector Job Role
Degree / academ
ic qualification
Safety qualification
HSE
, external society / association course
Internal company
training
Externally provided
company training
On the job learning
Guidance and
industry docum
entation
accident reports
Peer review inform
al
Peer review form
al
Conferences
Internal safety team
disseminating
knowledge
External consultants
Off
shor
e O
il an
d G
as
Senior manager
1 1 2 1 1
Site manager 1 1
Front Line manager
2 1 2 1 1 1 1
H&S manager
1 1 2 2 2 1 1 2 1 1
Sub total 4 2 1 5 5 4 2 0 1 2 3 1
Nuc
lear
Senior manager
1 1 1
Site manager 3 1 2 Front Line manager
1 4 1 1 1 1 1 3
H&S manager
1 1
Sub total 1 0 0 5 1 5 1 2 3 3 3 0
Total 7 7 4 17 11 19 6 11 2 5 12 15 3
85
Table 19 Why learning is compelling (Q2b)
Sector Job Role
Why is learning compelling
Easy to understand, with clear Provides powerful message Industry specific benefits Practical regarding safety
Chemicals
Senior manager 2 1 Site manager 2 3 1 Front Line manager 1 1 3 2 H&S manager 1 Sub total 6 1 7 3
Onshore Oil and Gas
Senior manager 1 1 Site manager 1 3 1 Front Line manager 3 1 H&S manager 4 2 2 2 Sub total 8 3 7 3
Offshore Oil and Gas
Senior manager 1 1 2 1 Site manager 1 1 Front Line manager 3 H&S manager 3 1 1 Sub total 4 2 6 3
Nuclear
Senior manager 1 Site manager 2 2 1 Front Line manager 2 1 2 2 H&S manager 1 Sub total 4 1 6 3
Total 22 7 26 12
86
Table 20 Approaches, principles or techniques to assess error, manage performance or influence behaviour (Q3a)
Analysis techniques Organisational approach Competence management
Safety related techniques
HF related techniques Engineering
related techniques
Root cause analysis
Risk analysis
Process Safety review and
analysis
HA
ZO
P
Task analysis and gap
analysis
HF analysis (analysis
technique not specified)
Predictive human error
analysis / PHA
FME
A
Fault tress analysis
Incentives and perform
ance indicators
Safety culture / culture m
anagement (step
change/hearts and minds)
Standards and Audits
Behavioural safety
Com
petence assessment
managem
ent e.g.perform
ance reviews
Permit T
o Work
Training needs analysis
Supervision arrangem
ents / briefings etc..
Training
Senior 1 1
Che
mic
als
manager
Site manager 3 1 1 2 1 1 1 1
Front Line manager
2 1 1 1 1 1 1 1 1 1
H&S manager
1 1 1 2
87
Analysis techniques Organisational approach Competence management
Safety related techniques
HF related techniques Engineering
related techniques
Root cause analysis
Risk analysis
Process Safety review and
analysis
HA
ZO
P
Task analysis and gap
analysis
HF analysis (analysis
technique not specified)
Predictive human error
analysis / PHA
FME
A
Fault tress analysis
Incentives and perform
ance indicators
Safety culture / culture m
anagement (step
change/hearts and minds)
Standards and Audits
Behavioural safety
Com
petence assessment
managem
ent e.g.perform
ance reviews
Permit T
o Work
Training needs analysis
Supervision arrangem
ents / briefings etc..
Training
Sub total 6 3 0 1 2 3 1 0 1 2 5 0 0 1 2 2 0
Ons
hore
Oil
and
Gas
Senior manager
1 1 1
Site manager 1 3 1
Front Line manager
3 1 2 1 2
H&S manager
1 2 1 3 2 1 1 1 1
88
Analysis techniques Organisational approach Competence management
Safety related techniques
HF related techniques Engineering
related techniques
Root cause analysis
Risk analysis
Process Safety review and
analysis
HA
ZO
P
Task analysis and gap
analysis
HF analysis (analysis
technique not specified)
Predictive human error
analysis / PHA
FME
A
Fault tress analysis
Incentives and perform
ance indicators
Safety culture / culture m
anagement (step
change/hearts and minds)
Standards and Audits
Behavioural safety
Com
petence assessment
managem
ent e.g.perform
ance reviews
Permit T
o Work
Training needs analysis
Supervision arrangem
ents / briefings etc..
Training
Sub total 5 5 1 5 4 1 1 2 0 1 1 1 0 2 0 0 1
Off
shor
e O
il an
d G
as
Senior manager
2 1 1 1
Site manager 1 1
Front Line manager
2 1 1 1
H&S manager
1 2 1 2 1 1 2 1 1
89
Analysis techniques Organisational approach Competence management
Safety related techniques
HF related techniques Engineering
related techniques
Root cause analysis
Risk analysis
Process Safety review and
analysis
HA
ZO
P
Task analysis and gap
analysis
HF analysis (analysis
technique not specified)
Predictive human error
analysis / PHA
FME
A
Fault tress analysis
Incentives and perform
ance indicators
Safety culture / culture m
anagement (step
change/hearts and minds)
Standards and Audits
Behavioural safety
Com
petence assessment
managem
ent e.g.perform
ance reviews
Permit T
o Work
Training needs analysis
Supervision arrangem
ents / briefings etc..
Training
Nuc
lear
Senior manager
1 1 1
Site manager 2 1 1
Front Line manager
2 1 1 3 1 2
H&S 1 1
manager
Sub total 5 0 0 0 1 1 0 0 0 0 1 1 5 0 2 3 0
Total 21 12 2 8 8 5 3 2 1 3 9 3 6 5 4 7 3
90
Table 21 What prompts the use of particular approaches, principles or techniques (Q3b&c)
Sector Job Role
Prompts Individual Organisational External
Culture HSE
Area of
interest
Methodology relevant and easy to apply
Perceived as valuable
Company policy and
strategy
Internal Incident
/ accident
change and / or
improvement program
inspector and / or external regulator
External accident and / or
incidents Industry
information
Peer groups / forums /
benchmarking Senior manager 1 1 1 1 Site manager 2 2 1 3 2 1
Chemicals Front Line manager 1 1 1 2 2 1 1 1 H&S manager
Sub total 2 2 2 2 4 3 5 2 1 2 Senior manager 1 1 Site manager 1 1 2 1 1 1
Onshore Oil Front and Gas Line
manager 2 1 3 2 1 2 H&S manager 1 1 2 2 1 3 1 4
Sub total 1 5 3 7 3 0 6 2 1 7
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Sector Job Role
Prompts
Individual Organisational External Culture HSE
Area of
interest
Methodology relevant and easy to apply
Perceived as valuable
Company policy and
strategy
Internal Incident
/ accident
change and / or
improvement program
inspector and / or external regulator
External accident and / or
incidents Industry
information
Peer groups / forums /
benchmarking
Offshore Oil
Senior manager 2 2 1 1 Site manager 1 1 1 Front
and Gas Line manager 1 1 2 1 1 2 H&S manager 1 1 2 1 2 1 1
Sub total 1 1 1 5 5 0 5 1 2 5
Nuclear
Senior manager 1 1 2 Site manager 2 1 2 1 2 Front Line manager 1 1 1 2 H&S manager 1 1 1
Sub total 0 0 0 5 2 0 4 0 2 7
Total 4 8 6 19 14 3 20 5 6 21
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Table 22 Techniques for the prevention of error and unsafe behaviour by sector (Q4)
Sector a3 b c d e f g
Count % Count % Count % Count % Count % Count % Count % Not very effective 1 1 7 3 21 0 0 0 0 0 0 0 0 1 8
2 2 14 2 14 0 0 1 7 4 29 1 7 2 15
Chemicals 3 4 29 5 36 2 14 5 36 6 43 3 21 5 38
4 5 36 4 29 8 57 5 36 4 29 7 50 4 31
Effective 5 2 14 0 0 4 29 3 21 0 0 3 21 1 8
Total 14 14 14 14 14 14 13 4+5 7 4 12 8 4 10 5
a b c d e f g
Count % Count % Count % Count % Count % Count % Count % Not very effective 1 0 0 2 11 2 11 0 0 0 0 1 5 1 5
2 3 16 6 32 1 5 1 5 2 11 1 5 4 21
Oil and gas onshore 3 5 26 3 16 4 21 2 11 5 26 4 21 7 37
4 7 37 6 32 6 32 7 37 6 32 9 47 7 37
Effective 5 4 21 2 11 6 32 9 47 6 32 4 21 0 0
Total 19 19 19 19 19 19 19 4+5 11 8 12 16 12 13 7
3 a = explain the concept of HF/E b = increase enforcement c = integrate HF/E d = improve knowledge (training) e = communications strategy f =partnership g = branded initiatives
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a b c d e f g
Count % Count % Count % Count % Count % Count % Count % Offshore oil and gas 1 1 8 2 15 0 0 0 0 1 8 0 0 1 8
2 1 8 2 15 2 17 1 8 3 25 1 8 2 17
a b c d e f g
Count % Count % Count % Count % Count % Count % Count %
Offshore oil and gas 3 4 33 4 31 4 33 1 8 1 8 3 25 3 25
4 6 50 4 31 4 33 9 69 6 50 4 33 3 25
5 0 0 1 8 2 17 2 15 1 8 4 33 3 25
Total 12 13 12 13 12 12 12
4+5 6 5 6 11 7 8 6
a b c d e f g
Count % Count % Count % Count % Count % Count % Count %
1 0 0 2 17 0 0 0 0 0 0 0 0 2 17
2 4 33 2 17 1 8 3 25 1 9 3 30 3 25
3 1 8 6 50 3 25 1 8 3 27 3 30 1 8
Nuclear 4 6 50 2 17 6 50 5 42 5 45 3 30 6 50
5 1 8 0 0 2 17 3 25 2 18 1 10 0 0
Total 12 12 12 12 11 10 12
4+5 7 2 8 8 7 4 6
a b c d e f g
All Not very effective 1 2 9 2 0 1 1 5
2 10 12 4 6 10 6 11
94
3 14 18 13 9 15 13 16
4 24 16 24 26 21 23 20
Effective 5 7 3 14 17 9 12 4
Total 57 58 57 58 56 55 56
4+5 31 19 38 43 30 35 24
a b c d e f g
All Not very effective 1 4% 16% 4% 0% 2% 2% 9%
2 18% 21% 7% 10% 18% 11% 20%
3 25% 31% 23% 16% 27% 24% 29%
4 42% 28% 42% 45% 38% 42% 36%
Effective 5 12% 5% 25% 29% 16% 22% 7%
4+5 54% 33% 67% 74% 54% 64% 43%
Rank 5 7 2 1 4 3 6
a b c d e f g
Chemicals 14 7 4 12 8 4 10 5
Oil and gas onshore 19 11 8 12 16 12 13 7
Offshore oil and gas 12 6 5 6 11 7 8 6
Nuclear 12 7 2 8 8 7 4 6
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Table 23 Techniques for the prevention of error and unsafe behaviour by job type (Q4)
a4 b c d e f g
Count % Count % Count % Count % Count % Count % Count %
Senior Manager
Not very effective 1 1 10 2 22 0 0 0 0 1 11 0 0 1 13 2 2 20 1 11 2 20 1 10 1 11 2 20 2 25 3 2 20 4 44 3 30 3 30 2 22 0 0 2 25 4 4 40 2 22 3 30 3 30 3 33 4 40 2 25
Effective 5 1 10 0 0 2 20 3 30 2 22 4 40 1 13 Total 10 9 10 10 9 10 8 4+5 5 2 5 6 5 8 3
a b c d e f g
Count % Count % Count % Count % Count % Count % Count % Not very effective 1 1 6 5 31 1 6 0 0 0 0 1 6 0 0
2 4 24 3 19 0 0 2 12 3 19 1 6 2 13 3 2 12 5 31 4 24 1 6 4 25 5 29 7 47
Site Manager 4 7 41 3 19 8 47 8 47 7 44 7 41 5 33 Effective 5 3 18 0 0 4 24 6 35 2 13 3 18 1 7
Total 17 16 17 17 16 17 15 4+5 10 3 12 14 9 10 6
a b c d e f g
Count % Count % Count % Count % Count % Count % Count % Front Line Manager Not very effective 1 0 0 5 31 1 6 0 0 0 0 1 6 0 0
4 4 a = explain the concept of HF/E b = more enforcement c = Better integratation of HF/E d = Increasing HF/E knowledge (training) e = communications strategy (better definition of HF/E) f =partnership
(association led activity) g = branded initiatives
96
2 1 5 3 19 0 0 2 12 3 19 1 6 2 13 3 6 32 5 31 4 24 1 6 4 25 5 29 7 47 4 9 47 3 19 8 47 8 47 7 44 7 41 5 33
Effective 5 3 16 0 0 4 24 6 35 2 13 3 18 1 7 Total 19 16 17 17 16 17 15 4+5 12 3 12 14 9 10 6
a b c d e f g
Count % Count % Count % Count % Count % Count % Count %
H&S Manager
Not very effective 1 0 0 0 0 1 9 0 0 0 0 0 0 1 8 2 3 27 3 25 0 0 1 8 2 18 0 0 1 8 3 4 36 3 25 1 9 3 25 3 27 3 27 4 33 4 4 36 4 33 5 45 5 42 5 45 5 45 4 33
Effective 5 0 0 2 17 4 36 3 25 1 9 3 27 2 17 Total 11 12 11 12 11 11 12 4+5 4 6 9 8 6 8 6
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Table 24 Attitude and awareness towards Human Factors by sector (Q6)
Sector a5 b c d e Count % Count % Count % Count % Count %
Poor 1 0 0 0 0 0 0 Not essential 0 0 Not relevant 0 0 2 0 0 3 21 0 0 0 0 0 0 3 5 36 6 43 9 64 1 7 2 14
Chemicals 4 5 36 3 21 3 21 7 50 0 0 Good 5 4 29 2 14 2 14 Essential 6 43 Relevant 12 86
Total 14 14 14 14 14
4+5 9 64% 5 36% 5 36% 13 93% 12 86% a b c d e
Count % Count % Count % Count % Count % Poor 1 0 0 1 5 0 0 Not essential 0 0 Not relevant 0 0
2 1 5 2 11 4 21 0 0 0 0 3 8 42 6 32 8 42 2 11 2 11
Oil and gas onshore 4 6 32 8 42 5 26 7 37 3 17 Good 5 4 21 2 11 2 11 Essential 10 53 Relevant 13 72
Total 19 19 19 19 18
4+5 10 53% 10 53% 7 37% 17 89% 16 89% a b c d e
Count % Count % Count % Count % Count % Offshore oil and gas Poor 1 0 0 0 0 0 0 Not essential 0 0 Not relevant 0 0
2 0 0 4 31 1 8 0 0 0 0 3 4 31 6 46 8 62 2 15 0 0 4 9 69 3 23 4 31 9 69 4 31
5 a = awareness of HF b = awareness of Ergonomics c = understanding of HF d = importance of HF e = relevance of HF to major accident prevention
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Good 5 0 0 0 0 0 0 Essential 2 15 Relevant 9 69 Total 13 13 13 13 13 4+5 9 69 3 23 4 31 11 85 13 100
a b c d e Count % Count % Count % Count % Count %
Nuclear
1 0 0 1 8 1 8 Not essential 0 0 Not relevant 1 9 2 0 0 1 8 2 17 0 0 0 0 3 3 25 6 50 4 33 0 0 1 9 4 6 50 4 33 5 42 2 17 1 9 5 3 25 0 0 0 0 Essential 10 83 Relevant 8 73
Total 12 12 12 12 11
4+5 9 75% 4 33% 5 42% 12 100% 9 82% a b c d e
Count % Count % Count % Count % Count % 1 0 0% 2 3% 1 2% 0 0% 1 2% 2 1 2% 10 17% 7 12% 0 0% 0 0% 3 20 34% 24 41% 29 50% 5 9% 5 10%
All 4 26 45% 18 31% 17 29% 25 43% 8 15% 5 11 19% 4 7% 4 7% 28 48% 43 76%
Total 58 58 58 58 57 4+5 37 64% 22 38% 21 36% 53 91% 50 88%
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Table 25 Attitudes towards Human Factors by job type (Q6)
a b c d e Count % Count % Count % Count % Count %
Senior
Poor 1 0 0 0 0 0 0 Not
essential 0 0 Not
relevant 0 0 2 0 0 4 40 1 10 0 0 0 0 3 5 56 1 10 6 60 0 0 2 22
Manager 4 3 33 5 50 3 30 7 70 2 22 Good 5 1 11 0 0 0 0 Essential 3 30 Relevant 5 56
Total 9 10 10 10 100 9 4+5 4 44% 5 50% 3 30% 10 100% 7 78%
a b c d e Count % Count % Count % Count % Count %
Poor 1 0 0 0 0 0 0 Not
essential 0 0 Not
relevant 0 0 Site 2 0 0 2 13 2 12 0 0 0 0
Manager 3 5 31 8 53 11 65 1 6 2 12 4 8 50 3 20 3 18 8 47 2 12
Good 5 3 19 2 13 1 6 Essential 8 47 Relevant 13 76 Total 16 15 17 17 17 4+5 11 69% 5 33% 4 24% 16 94% 15 88%
a b c d e Count % Count % Count % Count % Count %
Poor 1 0 0 1 6 1 5 Not
essential 0 0 Not
relevant 1 6 2 0 0 2 11 1 5 0 0 0 0
Front Line 3 4 21 7 39 7 37 1 6 0 0 Manager 4 10 53 7 39 8 42 5 28 1 6
Good 5 5 26 1 6 2 11 Essential 12 67 Relevant 16 89 Total 19 18 19 18 18 4+5 15 79% 8 44% 10 53% 17 94% 17 94%
100
a b c d e Count % Count % Count % Count % Count %
H&S Poor 1 0 0 1 9 0 0
Not essential 0 0
Not relevant 0 0
2 1 8 2 18 3 25 0 0 0 0 Manager 3 4 33 4 36 5 42 2 17 1 8
4 5 42 3 27 3 25 5 42 3 25 Good 5 2 17 1 9 1 8 Essential 5 42 Relevant 8 67
Total 12 11 12 12 12 4+5 7 58% 4 36% 4 33% 10 83% 11 92%
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Table 26 Making decisions about applying HF/E - by sector (Q7)
Sector Advice Guidance Events Count % Count % Count %
Strongly agree 1 6 43 7 50 5 36 2 4 29 4 29 5 36 3 0 0 0 0 0 0
Chemicals 4 2 14 0 0 2 14 Strongly disagree 5 2 14 3 21 2 14 Not part of my job 0 0 0 0 0 0 0
Total 14 14 14 1+2 10 71% 11 79% 10 71%
Advice Guidance Events Count % Count % Count %
Strongly agree 1 8 42 5 26 9 47 2 9 47 12 63 6 32 3 1 5 0 0 2 11
Oil and gas onshore 4 0 0 2 11 1 5 Strongly disagree 5 0 0 0 0 0 0 Not part of my job 0 1 5 0 0 1 5
Total 19 19 19 1+2 17 89% 17 89% 15 79%
Advice Guidance Events Count % Count % Count %
Offshore oil and gas Strongly agree 1 5 38 6 46 4 31 2 7 54 3 23 6 46 3 0 0 2 15 1 8 4 0 0 1 8 2 15
Strongly disagree 5 1 8 0 0 0 0
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Not part of my job 0 0 0 1 8 0 0 Total 13 13 13 1+2 12 92% 9 69% 10 77%
Advice Guidance Events Count % Count % Count %
Nuclear
Strongly agree 1 7 58 5 42 8 67 2 5 42 4 33 1 8 3 0 0 0 0 0 0 4 0 0 2 17 2 17
Strongly disagree 5 0 0 1 8 0 0 Not part of my job 0 0 0 0 0 1 8
Total 12 12 12 1+2 12 100% 9 75% 9 75%
Advice Guidance Events Count % Count % Count %
Strongly agree 26 45% 23 40% 26 45% 25 43% 23 40% 18 31% 1 2% 2 3% 3 5%
All 2 3% 5 9% 7 12% Strongly disagree 3 5% 4 7% 2 3% Not part of my job 1 2% 1 2% 2 3%
Total 58 58 58 1+2 51 88% 46 79% 44 76%
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Table 27 Making decisions about applying HF/E - by job type (Q7)
Advice Guidance Events Count % Count % Count %
Senior Manager
Strongly agree 1 3 30 5 50 5 50 2 4 40 2 20 2 20 3 1 10 1 10 1 10 4 0 0 1 10 1 10
Strongly disagree 5 2 20 1 10 1 10 Not part of my job 0 0 0 0 0 0 0 Total 10 10 10
1+2 7 70% 7 70% 7 70% Advice Guidance Events Count % Count % Count %
Strongly agree 1 10 59 6 35 7 41 2 6 35 8 47 5 29 3 0 0 0 0 2 12
Site Manager 4 0 0 1 6 0 0
Strongly disagree 5 1 6 2 12 1 6 Not part of my job 0 0 0 0 0 2 12 Total 17 17 17
1+2 16 94% 14 82% 12 71% Advice Guidance Events Count % Count % Count %
Front Line Manager Strongly agree 1 9 47 7 37 8 42 2 8 42 9 47 6 32 3 0 0 0 0 0 0 4 2 11 2 11 5 26
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Strongly disagree 5 0 0 1 5 0 0 Not part of my job 0 0 0 0 0 0 0 Total 19 19 19
1+2 17 89% 16 84% 14 74% Advice Guidance Events Count % Count % Count %
H&S Manager
Strongly agree 1 4 33 5 42 6 50 2 7 58 4 33 5 42 3 0 0 1 8 0 0 4 0 0 1 8 1 8
Strongly disagree 5 0 0 0 0 0 0 Not part of my job 0 1 8 1 8 0 0 Total 12 12 12
1+2 11 92% 9 75% 11 92%
105
10 APPENDIX III – stakeholder interview proforma
INTERVIEW PROFORMA – HUMAN FACTORS DECISION MAKING IN PROCESS SAFETY
Introduction
This work has been commissioned by Health and Safety Executive (HSE) and is being carried out by a strategic risk management consultancy Greenstreet Berman (GSB) (http://www.greenstreet.co.uk/). It concerns Key Decision Making and Human Factors (HF) in high hazard industries.
Your name was recommended either by HSE or because GSB believe you are well placed to speak authoritatively on this topic - on behalf of your industry. This note provides you with some background to the project. It also includes the questions, which you may wish to review, prior to the interview and contact details.
Background to the project
The research is intended to assist HSE with its aims of reducing accidents by improving the management of Process Safety. This involves talking to key decision makers to understand how they take account of issues concerning: human performance; behaviours and human error.
To help us to do this we want to ensure we are talking to the right people. A key part of this research is, therefore, to identify and profile key decision makers.
What is Human Factors (HF)
Human Factors (HF) are environmental, organisational and job factors as well as human and individual characteristics which influence behaviour at work and can affect health and safety. Human Factors covers many issues, ranging from: interface design, supervision, competence, staffing levels to the overall culture of the organisation.
Confidentiality & INTERVIEW DETAILS
Specific comments that you make during the interview will remain confidential. In some instances we may wish to quote something you have said but we will seek your permission first and discuss whether you would like to be acknowledged or remain anonymous. The interview will be conducted over the telephone and take approximately 45 minutes to complete. You do not need to write anything down; we will make notes during the interview - which we can provide a copy of, if you require.
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What we want to know
For this phase of the work we are particularly interested in trying to develop a profile of key decision makers. This will help us select the right people when we conduct the main part of the research – which involves 60 interviews. We therefore want your opinion on who are making the important decisions to control human error, improve performance and reduce unsafe behaviours. At the end of the interview it would also be helpful if you could provide any industry contacts to participate in the main interviews and workshops.
CONTACTS
HSE: Peter Mullins: [email protected] 0151 951 3955
GSB: David Pennie: [email protected] 0207 874 1576
1. Background information on the interviewee
Contact Person
Company name
Address
Job title
Position
Contact telephone Office:
Mobile:
2. “Who do you think makes the key decisions that take account of and seek to influence human performance (reducing errors and controlling unsafe behaviour)?
It is important to explore different candidates with the interviewee Prompt: “what about: Group directors/CEO, senior managers, heads of department, individual plant managers, supervisors, site operatives”.
It maybe easier for the interviewee to think in terms of the department where the key decision maker
107
resides, Prompt: “within which departments are decisions made about issues that impact on error and unsafe behaviour: Engineering, human resources, H&S Assurance, maintenance; Training; Operations, Planning Finance”.
What are the different types of issues that these decision makers deal with?
Prompt: what about? (Engineering dep.) Plant modifications, equipment procurement, (Human resources) – Counselling, employee relations etc (H&S/Assurance) – safety culture, behavioural modification etc (Maintenance dep.) – hand over, task design etc (Training dep.) – assessing competence, job analysis etc (Operations dep.) – workloads, shift system, procedures (Planning dep.) – incident analysis. (Finance dep.) Cost/benefit analysis (Other dep.)
How do these decision makers improve performance, prevent error and control unsafe behaviours?
Process - (HF good practice guidelines are integrated at the start of a programme of work; HF is considered when prompted by strategy documents or legislation; HF is considered when an unforeseen problem is encountered; HF is rarely considered).
Methods - What different methods, if any, might be used: Please note these may not just be involvement or analysis methods but could also include engineered safe guards. Prompt: “What about: RA, HAZOPs Standards BSI/ISO, interlocks, Optioneering, TA, or are no recognised formalised methods used”.
108
3. HSE lists topics (http://www.hse.gov.uk/humanfactors/majorhazard/index.htm) where HF can help improve Process Safety by reducing error and unsafe behaviours. Is it possible to say who has responsibility for making decisions about these topics and how these decisions occur?
Topic – Decision area Where does the decision occur (at what level within the organisation)? Group directors/CEO, senior managers, heads of department, individual plant managers, supervisors, site operatives)
And/or within which Department? Engineering, Human resources, H&S, Maintenance, Training Operations, Planning, Assurance Finance Other, extra departmental)
Do formal decisions take place and, if so, can you briefly say how these might occur (for example: corporate policy, strategic/operational Long term/short term. In isolation or group decision made collaboratively across departments. Resources – HF. Information consulted. Monetary constraints. No formal decision making as such.
How is HF incorporated into tackling these topics (What Methods/strategies are used?) (RA, HAZOPs Standards BSI/ISO, interlocks, Optioneering, TA, No formalised method)
Alarm handling; Optimizing alarm system design to facilitate accurate and timely fault prompting and diagnosis to operators. Interfaces; Human-system interactions, screens, controls etc Safety critical communications; Spoken and written communication between team members or department e.g. shift handover Supervision; Monitoring performance and compliance, providing leadership & facilitating communication
109
3. HSE lists topics (http://www.hse.gov.uk/humanfactors/majorhazard/index.htm) where HF can help improve Process Safety by reducing error and unsafe behaviours. Is it possible to say who has responsibility for making decisions about these topics and how these decisions occur?
Topic – Decision area Where does the decision occur (at what level within the organisation)? Group directors/CEO, senior managers, heads of department, individual plant managers, supervisors, site operatives)
And/or within which Department? Engineering, Human resources, H&S, Maintenance, Training Operations, Planning, Assurance Finance Other, extra departmental)
Do formal decisions take place and, if so, can you briefly say how these might occur (for example: corporate policy, strategic/operational Long term/short term. In isolation or group decision made collaboratively across departments. Resources – HF. Information consulted. Monetary constraints. No formal decision making as such.
How is HF incorporated into tackling these topics (What Methods/strategies are used?) (RA, HAZOPs Standards BSI/ISO, interlocks, Optioneering, TA, No formalised method)
Behavioural safety; Analyzing and defining safe and unsafe behaviours through workshops and observations and then providing feedback/advice to reinforce safe behaviours. Procedures; Step-by-step instructions and related information needed to help carry out tasks safely. They may include checklists, decision aids, diagrams, flowcharts and other types of job aids. Training & Competence Ensuring activities are performed to a recognised standard on a regular basis.
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3. HSE lists topics (http://www.hse.gov.uk/humanfactors/majorhazard/index.htm) where HF can help improve Process Safety by reducing error and unsafe behaviours. Is it possible to say who has responsibility for making decisions about these topics and how these decisions occur?
Topic – Decision area Where does the decision occur (at what level within the organisation)? Group directors/CEO, senior managers, heads of department, individual plant managers, supervisors, site operatives)
And/or within which Department? Engineering, Human resources, H&S, Maintenance, Training Operations, Planning, Assurance Finance Other, extra departmental)
Do formal decisions take place and, if so, can you briefly say how these might occur (for example: corporate policy, strategic/operational Long term/short term. In isolation or group decision made collaboratively across departments. Resources – HF. Information consulted. Monetary constraints. No formal decision making as such.
How is HF incorporated into tackling these topics (What Methods/strategies are used?) (RA, HAZOPs Standards BSI/ISO, interlocks, Optioneering, TA, No formalised method)
Organisational change; Changing staff numbers, combining departments, or changing roles & responsibilities Staffing levels and workload; Having the right numbers of the right people, in the right place at the right time. Managing human failures; Aiming to optimise human performance and reduce human failures.
Fatigue from shift work and overtime; Issues that arise from excessive working time or poorly designed shift patterns.
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3. HSE lists topics (http://www.hse.gov.uk/humanfactors/majorhazard/index.htm) where HF can help improve Process Safety by reducing error and unsafe behaviours. Is it possible to say who has responsibility for making decisions about these topics and how these decisions occur?
Topic – Decision area Where does the decision occur (at what level within the organisation)? Group directors/CEO, senior managers, heads of department, individual plant managers, supervisors, site operatives)
And/or within which Department? Engineering, Human resources, H&S, Maintenance, Training Operations, Planning, Assurance Finance Other, extra departmental)
Do formal decisions take place and, if so, can you briefly say how these might occur (for example: corporate policy, strategic/operational Long term/short term. In isolation or group decision made collaboratively across departments. Resources – HF. Information consulted. Monetary constraints. No formal decision making as such.
How is HF incorporated into tackling these topics (What Methods/strategies are used?) (RA, HAZOPs Standards BSI/ISO, interlocks, Optioneering, TA, No formalised method)
Organisational culture; Influence human behaviour and human performance at work Integration of HF into RA/investigation Investigations should consider why human failures occurred. Finding the underlying causes. Design The design of control rooms, plant and equipment – these can have a large impact on human performance Other
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11 APPENDIX IV –KDM INTERVIEW PROFORMA
1 INTERVIEW PROFORMA – PROCESS SAFETY DECISION MAKING
Introduction
This interview concerns Process Safety decision making in the high hazard industries, particularly where Process Safety is influenced by the actions and behaviour of people. It has been commissioned by Health and Safety Executive (HSE) and is being carried out by Greenstreet Berman (GSB) (http://www.greenstreet.co.uk/).
Your name was recommended either by HSE or because GSB believe you are someone whose decisions might influence Process Safety.
This note provides you with some background to the project. It also includes the questions, which you may wish to review, prior to the interview and contact details.
Background to the project
The research is intended to assist HSE with its aims of reducing accidents by improving the management of Process Safety. This involves talking to people in high hazard industries to understand how Process Safety decision making may be further supported.
Confidentiality & INTERVIEW DETAILS
We offer assurance that any comments that you make during the interview will remain confidential. In some instances we may wish to quote something you have said but we will seek your permission first and discuss whether you would like to be acknowledged or remain anonymous. The interview will be conducted over the telephone and take approximately 30-60 minutes to complete. You do not need to write anything down; we will make notes during the interview - which we can provide a copy of, if you require. You may however find it helpful to have a pencil/pen and paper handy to jot anything down you might want to remember at a later point in the interview.
What we want to know
For this phase of the work we are particularly interested in understanding how you go about making decisions that could influence Process Safety and what influences aspects of this decision process. We also want to explore how and where you have developed your knowledge about Process Safety and major accident prevention, and to explore how people like you can be further supported.
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CONTACTS
To find out more about this research please feel free to contact:
• HSE: Peter Mullins, [email protected], 0151 951 3955 • GSB: David Pennie, [email protected], 020 7874 1576
Background information on the interviewee
Sector
Contact person’s name
Company name
Size of Company (L or SME)
Position
NOTE TO INTERVIEWER: complete after interview on basis of job title
Senior Manager
H&S manager/safety case manager
Site manager/installation manager
Operations/production/engineering/maintenance manager
Job title
Contact telephone Office:
Mobile:
Other information
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Question 1
Please think of a recent example of where you have been personally involved in a decision, or development activity or assessment process that directly or indirectly influenced Process Safety. For example, a review of staffing levels on a site, introduction of a new control room, re-design of a control panel, development of operator training standards, revision of a permit to work system and so on.
We would like you to talk through the process you went through.
Interviewer’s prompts:
1. What was the issue?
2. How did it relate to Process Safety?
3. What were the key considerations and factors that needed to be taken into account?
4. What were the main potential causes of Process Safety risks?
5. How did you go about identifying the Process Safety implications of the issues under review? Did you (or your colleagues) apply any specific safety analysis techniques, standards or requirements?
6. What were the steps that you went through to reach the decision/complete the assessment/development process? Why was this approach adopted?
7. Who was involved in this review/decision process? [If not mentioned] How about workers?
8. In what way was human error and human performance a consideration or risk? Why did you think this?
9. How did you go about assessing the possibility of error? Why did you assess it in this way? Were you or are you now aware of any other way of assessing human error? (if applicable) Where did you hear about that?
10. What sort of risk controls did you consider for prevention or management of human error? Why did you consider those options? Are you aware of any other ways of preventing human error? (if applicable) Where did you hear about them?
11. What risk controls did you agree on for preventing human error and improving human performance, and why?
12. What prompted you to consider managing human error and human performance in this way?
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13. What might have prompted you to consider the possibility of human error to a greater extent, or to adopt a different approach to assessing human error and how to best manage human performance?
Question 2
Please think of a good example of where you have learnt about Process Safety and ways of improving Process Safety, something that you found useful.
a) Please explain where you received information from.
Interviewer prompts if needed:
Internal company training, website, conference, CPD (continuing professional development) from an institute, university, on job learning, conferences, major accident reports etc
b) What was it about this ‘information’ that was useful and influential/compelling? Why was it useful?
Interviewer prompts if needed:
Relevance to their job, sector specific, novel, addressed a current issue, based on case studies, authoritative etc
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Question 3
a) Can you recall any examples of where you have applied particular approaches, principles or techniques to assess error, manage human performance or influence behaviour
Interviewer prompts if needed: Hearts & minds, Step Change, Workload analysis, Task Analysis, Gap analysis, Training Needs Analysis (TNA), Job safety analysis, Behavioural safety, Workplace mapping, Root cause, Error analysis (SHERPA, HEART, HRA), competence standards, supervisory systems, ergonomics etc
b) Please describe what prompted this
Interviewer prompts if needed: – an accident, HSE enforcement, safety case requirement, company standard etc
c) What, in your opinion, would prompt or help you to apply other approaches to the prevention and management of human error and unsafe behaviour and human performance– in relation to Process Safety?
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Question 4
There are a number of possible options for improving the application of knowledge, techniques and principles for the prevention of error and unsafe behaviour, and improvement of human performance. I am going to ask you to rate some of these and then ask you a question about each. You may find it helpful to write the rating scale down on a piece of paper – the scale runs from 1 to 5 where 1 is not very effective and 5 is very effective.
(a) HSE to better explain the concept of Human Factors and provide a clearer definition of what it is.
Rating
What points about the concept of Human Factors do you think should be conveyed by a clearer definition?
(b) HSE to increase enforcement of Human Factors as part of safety case and related inspection processes.
Rating
Please discuss the strengths and weaknesses of this option?
(c) Rather than present and promote Human Factors as separate ‘discipline’ in its own right, HSE to build Human Factors knowledge, techniques and requirements IMPLICITLY into standards (e.g. engineering standards, safety case requirements, best practice approaches to training etc, without attempting to define this as Human Factors).
Rating
Please discuss the strengths and weaknesses of this option?
(d) Improve knowledge of Human Factors amongst people like you through the provision of training and professional development programmes, such as part of the Continuing Professional Development offered by professional institutes.
Rating
Please discuss the strengths and weaknesses of this option?
(e) HSE to develop a communications campaign to raise awareness and understanding of Human Factors (for example: conveying the same message through joint conferences, publications, articles on websites and in journals).
Rating
Please discuss the strengths and weaknesses of this option?
(f) A programme of activity led by industry associations and professional institutes, with HSE support (for example: production of guidance, agreement of best practice, identification of top Human Factor priorities, % of companies with Human Factors champion within the company, or with access to specialist Human Factors advice).
Rating
Please discuss the strengths and weaknesses of this option?
(g) The provision of more branded initiatives, such as Step Change or Hearts and Minds, which include a range of industry specific activities and programmes aimed at reducing error and unsafe behaviour (which are based on Human Factors principles but branded and presented as an industry specific initiative rather than as a Human Factors initiative).
Rating
Please discuss the strengths and weaknesses of this option?
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Question 5
What do you think is the most effective thing that the HSE could do to achieve greater consideration of human error and how to prevent it, with respect to Process Safety?
Question 6 – Attitudes towards Human Factors (HF)
I am going to ask you to rate some statements in terms of how much you agree. You may find it helpful to write the scales down for each question. The first three will be rated from 1 to 5 with 1 as poor and 5 as good.
a) How would you rate your awareness of Human Factors? Rating
b) How would you rate your awareness of Ergonomics? Rating
c) How would you rate your understanding of Human Factors? Rating
The next question will be rated from 1 to 5 with 1 as not essential and 5 essential.
d) How would you rate the importance which you place on Human Factors for your business?
Rating
The last question of this section will be rated from 1 to 5 with 1 as not relevant and 5 relevant.
e) How would you rate the relevance of Human Factors to major accident prevention?
Rating
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Question 7 - Applying Human Factors
I am going to ask you to rate three statements in terms of how much you agree. You may find it helpful to write the rating scale down on a piece of paper – the scale includes ‘strongly disagree’, ‘disagree’, ‘neither’, ‘agree’, ‘strongly agree’ and ‘not part of my job’.
When I have read out each statement, please tell me which of these responses is closest to your response.
Strongly disagree
Disagree Neither Agree Strongly Agree
Not part of my job
a) I seek advice from others when making decisions about preventing error and improving human performance.
b) I have used guidance on Human Factors when considering Process Safety.
c) Past events or incidents have prompted me into finding out more about Human Factors or applying a Human Factors approach.
Question 8
Do you have any other suggestions or comments on how best to promote greater consideration of human error and how to prevent it and improve human performance, with respect to Process Safety?
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12 APPENDIX V – FINDINGS FROM DESKTOP REVIEW OF MAJOR ACCIDENTS
The published reviews of the accidents provided only limited information on HF decision makers in the high hazard industries. Accident reports tended to focus more on general lessons learnt, process safety and the overall quality of the safety management system rather than identifying key decision makers.
The public report of the fire and explosion at the Conoco Phillips Humber refinery on 16 April 2001 sites a number of safety management issues that contributed to the explosion (failure to implement a Management of Change procedure or apply adequate inspection routines). The report, however, does not state who was responsible for these failures.
The HSE investigation into the incident at the Thorp reprocessing plant (2005) identified the direct cause as a failure to ensure that leak detection equipment was in working order, and a failure to follow key operating instructions. These failures, however, were a product of broader organizational issues concerning inadequate monitoring arrangements and management oversight. The HSE report makes recommendations to improve the auditable trail of decision making process associated with complex systems but does not identify key decision makers per se.
The ICL/Stockline explosion (2004) was a result, according to workers of seriously deficient safety standards where they were actively discouraged from raising concerns. Working conditions were “primitive” with management driven by cost-minimisation and reluctance to respond to employee concerns. In 2007 the companies involved were fined £400,000 but no individuals were prosecuted.
The explosion at the Philips Petroleum Houston site (2000) was, according to OSHA6, a consequence of a failure to train workers properly and alleged serious violations of safety standards at the facility. OSHA stated there was a need to reassess worker safety and health in all areas of the plant, improve training and a commitment from plant and corporate management to make safety an ongoing high priority. OSHA proposed a $2.5 million in penalties but did not identify individual responsibility. This was not a one of incident: “Unfortunately, this tragedy is not an isolated incident, but one in a series of incidents at this site, Three workers lost their lives in explosions at this plant in less than a year's time, and 23 others were killed in a major explosion in 1989” - Labor Secretary Alexis M. Herman.
6 U.S. Department of Labor Occupational Safety & Health Administration (OSHA)
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Consideration of other incidents (listed above) does, however, provide some insight into key decision making by providing indication of culpability. For example the company responsible for the 1999 Tokairmura Criticality incident conceded that it violated both normal safety standards and legal requirements. There was a poor safety culture where workers routinely took dangerous shortcuts and violated rules with the knowledge of plant managers. Workers with insufficient expertise were also carrying out tasks with incorrect equipment and under time pressure. Following the event six executives who admitted negligence in the 1999 incident received suspended prison terms. The former head of the plant, received a five-year prison term suspended for three years. This would tend to indicate that the accident was due to the failure of senior management to make decisions to address the serious inadequacies in the plants overall safety management.
A report by the IAEA into the incident at the Paks nuclear plant in Hungary (2003) indicated that a possible contributing factor was the shifting of responsibility for operation of the fuel cleaning system to the contractor. The investigation by the HSE’s Human Factors team into the Grangemouth incident (2000) also found decentralised management and a resulting difference in system, style and culture across the Complex. This had also inhibited development of a strong, consistent overall strategy for major accident prevention and a barrier to cross-site communication and shared learning. The team stated the different business streams operating at the complex provided a compelling explanation of why the incidents occurred.
The Baker report into the Texas City Oil refinery (2005) fire also identified a problem with delegated safety responsibility: “…its decentralized management system and entrepreneurial culture have delegated substantial discretion to U.S. refinery plant managers without clearly defining process safety expectations, responsibilities, or accountabilities.”
The Baker report also provides some useful information about the hierarchy of decision making and accountability for process safety performance. At BP refineries authority was viewed as a line running from:
• The Group Chief Executive;
• The Chief Executive, Refining and Marketing;
• The Group Vice-President, Refining - the most senior manager of the refining business;
• The Refining Vice President—North America;
• The individual refinery plant managers;
• Operating personnel at the refineries.
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The Baker report goes on to state: “Three people appear to make some of the most important and strategic decisions regarding refineries: the Chief Executive, Refining and Marketing; the Group Vice-President for Refining; and the Refining Vice President—North America. These individuals collectively, however, have line responsibility for monitoring all aspects of performance in the refineries, including financial, budgetary, environmental, and otherwise. Because process safety objectives may potentially conflict, particularly in the short-term, with other objectives such as production, meeting budgets, cost cutting, and scheduling, those making decisions relating to the refining business must necessarily weigh all of these considerations to the possible detriment of process safety.”
This offers the insight that even though very senior personnel are involved in decision making regarding safety (and by extension HF), decisions may be conflicted because of other responsibilities.
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Published by the Health and Safety Executive 11/09
Executive Health and Safety
Repositioning human factorsIdentifying barriers to understanding human factors in prevention of major accidents among key decision makers and managers in the industries concerned
This report, and the work it describes, explores how HSE might reposition Human Factors/Ergonomics (HF/E) so it is more central to the thinking of Key Decision Makers (KDMs); within high hazard industries belonging to the Oil and Gas, Chemical and Nuclear sector. The findings suggest that although knowledge and understanding of HF/E is penetrating through there is recognition by KDMs that they need to do more.
Possible options to help improve the application of knowledge and techniques in the prevention of error and unsafe behaviour include:
n improve knowledge and understanding of HF/E, primarily through training;
n develop and promote tools and guidance to help enhance this knowledge and assist in the practical application of this knowledge to the prevention of major accidents; and
n facilitate peer review to critique safety management system and processes and to demonstrate how particular HF/E techniques can be applied.
Improving knowledge; developing tools and guidance and facilitating peer review could be delivered in co-operation with industry associations and professional institutes. The eventual aim should be to better integrate HF/E into day-to-day management.
This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.
RR758
www.hse.gov.uk