1StepChangeinSafetyHumanFactorsSteveMurphyTAQAHSEStepChangeHumanFactorsco-chairApril23,20182HumanFactorsDefiningthe‘issue’April23,2018WhatareHumanandOrganisationalFactors-HSEApril23,20183WhatareHumanandOrganisationalFactors–EnergyInstituteApril23,20184HFreferstoallofthosethingsthatcouldaffecthumanperformanceinatask.Thewordergonomicsisusedtodescribebroadlythesamesubject.“…environmental,organisationalandjobfactors,andhumanandindividualcharacteristicswhichinfluencebehaviouratwork.Carefulconsiderationofhumanfactorscanimprovehealthandsafetybyreducingthenumberofaccidentsandcasesofill-healthatwork.”WhatareHumanandOrganisationalFactors–StepChangeApril23,20185HFrefers“…environmental,organisationalandjobfactors,andhumanandindividualcharacteristicswhichinfluencebehaviouratworkinawaywhichcanaffecthealthandsafety.”Humanfactorscoversahugerangeoftopicswhichcanbegroupedunderthreekeyheadings:ButWhatareHumanandOrganisationalFactorsreally?April23,20186TheEIidentifies19topics:1.Alarmhandling2.Organisationalchange3.Maintenance4.Fatigue5.Safetycriticalprocedures6.Trainingandcompetence7.Ergonomics8.Safetyculture9.Communications10.Taskanalysis11.Humanerrorandnon-compliance12.Humanreliabilityanalysis13.Behaviouralsafety14.Incidentandaccidentanalysis15.Humanfactorsintegration16.Performanceindicators17.Leadership18.Pressureandstress19.Occupationalsafetyvs.processsafetyTheHSEidentify20topics:1.Humanfactorsinriskassessment2.Incidentinvestigation3.Procedures4.Trainingandcompetence5.Staffinglevels6.Workload7.Supervision8.Contractors9.Organisationalchange10.Shifthandovers11.PTW12.Controlrooms13.Humancomputerinterfaces14.Alarmmanagement15.Lighting,comfort,noiseandvibration16.Fatigueandshiftwork17.Behaviouralsafety18.Learningorganisations19.Maintenanceerror20.IntelligentcustomersStepChangeidentify15topics:1.Humanfactorsindesign2.Procedures3.Riskassessmentandincidentinvestigation4.Safetycriticalcommunications5.Organisationalchange6.Staffinglevelsandworkload7.Contractorinterfaces8.Learningorganisations9.Leadership10.Maintenanceinspectionandtesting11.Supervision12.Fatigue13.Managinghumanfailures14.Trainingandcompetence15.BehaviouralsafetyHumanandOrganisationalFactorsinRealLife–PiperAlphaApril23,20187July6th1988Hydrocarbongaspumpedintocondensatepumpwhichwasundermaintenanceandblankedoffwithnosafetyvalve,highpressuregasleakwhichthenignited167dead61survivorsPersonnelwhohadtheauthoritytoorderevacuationhadbeenkilledwhenthefirstexplosiondestroyedthecontrolroom.Nearbyconnectedplatformscontinuedtopumpgasandoiluntilthepipelinesrupturedintheheatinthesecondexplosion.Theiroperationscrewsdidnotbelievetheyhadauthoritytoshutoffproduction.HumanandOrganisationalFactorsinRealLife–LongfordGasPlantApril23,20188September25th1998Hydrocarbonvapourcloudexplodedafteraruptureinaheatexchangercausedbypumpinghotfuelintoacoldvessel.2dead8injuredApproximately10metrictonnesofhydrocarbonvapourventedfromtherupture.Avapourcloudformedanddrifteddownwind.Whenitreachedasetofheaters170metresaway,itignited.Thiscausedadeflagration(aburningvapourcloud).Theflamefrontburntitswaythroughthevapourcloud,withoutcausinganexplosion.HumanandOrganisationalFactorsinRealLife–TexasCityApril23,20189March23rd2005HydrocarbonvapourcloudexplodedaftertheoverfillingandoverheatingofRaffinateSplitterTower15dead170injuredAthirdpartysiteinspectionreportinJanuary2005foundnumeroussafetyissues,including"brokenalarms,thinnedpipe,chunksofconcretefalling,boltsdropping60ft.andstaffbeingovercomewithfumes."Thereport'sco-authorstated,“Wehaveneverseenasitewherethenotion'Icoulddietoday'wassoreal.”10Thehumancontribution‘Ratherthanbeingthemaininstigatorsofanaccident,operatorstendtobetheinheritorsofsystemdefectscreatedbypoordesign,incorrectinstallation,faultymaintenanceandbadmanagementdecisions.Theirpartisusuallythatofaddingthefinalgarnishtoalethalbrewwhoseingredientshavealreadybeenlonginthecooking’Reason1990April23,2018HumanFactorsToolkitStepChangeinSafetyHumanFactorsApril23,20181112AccessingtheHumanFactorsquestionnaireApril23,201813QuestionnairecoverpageApril23,201814Assessmenttype-PeopleApril23,2018Whathappenswiththeassessmentresults?April23,201815Wheretostart?“Humanbeings,whoarealmostuniqueinhavingtheabilitytolearnfromtheexperienceofothers,arealsoremarkablefortheirapparentdisinclinationtodoso.”DouglasAdamsIncidentInvestigationsApril23,20181617Whatnext?•Alltheassessmentcategorieshaveextraguidance/reading•StepChangeareworkingonmoretargetedguidanceoncewehavefinishedtheanalysis•Websites:▪https://www.energyinst.org/technical/human-and-organisational-factors▪http://www.hse.gov.uk/humanfactors/▪https://www.stepchangeinsafety.net/safety-resources/human-factorsApril23,201818Whatnext?•Reading:▪‘TheFieldGuidetoUnderstandingHumanError’SidneyDekker▪‘HumanFactorsandBehaviouralSafety’JeremyStranks▪‘HumanFactors,howtotakethefirststeps’StepChangeinSafetyApril23,2018
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