Competence?
Robert Miles: Human & Organisational Factors
Offshore Safety Division, Health and Safety Executive
rob.miles@hse.gsi.gov.uk
The UK offshore safety in regime is a
permissioning regime:
• The duty holder (usually the operator) sets out all
of the hazards, and all of the means by which
these are controlled, in a Safety Case.
• The HSE assesses that case and accepts it once
it is satisfied that the measures described are
sufficient for safe operation.
• The duty holder (operator) must then operate the
installation (or rig) in the same manner as
described to HSE in the Safety Case.
• For HSE integrity is “doing what you told
us you would” and through that staying
safe.
For HSE integrity is “doing what you told us you would”.
In a safety case operators usually tell us that they:
• Only employ staff competent for the job.
• Allow enough time for planning and completing
the job safely.
• Conduct adequate risk assessment.
• Provide all necessary training.
• Manage contractors to the same standards as
their own operations.
• Have up to date procedures for every hazardous
task.
• Maintain equipment to a safe standard.
• Audit and review their performance.
• Comply with the Regulations.
..but…..
• When we investigate accidents and
incidents or carry out inspections we
usually find one or more of these things
has not been happening.
• The reasons why often relate to the way
people throughout the organisation value
(or not) safety and integrity and how they
learn.
• Safety is everyone’s responsibility, it is
shared between workers, managers and
owners.
Safety
Business
risk
Psychosocial
risk
Accidents
& injuries
Losses &
bankruptcy
Sickness &
Resignations
Accidents
& injuries
Losses &
bankruptcy
“I don’t know how
to do my job”
Sickness &
Resignations
Explosion & fires at BP Texas
City refinery, March 23, 2005
BP Texas City, 23 March 2005
• “Failure to follow the startup procedure
contributed to the loss of process control.
Key individuals (management and
operators) displayed lack of applied skills
and knowledge and there was a lack of
supervisory presence and oversight during
this startup.”
Raffinate tower overfilled for 3
hours:
Training and competence issues
• Move to computer-based training without
effective verification (“a business decision driven
by cost”)
• 1998 to 2004: training staff reduced from 28 to 8
and budget halved
• 2002 -2005: audits and reviews identified ongoing deficiencies in operator competency …
• … yet managers relied more on operating
personnel and less on engineering controls to
prevent accidents
• No effective training for abnormal situation
Esso Longford, Sept. 1998
Esso Longford, Sept. 1998
• “Those who were operating GP1 on 25 Sept
1998 did not have knowledge of the dangers
associated with loss of lean oil flow and did
not take steps necessary to avert those
dangers.
• Nor did those charged with supervision of
the operations have the necessary
knowledge, and the steps taken by them
were inappropriate”
Leading indicators?
•
•
•
•
•
•
•
•
Predictive of accidents
Gas detection vs fire alarm
inspection
attendance at training?
near miss reports acted upon
un- actioned defect reports (-ve)
% competent staff
need to be things that we can change: not
independent
• We inspect leading indicators!
Enough competent crew
Reliable usable equipment
A well organised work place
An effective shift system
A weakness any element can emerge as a problem everywhere
Published Guidance
• Developing and maintaining staff
competence (Railway Safety
Publication 1), Second edition
2007, Office of Rail Regulation
(ORR), ISBN 07176 1732 7
• Competence assessment for the
hazardous industries. HSE research
report RR086/2003
Competence management system
These are corporate
policy decisions
How to stay alive...
A Bow-Tie approach
RR637 – Optimising Hazard Management
by Workforce Engagement and Supervision
Specify human element in this barrier
(i.e. operator competence or
maintenance competence
Do this for all the safety barriers
Specify the human element in this barrier
(i.e. operator competence or
maintenance competence
Do this for all the safety barriers
Specify the human element in this barrier
(i.e. operator competence or
maintenance competence
Post A
Post B
Aggregate these into posts
Post A
Barrier 1
Barrier 2
Post B
Barrier 3
Barrier 4
Barrier 5
Skill 1
Skill 2
Skill 3
Skill 1
Skill 3
Skill 4
Skill 4
Skill 1
Skill 2
Skill 1
Skill 2
Skill 3
x
x
x
x
x
x
x
x
x
x
x
x
Post A
Post B
Barrier 1
Barrier 1
Barrier 1
Barrier 2
Barrier 2
Barrier 2
Barrier 3
Barrier 4
Barrier 4
Barrier 5
Barrier 5
Barrier 5
Skill 1
Skill 2
Skill 3
Skill 1
Skill 3
Skill 4
Skill 4
Skill 1
Skill 2
Skill 1
Skill 2
Skill 3
x
x
x
x
x
x
x
x
x
x
x
x
Post A
Barrier 1
Barrier 2
Post B
Barrier 3
Barrier 4
Barrier 5
Skill 1
Skill 2
Skill 3
Skill 1
Skill 3
Skill 4
Skill 4
Skill 1
Skill 2
Skill 1
Skill 2
Skill 3
x
x
x
x
x
x
x
x
x
x
x
x
A Regulatory perspective:
• HSE would serve a Prohibition Notice
for a failure to provide sufficient
competent staff to undertake a
hazardous activity safely.
• We would serve the PN on the activity
and set criteria for a resumption.
• We may choose to allow limited
operation to enable competence to be
improved by on-the-job training.
Leadership and management
• Texas city showed that there could be a lack
of competence in senior management.
• Regulators are now alert to this and
prepared to act
After Texas City BP trained
executives in how a refinery
• These failings could be:
works!
– in safety leadership, or
– technical ability – knowledge of the processes and
plant.
• An organisation needs competent specialists
• Competent investigations - how else do you
learn?
What do I understand by
“competence”?
• An individual attribute?
• A team attribute?
• A trait like personality, a “quality” or an
aptitude, or something anyone can
learn? Psychometric testing!
• How long does it last?
• Bought-in or developed in-house?
• Trained in a class or learned on the job?
*Manager: “Joe keeps having accidents”, HSE : “Well why do you keep employing him?”
How would I capture a
lack of competence?
•
•
•
•
•
•
When recruiting?
Before the job started?
During a job?
When appointing a contractor?
During the contract?
When a contractor’s employee arrives
offshore?
• What happens then?
The Real World..
• Most competence is bought in on contract.
• Managed through the supply chain.
• Competence assurance can become a
monster – 1 job – 340 pages of criteria.
• One large operator – system can not get
above 70% because it is too complex. Now
downgraded to an “advisory element” of the
SMS. Cost £Ms
The Real World …2
• People do forge certificates, so verify!
• Self assessments are very unreliable. The truly
incompetent lack insight
• Training centres who fail too many do not survive.
• Multi-choice is not understanding
• Beware of inclusiveness – (the dyslexia issue)
• Is Competence being used to personalise
organisational failings (i.e a lack of procedures)?
• Licensing – people and organisations. How often
does the I.Mech.E strike people off.
The Real World …2
• People do forge certificates, so verify!
• Self assessments are very unreliable. The truly
incompetent lack insight
• Training centres who fail too many do not survive.
The standing
of a profession is proportional
• Multi-choice
is not understanding
the number of members struck off.
• Beware oftoinclusiveness
AKA the “John West” approach
• Is Competence being used to personalise
organisational failings (i.e a lack of procedures)?
• Licensing – people and organisations. How often
does the I.Mech.E strike people off.