Risktec Solutions
risk management and assessment for business
Identifying The Human Element Of Risk
By
Paul Lawrence
18th October 2012
Risktec – Identifying the human element of risk, Rev. 1, Slide 1
© 2012
© 2012
Risktec
Risktec
Solutions
Solutions
Limited
Limit
Identifying The Human Element Of Risk
How do we identify, understand and
manage the risk from the human element
in a system?
We can be pro-active by using HF tools,
techniques and methodologies
Risktec – Identifying the human element of risk, Rev. 1, Slide 2
© 2012 Risktec Solutions Limited
Overview
What is Human Factors?
Tools, techniques and methodologies
Human Factors Integration (HFI)
Benefits of HF
How do humans contribute to risk?
Classifying human error and violations
Risktec – Identifying the human element of risk, Rev. 1, Slide 3
© 2012 Risktec Solutions Limited
So... What is Human Factors....
Risktec – Identifying the human element of risk, Rev. 1, Slide 4
© 2012 Risktec Solutions Limited
Human Factors Definition
‘Human Factors’ refer to environmental,
organisational and job factors, and
human and individual characteristics
which influence behaviour at work in a
way that can affect health and safety’.
(HS(G)48)
Risktec – Identifying the human element of risk, Rev. 1, Slide 5
© 2012 Risktec Solutions Limited
HF – A Simple Model
The INTERACTION between:
The Individual
The Job and
The Organisation
Individual
Job
Organisation
Ref: HSE in HSG48 “Reducing Error and Influencing Behaviour”
Risktec – Identifying the human element of risk, Rev. 1, Slide 6
© 2012 Risktec Solutions Limited
Aspects of Human Factors
INDIVIDUAL
• Attitudes and perceptions
• Skills and experience
• Physiological (e.g. gender, age)
• Cognitive (e.g. memory, attention)
• Personality and preferences
• External factors (e.g. domestic)
• Limitations in human capability
Risktec – Identifying the human element of risk, Rev. 1, Slide 7
© 2012 Risktec Solutions Limited
Human Limitations
We do some things better than machines or
computers but…
…some things are best left to the system
Our limitations need to be understood and
managed
Risktec – Identifying the human element of risk, Rev. 1, Slide 8
© 2012 Risktec Solutions Limited
Aspects of Human Factors
JOB
• Task and system design
• Work management (e.g. team
structure, task allocation,
operating philosophy)
• Workspace and interfaces
• Displays and controls
• Procedures and instructions
• Training and competency
• Working environment
Risktec – Identifying the human element of risk, Rev. 1, Slide 9
© 2012 Risktec Solutions Limited
Task and System Design
Human Factors Engineering or Human
Factors in Design typically includes:
–
–
–
–
System function and automation decisions
System operational philosophy
Task sequence and interaction
Workspaces and interfaces
Risktec – Identifying the human element of risk, Rev. 1, Slide 10
© 2012 Risktec Solutions Limited
Aspects of Human Factors
ORGANISATION
• Culture
• Team working
• Organisational goals
• Leadership and supervision
• Communications
• Safety management
• Management of change
Risktec – Identifying the human element of risk, Rev. 1, Slide 11
© 2012 Risktec Solutions Limited
Human Factors Integration
In order to effectively apply HF we use a management
technique known as HFI....
Human Factors by itself is a scientific and engineering discipline
Applying HF involves the use of many HF tools but HF
Integration is NOT a tool…HF Integration is:
“a systematic process for identifying, tracking and
resolving human related issues to ensure a balanced
development of both technologies and human aspects of
systems”
It is related to Project Management and Risk Management
Risktec – Identifying the human element of risk, Rev. 1, Slide 12
© 2012 Risktec Solutions Limited
HF Throughout the Lifecycle
Typical Project Lifecycle
Screening/
acquiring asset
Concept
evaluation
What will the system do?
Who is required to interface with it?
What does good performance of the
system look like?
What does that mean for the user?
What are the known HF issues with
each technology?
Level of automation decisions
HF pros/cons during “optioneering
Design, build
and modify
Operate and
maintain
Are there operational errors?
Are there maintenance errors?
Are there H&S issues?
Do personnel need retraining?
Have we modified any systems or
processes?
How is our safety culture?
Highest level of HF effort
Detailed analysis and design input
Iterative design and “as-built” changes
mean frequent/constant HF presence
Risktec – Identifying the human element of risk, Rev. 1, Slide 13
Abandon
How do we move from
operations to shut down safely?
Changes in operating concept
Is re-skilling needed?
Motivational issues
© 2012 Risktec Solutions Limited
HF Tools and Techniques
Usability Assessment Techniques
• Checklists
• Interface Surveys
• Questionnaire for User Interface Satisfaction
(QUIS)
• Software Usability Measurement Inventory
(SUMI)
• System Usability Scale (SUS)
• User Trials
Workspace, Workstation & HMI Design
• Link Analysis
• Workspace Design Guides
• Workstation Design Guides
• Task Environment Design
• Synthetic User Modelling (Anthropometric)
• Human Factors Trade-Off Analysis
• Human Factors Style Guide
• Layout Analysis
Requirements Analysis Tools
• Mission Analysis
• Operational Scenario Description
• Target Audience Description
• Functions Analysis and Allocation
• Safety Critical Task Identification
• Operability Criteria Definition
• User Performance Criteria Definition
• Role Definition
HF Input to Design
Team Design & Assessment Techniques
• Complement Validation
• Task & Role Performance Modelling
• Groupware Task Analysis
• Team Cognitive Task Analysis Techniques
• Behavioural Observation Scales
• Team Workload Assessment
• Team Communication and Co-Ordination Analysis
• Social Network Analysis
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Task Analysis Techniques
• Hierarchical Task Analysis
• Tabular Task Analysis
• Verbal Protocol Analysis
• Timeline Analysis
• Goals, Operators, Methods and Selection Rules
Technique
• Keystroke Level Model (KLM)
Mental Workload Assessment Tools
• Task Load Index (NASA-TLX)
• Defence Research Agency Workload Scales
(DRAWS)
• Subjective Workload Assessment Technique
(SWAT)
• Subjective Workload Dominance (SWORD)
• Workload Profile Technique
• Individual Self-Assessment (ISA
Cognitive & Situational Awareness Analysis
Techniques
• Applied Cognitive Task Analysis
• Cognitive Task Load Analysis
• Critical Incident Technique
• Critical Decision Method
• SA Requirements Analysis
• Mission Awareness Rating Scale (MARS)
• Situation Awareness Rating Technique (SART)
© 2012 Risktec Solutions Limited
HF Throughout the Lifecycle
When is it best to apply HF?
The answer is ALWAYS “as early as possible”!
Diagram from “A Business Case for Human Factors
Investment” HUM.ET1.ST13.4000-REP-02. EATMP (13/12/99)
Risktec – Identifying the human element of risk, Rev. 1, Slide 15
© 2012 Risktec Solutions Limited
HF Throughout the Lifecycle
“There is an ‘iron’ law that should never be ignored. To
consider Human Factors properly at the design and
certification stage is costly, but the cost is paid only
once. If the operator must compensate for incorrect
design in his training program, the price must be paid
every day. And what is worse, we can never be sure
that when the chips are down, the correct response will
be made.”
Ref. Wiener, 1988
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© 2012 Risktec Solutions Limited
Benefits of HFI
Cost savings
Increased productivity
Increased capacity
Decreased delays
Project delivered on time
Reduced number of
human errors
Reduced maintenance
costs
Reduced lifecycle risk
Increased acceptability
Improved usability
Increased safety
Increased system reliability
Increased maintainability
Early end-user involvement
Improved job design
Improved human-computer interface
Improved selection and training
More effective product testing
More usable system documentation
Better working environment
Enabling Benefits
Risktec – Identifying the human element of risk, Rev. 1, Slide 17
Qualitative Benefits
Quantitative Benefits
Delivered Benefits
Ref: A Business Case for Human Factors
Investment HUM.ET1.ST13.4000-REP-02
© 2012 Risktec Solutions Limited
How do humans contribute to risk?
How do we identify the human element?
Risktec – Identifying the human element of risk, Rev. 1, Slide 18
© 2012 Risktec Solutions Limited
Risk Assessment Tool
Hazard Identification (HAZID) Study
HAZOP – Hazard and Operability Study
SIMOPS (Simultaneous Operations) Study
Bowtie Analysis
Risk Assessment Matrix (RAM)
FTA – Fault Tree Analysis
ETA - Event Tree Analysis
FMEA – Failure Modes and Effects Analysis
SIL - Safety Integrity Level Study
LOPA - Layers of Protection Analysis
Physical Effects Modelling (PEM)
QRA - Quantitative Risk Assessment
PSA – Probabilistic Safety Assessment
Job Safety (or Hazard) Analysis (JSA / JHA)
Process Hazard Analysis (PHA)
Structured What-if Technique (SWIFT)
Risktec – Identifying the human element of risk, Rev. 1, Slide 19
© 2012 Risktec Solutions Limited
Example barrier diagram
Initiators
Barriers/
controls
Risktec – Identifying the human element of risk, Rev. 1, Slide 20
Event
Mitigations
Consequence
© 2012 Risktec Solutions Limited
Example barrier diagram
The human element can be either Implied or explicit
Risktec – Identifying the human element of risk, Rev. 1, Slide 21
© 2012 Risktec Solutions Limited
Human Error and Violation
Human Error
–
‘A failure to perform a required action within
the tolerance limits necessary for adequate
and safe system performance’
Violation
–
“Deliberate deviations from the rules,
procedures, instructions and regulations
drawn up for the safe operation of plant or
equipment.”
(Human Factors in Reliability Group 1995)
Risktec – Identifying the human element of risk, Rev. 1, Slide 22
© 2012 Risktec Solutions Limited
Basic Error Types
TYPES OF ERROR
Unintentional
Acts
The outcome
was not
intended
Intentional
SLIP
e.g. pressing the wrong button
LAPSE
A memory failure – e.g.
Forgetting to open a valve
MISTAKE
An incorrect judgement – we
believe we have done the
right thing but we are wrong.
Acts
The outcome
was intended
Risktec – Identifying the human element of risk, Rev. 1, Slide 23
A failure of attention – we do
the wrong thing by accident.
e.g. misdiagnosis
VIOLATION
We INTENTIONALLY
break the rules
© 2012 Risktec Solutions Limited
Human Failure
Skill based
errors
Slips
Lapses
Error
Mistakes
Human
failure
Rule based
mistakes
Knowledge
based mistakes
Routine
Violation
Situational
Exceptional
Optimising
Risktec – Identifying the human element of risk, Rev. 1, Slide 24
© 2012 Risktec Solutions Limited
What Causes Human Error (HE) ?
Usually not just a basic mistake by
the man at the sharp end!
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





System design deficiencies
Inadequate plant status information
Procedure design
Management style
Poor training
Poor maintenance
Poor communications
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© 2012 Risktec Solutions Limited
Contributing Cognitive Factors
Expectancy/Mindset/Tunnel Vision
–
–
–
Seeing/hearing what you want to see/hear
Subconsciously ignoring information that does not fit
your picture of reality
Inability/reluctance to reconfigure your mental model
despite evidence that it is wrong
Situation awareness
–
–
–
Mental model of surroundings, task, your state and
factors that may influence these
Good situation awareness enables prediction of possible
future situations
Impaired by excess workload, stress and/or fatigue
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© 2012 Risktec Solutions Limited
Accidents Due to Error
January 1986 - Space Shuttle Challenger



conflicting goals
incompetence
organisational rigidity
December 1988 - Clapham Junction


bad workmanship
poor supervision and
management
September 1998 – Esso Longford



poor plant design
poor alarm management
poor training
Risktec – Identifying the human element of risk, Rev. 1, Slide 27
© 2012 Risktec Solutions Limited
Accidents Due to Error
Three Mile Island


Operators failed to recognise
relief valve had failed open
Vaporised reactor coolant
escaped from reactor
containment
Ladbroke Grove Train Crash


Novice train driver failed to see
red signal
Routed local train into path of
express train
Risktec – Identifying the human element of risk, Rev. 1, Slide 28
© 2012 Risktec Solutions Limited
Accidents Due to Violation
Chernobyl



Unauthorised Reactor
Experiment
Reactor trip system switched off
Control rods positioned outside
of permitted limits
Herald of Free Enterprise


Ferry set sail with bow doors
open
Assistant Bosun not at post
when ship set-sail
Risktec – Identifying the human element of risk, Rev. 1, Slide 29
© 2012 Risktec Solutions Limited
Human Reliability (Error) Analysis
Task Analysis forms the
starting point of HRA
A structured approach for
identifying the human
contribution to risk
Qualitative assessment
followed by probabilistic
quantification if required
Task Analysis
Human Error Identification
Human Error Assessment
Error Reduction and Mitigation
Risktec – Identifying the human element of risk, Rev. 1, Slide 30
© 2012 Risktec Solutions Limited
HRA: Tools
A range of different techniques available:
ASEP
Accident Sequence Evaluation Programme
AIPA
Accident Initiation and Progression Analysis
APJ
Absolute Probability Judgement
ATHEANA A Technique for Human Error Analysis
CAHR
Connectionism Assessment of Human
Reliability
CARA
Controller Action Reliability Assessment
CES
Cognitive Environmental Simulation
CESA
Commission Errors Search and Assessment
CM
Confusion Matrix
CODA
Conclusions from occurrences by descriptions
of actions
COGENT
COGnitive EveNt Tree
COSIMO
Cognitive Simulation Model
CREAM
Cognitive Reliability and Error Analysis Method
DNE
Direct Numerical Estimation
DREAMS
Dynamic Reliability Technique for Error
Assessment in Man-machine Systems
FACE
Framework for Analysing Commission Errors
HCR
Human Cognitive Reliability
HEART
Human Error Assessment and Reduction
Technique
HORAAM
Human and Organisational Reliability Analysis
in Accident Management
HRMS
Human Reliability Management System
Risktec – Identifying the human element of risk, Rev. 1, Slide 31
INTENT Not an acronym
JHEDI
Justified Human Error Data Information
MAPPS
Maintenance Personnel Performance Simulation
MERMOS
Method d'Evaluation de la Realisation des
Missions Operateur pour la Surete (Assessment method for
the performance of safety operation.)
NARA
Nuclear Action Reliability Assessment
OATS
Operator Action Tree System
OHPRA
Operational Human Performance Reliability
Analysis
PC
Paired comparisons
PHRA
Probabilistic Human Reliability Assessment
SHARP
Systematic Human Action Reliability Procedure
SLIM-MAUD Success likelihood index methodology, multiattribute utility decomposition
SPAR-H
Simplified Plant Analysis Risk Human
Reliability Assessment
STAHR
Socio-Technical Assessment of Human
Reliability
THERP
Technique for Human Error Rate
Prediction
© 2012 Risktec Solutions Limited
HRA: Error Reduction and Mitigation
Error Reduction and Mitigation
Identify & instigate control measures
Prioritise remedial measures based on
understanding of:
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–
–
–
Psychological precursors
Error producing conditions & performance shaping
factors
Adequacy of existing error defences
Impact of error on overall system risk
Address underlying cause
–
Individual, Job, Organisation
Risktec – Identifying the human element of risk, Rev. 1, Slide 32
© 2012 Risktec Solutions Limited
Reduce & Manage Errors & Violations
INDIVIDUAL
– Effective training and competence
management
JOB
– Apply HF principles to the design
of systems and processes
– Review and improve procedures
– Design tasks so violations are
difficult or impossible
ORGANISATION
– Near-miss incident reporting
– Adopt a ‘Just Culture’
– Look for root causes, not
scapegoats
– Feedback results to staff
Risktec – Identifying the human element of risk, Rev. 1, Slide 33
© 2012 Risktec Solutions Limited
Left with a true understanding of the residual
risks from the human element of your system
You manage this with good culture which
instigates the behaviours you want....
Risktec – Identifying the human element of risk, Rev. 1, Slide 34
© 2012 Risktec Solutions Limited
Thank you for your attention
Paul Lawrence
Risktec Solutions Ltd
01925 611257
Paul.Lawrence@Risktec.co.uk
Risktec – Identifying the human element of risk, Rev. 1, Slide 35
© 2012 Risktec Solutions Limited