Module 1: Managing Human Factors
Human Factors in Risk Management
Ronny Lardner CPsychol AFBPsS, AIChemE
Founder / Registered Psychologist
The Keil Centre Ltd
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About The Keil Centre…
• Based in Edinburgh, UK & Australia
• 20 staff & associates
• International client base
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About your Workshop Leader…
• Founder and former Director of the Keil Centre
• First Course Director for IChemE Human Factors Course in
UK and Europe
• >25 years technical experience in human factors
• Chartered Psychologist
• Associate IChemE Fellow
• Specialist in human factors in health and safety
• Oil & gas, chemical processing, mining, rail, manufacturing
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Introductions
• Nominate a spokesperson for your group
• For each group member, find out:
– Their reason for wanting to come on the course
– One interesting / unusual fact about them, which others do not
know
• Spokesperson to introduce each member:
– Name
– Role
– Interest
– Unusual fact
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Workshop Overview
• What is human factors?
• Why is human factors important for health and safety risk
management?
• Managing and measuring the company’s HF performance
• Programme overview & useful resources
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What is Human Factors?
A work system = the complete work context
e.g. an offshore platform with its various functions such as drilling and
well construction, crude production / export etc
Simplistic view of the life
cycle stages of a system
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What is Human Factors?
Optimise system, and health and safety performance by
focusing on the human interactions within a work system
Capabilities &
limitations – but
humans make
the system work
Human factors
applies to any / all
human interactions
– inter-dependent
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What is Human Factors?
Communication, team work,
training / competency, staffing,
safety culture, management of
change, fatigue / stress
Cognitive /
physical tasks –
allocation of
functions
Simple spanner
to complex
control system –
direct human
interface
Immediate
workspace (e.g.
control console) &
wider work area
(e.g. plant areas)
Noise / vibration, thermal,
lighting – need to protect
users & design to enhance
performance
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What is Human Factors?
• Draws on human sciences:
– Cognitive Psychology
– Occupational Psychology
– Anatomy / Physiology
– Biomechanics
– Anthropometry
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Developments Across Industry
Pre-1970
1980s
1990s
2000s
2010+
COMAH
1999
HSE
guidance
Process
Defence
Cockpit
studies
WW2
Research continues to develop & embed HF into engineering, safety & operations
First GUI &
user testing
Consumer
products
Guidance
Standards
Nuclear
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User testing continues
to develop
Usability standards
Rail
General
industry
OGP, EI, HSE
guidance, ASM etc.
Requirement for large
development projects
HRA, control rooms, human factors engineering,
organisational change, research
Focus on
health &
personal
injury
Time &
motion
1920s
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More focus on safety
& organisational
performance
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Why is Human Factors Important?
•
Major accidents
–
–
•
80% of incidents have human factors contributions
“behavioural safety” not enough
Occupational health
–
–
–
Environmental / inherent hazards
Musculoskeletal injury
Stress related disorders
•
Performance and cost benefits
•
Regulators, such as UK Health and
Safety Executive
–
–
–
•
Being adopted throughout the world
General guidance on human factors HS(G)48
NOPSEMA, state mining regulators
Client / partner expectations
–
–
Developing their own expertise
e.g. Woodside, Chevron and many others
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Most Common ‘Human Factors’
Contributors to Major Accidents
in Hazardous Industries?
Known as the HSE’s top ten
Human & Organisational Factors (HOFs)
 Managing human failure
 Procedures
 Training and competence
 Staffing
 Organisational change
 Safety-critical communication
 Human factors in design
 Fatigue & shiftwork
 Organisational (safety) culture
 Maintenance, inspection and testing
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Human & Organisational Factors
Worksheet
B(riefing) N(ote) 6
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X
X
X
X
X
X
X
X
X
X
X
X
X
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X
X
X
X
Safety Culture
X
X
X
X
Fatigue / shift work
X
X
X
X
X
X
X
Human Interface
Design
X
X
X
Safety Critical
Communications
X
X
X
Organisational
Change
X
X
X
Staffing
Training /
Competence
Oil & gas
Piper Alpha
Buncefield
Texas City
Nuclear
Three Mile Island
Chernobyl
Chemicals and plastics
Formosa
Bhopal
Flixborough
Transport
Herald of Free enterprise
Kegworth
Procedures
Major Accident
Human failure
(including
maintenance)
Recurrent Themes in Major Accidents
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
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Practical Session
• US Chemical Safety Board DVD
reconstruction
– View sections of DVD to illustrate
topics
• Review selected sections of
DVD
• Use worksheet to “spot” human
factors topics
• Discussion
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Break
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Management Frameworks for HF
Where does human factors belong?
Design of the
equipment,
workspace,
environment,
procedures…
Engineering
• Staffing / workload
• Training / competency
• Team organisation
• Communication
• Management of change
• …….
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• Health Hazards
• System safety
• Safety case
Environment
Health
Safety
Operations
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HSE’s Summary
1. Imbalanced focus on technical hardware issues, at
expense of ‘human’ issues
2. Focus on the human contribution to personal safety rather
than to the initiation /control of major accident hazards
3. Focus on ‘operator error’ rather than recognising ‘system
and management failures’ which lead to ‘error’
Need a focus on HF within Risk Management for all aspects
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Incident rate
Improvement Gap
Improvement
Plateau
Time
Do need a focus on ‘humans’ to reduce incident rates
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Example using Bow Tie Analysis
HAZARD
THREAT
THREAT
Preventative
barriers
+
+
Mitigating
controls
-
CRITICAL TOP
EVENT
+
THREAT
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+
CONSEQUENCE
+
CONSEQUENCE
+
CONSEQUENCE
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Example
where
human
error is
cited
Overpressure
Failure
Flange Leak
Fatigue - Failure
Corrosion/
External, Material
Failure
Weld Defect
Dropped Objects/
Swinging Loads
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Gas System Gas
Hydrocarbon
Inventory
+
+
+
+
-
+
Site: Loss of
Containment
-
+
Fire
+
Explosion
+
Gas Ingress into
buildings
+
Toxic Release
+
Escalation to
structure
+
Human Error
+
Helicopter Crash
+
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Unignited Gas
Cloud - Helicopter
Impairment
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Closer Look at Human Error
Site: Loss of
Containment
Human Error
Operational
Competency
Operational
Procedures
(Critical Activity)
Xxx Competency
Assurance and
Training
Xxx operating
procedures - Fuel
Gas System
Xxx Start-up and
operating
procedures - Flare
& Drains System
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Task Risk
Assessment and
Permit to work
controls
Management of
change to ensure
approval and
communication of
changes
XXX Procedure Permit to Work
XXX Non Standard
Operational Risk
Assessment
Procedure
Xxx MoC
Procedure
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Group Discussion
• Is the Bow Tie analysis in this example sufficient in
determining human contribution to the critical top
event, i.e. loss of containment?
• Are there sufficient controls?
• If you answered ‘No’ to either question, please
identify why.
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Humans and Barrier Management
Identify how humans can undermine barriers
Rob Miles, HSE, 2004
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Structure for HF
• Many organisations do ‘some’ HF
– Possibly labelled as something else
– Maybe in a sporadic way or just some elements
•
Comprehensive framework
– Ensure adequate depth and breadth
– Does not need to be complex
• Key elements:
– What it is trying to achieve? (Goals)
– How will it achieve its goal? (Structure)
– How well is the organisation performing? (Measurement,
Action, Review)
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HF Management Framework
• Goals
– Positive (e.g. performance improvement)
– Avoidance of negative (e.g. reduce human failure rate,
injuries, accidents, lower design cost)
– Consider Key Performance Indicators (KPIs)
• Structure
– HF in design
– HF in operations
– (Decommissioning falls into both)
• Measurement, action, review
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Diagrammatic Overview
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Current Models for
HF Management
• Topic based, e.g.
– HSE’s top ten
– Energy Institute guidance
– Oil and Gas Producers (OGP) – 454 – HF in Engineering Projects
• Risk based
– HSE’s roadmap, supported by inspectors toolkit
• Human Factors Maturity
– Human Factors Maturity® Model
– Industry best practice in HF
– Measure against the benchmark
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HF in Design / Engineering
• OGP deals with the process of
integrating Human Factors
Engineering in projects
• Specific relevant topics would then be
derived from relevant standards,
– e.g. Control room design, plant design,
human machine interface
http://www.ogp.org.uk/pubs/454.pdf
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Latest HSE Roadmap
• Managing Human Performance
• Human Factors in Process Design
• COMAH-Critical Communications
Risk assessment
Incident investigation
Process control system HMI
Human factors integration
Shift handover
Permit systems
• Design and Management of Procedures (& Supervision)
• Competence Management Systems
• Managing Organisational Factors
MOrgC
Shiftwork & fatigue
Staffing & workload
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Topics Are Interconnected
• Risk based approach
– Start with major accidents
– Understand safety critical tasks
– Identify how human failure may occur
– How the error occurs
– How it is made more likely – Performance Shaping Factors
– (PSF = PIF = EPC)
– Engineer out
– Review ripple effects of engineering out
– Use hierarchy of controls, including human controls
– Make the human controls robust
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HSE’s HF Roadmap
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HSE’s HF Inspectors Toolkit
http://www.hse.gov.uk/humanfactors/toolkit.htm
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Excerpt from the Toolkit
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Measurement, Action, Review
• Regardless of approach, can use gap analysis to
measure / develop actions / review:
– Include:
– Operations
– Design
– Starting point / tools might include:
– E.g. HSE toolkit to gather evidence – mainly operations in focus
– E.g. OGP 454 – design aspects for engineering projects
• Produce action plan to close gaps.
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Review Your Company
• Perform a high level review the HOF Top Ten for your
company
• Use handout to record your discussions
• Consider:
– Current situation
– Key gaps
– The top 3 priorities
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Modules 1 & 2
Whole course is 4 modules
Module 1 – Managing Human Factors
Workshop
1
2
3
4
Topic
Human factors in risk management
Managing safety culture & behaviours
Safety critical communications
Managing organisational change
Module 2 – Managing Human Failure
Workshop
1
2
3
4
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Topic
Reducing human error
Managing non-compliance
Human factors in incident investigation
Managing personal resilience in the workplace
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Modules 3 & 4
Module 3 – Strengthening Organisational Performance
Workshop
1
2
3
4
Topic
Training & competence
Effective supervision & safety leadership
Staffing & workload
Managing fatigue
Module 4 – Human Factors and Design
Workshop
1
2
3
4
Topic
Integrating human factors in design
Ergonomic risk assessment and workspace design
Developing effective procedures
Design of the human-machine interface
Delegates can do whole course or individual modules
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General Ethos
• Based on the top ten human factors
contributors to major accidents
• Style of delivery
– Recognised practitioner experts
– Activities / discussion
– Open source resources, where possible
– Networking with other delegates / industries
– Award for best application of HF
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Some Useful Internet Resources
• Step Change in Safety – “Human Factors: How to take the
first steps…”
• http://www.stepchangeinsafety.net/
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Health and Safety Executive
http://www.hse.gov.uk/humanfactors/index.htm
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Energy Institute
https://www.energyinst.org/technical/human-and-organisational-factors
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Eurocontrol
http://www.eurocontrol.int/articles/human-performance-atm
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Institute of Ergonomics & HF
http://www.ergonomics.org.uk
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Defence Technology Centre
https://www.defencehumancapability.com/HFIDTCLegacy.aspx
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International Maritime Human
Element Forum
http://www.he-alert.org/
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Other Websites
• American Bureau of Shipping
– Guidance Notes on Ergonomics for Marine Systems &
Ergonomic Design of Navigation Bridges
– http://www.eagle.org/
• Institution of Engineering and Technology
– Human Factors Engineering Network: Guidelines &
Forum
– http://www.iee.org/oncomms/pn/humanfactors/
• NIOSH (USA)
– Ergonomics and Musculoskeletal Disorders Guidance
– http://www.cdc.gov/niosh/topics/ergonomics/
• OSHA (USA)
– Access to ergonomic e-toolkit and other guidance
– http://www.osha.gov/SLTC/ergonomics/index.html
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Other Websites
• Cornell University Ergonomics Web
– Ergonomics and Musculoskeletal Disorders – best
practise guidance on the design of hardware,
software and workplaces
– http://ergo.human.cornell.edu/
• Human Factors and Ergonomics Society
– The US professional Body for Human Factors
Specialists and Ergonomists. Access to guidance,
publications and link.
– http://www.hfes.org/web/Default.aspx
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Session Summary
• Human Factors covers a broad range of topics
• Top ten recurring issues for major accidents
• Need to manage human factors comprehensively
– Operations
– Design
• Tools are available to identify how well your company is
performing
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