2007 north wales ohs - human factors overview
TRANSCRIPT
Tel: 01492 879813 Mob: 07984 [email protected]
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Human Factors
North West Wales Occupational Health and Safety Group
28 March 2007
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A bit about me
Chemical engineer10+ years working as a risk and safety consultant
Specialising in human factorsMost work in major hazard industries
Self-employed for 2 yearsLive in LlandudnoRegistered member of the Ergonomics SocietyNebosh General Certificate.
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My aim for today
Introduce human factors’ and its role in safetyTell you what we have learnt about human factors in major hazard industriesGive some ideas of how this applies to lower hazard activities.
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Physical demands - musculoskeletal disordersPsychological demands - stressSocial conditions - job satisfactionHuman error - cause of accidents.
Human Factors
“Environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work in a way which can
affect health and safety”
HSG48 Reducing error and influencing behaviour
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Audience participation
Has anyone recently made an error?Has anyone recently violated a rule or procedure
You knew the rule or procedureBut decided to do it differently.
Human factors is impotent when your asessing tge risks in your organization
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Major accidents involving human factors
Piper Alpha Herald of Free Enterprise Chernobyl
Clapham Junction Esso - Longford Fixborough
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Errors in lower hazard industriesInland revenue – record deletedAustralian immigration – deported wrong personNasa Polar Lander to Mars – crashedSunday Mirror – photos of wrong personDWP – 40,000 PC out of action for 5 daysPC World – fned for selling old computers as newIVF clinic – mixed race twins for white coupleBarclay’s Bank – 62,000 people’s wages late$30 billion loss for errors in patentUK industry – errors cost £9.3 billion per yearNHS - 30,000 deaths per year
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Piper AlphaVery big eventSeries of quite small errors
Initial explosion = gas release equivalent to 10kg
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ChernobylOperators not told about poor reactor designGiven instructions - assumed must be safe
Fatality of Mark & Luke Wells – working as contractors for British WaterwaysNot told about previous accidentGiven a job that had not been assessed
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Esso Longford (Australia)Operators given training - but did not understand what it meant
Cecil Kumar lost his hand in a hydraulic pressHe had been trained but the light curtain around the machine was not set up properly
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FlixboroughPlant modification designed by someone without necessary competence
Q Carpark in GlasgowLarge concrete slab fell 4 floors Project manager ignored advice because was not competent in structures
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Hence interest in human factors
Up to 80% of accident causes can be attributed to human factorsAll accidents involve a number of human failuresHuman factors is concerned with
Accepting that errors and violations are not random ‘acts of God’They are predictable and preventableDifferent circumstances create different types of errors.
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Human FactorsWhat are people being asked to do(the task and its characteristics)?
Who is doing it (the individual and their competence)?
Where are they working (the organisation and its attributes)?
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Simple errorsCompetent and experienced people Minor lack of precision or attention to detailTraining won’t help – or telling people to “be more careful”Procedures won’t be readNeed to design systems to that they are
Arranged in a logical wayLabelled clearlyCan be used without thinking.
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More complex errorsMaking the wrong decisions or choicesPeople don’t understand how the system worksPresented with confusing or misleading informationTraining can helpProcedures can help in some circumstancesLetting people concentrate
Minimise fatigue and distractions.
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Made in China
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ViolationsDeliberate deviations from rules & proceduresMost are motivated by trying to get the job doneLike errors, they are caused
Difference between policies and practicesImpractical recommended practicesInappropriate prioritiesLack of understanding hazards and risksLack of feedbackGroup or peer pressureFrustrationFeeling that it doesn’t matter.
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Taking short cuts
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What should you do?
Have a clear view of:Errors and violations that can cause accidentsRisk control measures that rely on human actionsConsequences of human failure
Consider human factors when:Carrying out risk assessmentsInvestigating incidentsBuying new equipmentDeveloping systems
Make sure working arrangements help people work reliability.
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HSE’s Top Ten Human FactorsOrganisational changeStaffing levels and workloadTraining and competenceAlarm HandlingFatigue from shiftwork & overtimeIntegrating human factors into risk assessment and investigation Communication/interfacesOrganisational cultureHuman factors in designMaintenance error
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Risk assessments
Confusing equipment controls Illogical or inconsistent layout
Poor labellingIllegible, missing or hand written
Complex tasksPossible short-cutsPeople working when fatigued or stressedDistractions and poor working conditionsReliance on communication.
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Incident investigationHuman error is NOT a root causeYou need to understand why errors or violations occurTelling people to be more careful is not a solution
Neither is writing more proceduresOr repeating more of the same training
If you can’t find the cause of the error or violation you are saying it will happen again
Be very wary of taking disiplinary action.
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Buying new equipment
Try to make sure controls are consistent with current equipment or normal conventionsIdentify specific training needsDon’t rely on the manufacturers instructionsInclude ergonomics in your purchasing specifications.
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Stress
People pay less attentionThey do not communicate so wellAs well as being bad for health, stressed people make more errors.
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Communication
.There were 20 sick sheep, one died, how many were left?
Error is an integral part of communication.
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What are your procedures like?
A – Clear, concise and comprehensive
B – Clear, concise, some gaps
C- Wordy and complex
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Procedures - 80% rule
Page 1
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Page 4Page 5
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% Whole read procedures
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Better procedures
Procedures can assist in risk controlDifferent types – depending on risk of activity
Mandatory – few where step-by-step instructions are necessaryJob aids – summarise key informationGuidelines – primarily for training
Only write the procedures that are really neededAim them at experienced people
Not someone off the street.
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Training
Only a small part of people becoming competentThe following affect how people work
KnowledgeSkillsAttitudeHabits
Most learning is done ‘on the job’Often very unstructured.
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Something to beware of
Any of these sound familiar?Forgetting to take your changeForgetting to take your receiptLeaving headlights on when getting out of the carLeaving the gas on when finished cookingLeaving the original in the photocopierForgetting the attachment on an email
All examples of where there is an extra step after the main task is complete.
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Where does ergonomics fit in?
ErgonomicsHuman capabilitiesHardware designWork stationsUser interfacesWorking environmentManual handlingPersonal safety, health and well being
Human factorsWhole systemOrganisationCultureTasksErrorsProceduresTraining and competenceAccidents
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And what is Behavioural Safety?
Tends to be more concerned withPhysical activitiesPersonal safety accidentsFailures of people at the sharp end
The premise is that people are free to choose the actions they makeHuman factors is based on the principle that people are ‘set up’ to fail
Management and organisational root causes.
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Where does human factors fit with ‘Traditional’ Health and Safety
Management responsibilitySafety culture.
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Management of Health & Safety at Work
Regulations (MHSWR, 1999)
“Every employer shall make and give effect to such arrangements as are appropriate, having regard to the nature of his activities and the size of his undertaking, for the effective planning, organisation, control, monitoring and review of the preventative and protective measures” (Regulation 4).
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Robens Report, 1972
“Promotion of health and safety at work is an essential function of good management … Good intentions at the board level are useless if managers further down the chain and closer to what happens on the shop floor remain preoccupied exclusively with production problems”
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Industrial Accident Prevention
“Underlying accident causes are faults of management and supervision plus the unwise methods and procedures that management and supervision fail to correct…”
Heinrich (1931)
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