no 1 human factors hsl amended
TRANSCRIPT
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Human Factors and Changing
perspectives
• “If this was March 22nd 2005 – the day
before the explosion – and I was
standing here addressing this audiencethe day before the explosion, my
remars to you would ha!e been much
different"#
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Changing perspectives (2)
• “$my confidence in the %& 'roup(s safetyculture, safety standards, safety managementsystems and safety audit programmes would
ha!e been e!ident"#• “I(d ha!e pointed to some statistics – for
example, how in the pre!ious fi!e years thecompany had reduced its )*+ recordable
in-ury rate by almost .0 percent and its fatalityrate by .5 percent"#
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Changing perspectives (3)
• “I(d ha!e argued that this positi!e trend
reflected a concerted, systematic
approach to safety"#• “I(m sure I(d ha!e mentioned how
e!eryone woring in a %& facility is
empowered and expected to raisesafety concerns and to stop wor if they
thin conditions are unsafe"#
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Changing perspectives (4)
• “"" I would ha!e described our efforts to
continuously dri!e up safety standards
regardless of our impro!ing record"• $ on March 2/rd 2005 it became clear that
none of this was enough"#
John Mogford, 24 April 2006, Senior Group VicePresident, Safety & Operations, BP, CCPS Congress
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Methods for Human Error Assessment
• he 1"" +ealth and *afety 3xecuti!e has
identified more than .0 methods
• /2 are rele!ant to Ma-or +a4ards• he next page lists some common ones and
then we mo!e into one of the simple
accepted methods
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Common methods for Human Factor
(error) Assessment
• +uman 3rror ssessment and eduction
echni6ue 7+38
• echni6ue for +uman 3rror ate &rediction7+3&8
• *uccess 9ielihood Index Method 7*9IM8
•ecnica 3mpirica *tima 3rrori )peratori
73*3)8
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HRA Assessment
• 1sing the +uman 3rror ssessment
and eduction echni6ue 7+38
• &re:processed + method
• ;irst published <=>5
• )ne of ?0 or so other + methods
• %ased on +uman ;actors literature
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HRA accuracies achieved so far
• @0:>.A of all predictions within factor of <0 of
true !alue o!er range 0"0000< to <"0
• !erage .2A within factor of <0• !erage />A within factor of /
– irwan 7<==.8
– cf" for *ystems eliability ssessments, – @?A of predictions within factor of two,
=/A within factor of four 7*naith, <=><8
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fter irwan, <==.
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Understanding the method
• 'eneric as ypes 7'8
– +uman reliability is dependent on
the nature of the tas beingperformed
– 1nder perfect conditions the
associated le!el of reliability is fairlyconsistent
• 3rror &roducing Bonditions 73&B8
– May degrade reliability
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eneric !as" !#pes (!!s)
;or example
• 78 otally unfamiliar tas, performed at speed
with no real idea of the liely conse6uences ofactions taen$ 70"558
• 738 outine, highly:practised, rapid tas
in!ol!ing relati!ely low le!el of sill$70"028
• 7M8 Miscellaneous tas for which no description
can be found$70"0/8
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Error $roducing Conditions (E$Cs)
• /> 3&Bs described in +3
• 3xamples
– 1nfamiliarity 7x<.8
– ime shortage 7x<<8
– )perator inexperience 7x/8
– 1nreliable instrumentation 7x<"@8
• ssessment of how important each is
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Human Fai%ure &cenario to Assess
&art of a procedure to establish the start
up of a piece of plantC
;ailure of )perator to establish rundown to
tanage 7set *plitter tower le!el control to
uto with 50A set point8 prior to addingheat to *plitter
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Human Re%ia'i%it# Assessments
• 1nder “normal# conditions
• 1nder conditions that can degrade
human reliability
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Fai%ure to esta'%ish rundon
(norma%* situation)
'eneric as ype
as ;C estore or shift a system to originalor new state following procedures, withsome checing – this tas is missionoriented and could include up to fi!e
discrete elements or actions, but wouldnormally only in!ol!e one basic acti!ity
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Fai%ure to esta'%ish rundon
(norma%* situation)
eneric !as" +omina% Human
Unre%ia'i%it#
!as" F ,-,,3
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Fai%ure to esta'%ish rundon
(Conditions affecting human re%ia'i%it#)
• Dot following procedures
• Do independent checing 7e"g" super!isor8
•1nreliable instrumentation
• Impo!erished 6uality of information 7e"g" shift hando!er8
• 1nclear allocation of function and responsibility
• Eisruption of normal sleep cycles
• )perator inexperience• 9ow worforce morale
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Fai%ure to esta'%ish rundon
Conditions affecting human re%ia'i%it#
eneric !as" +omina% Human Unre%ia'i%it#
as ; ,-,,3
Error $roducing Conditions
;actor otal +3 ssessed &roportion ssessed
ffect of ffect 7from 0:<8 ffect
&rocedures x2 0"> 72:<8 x 0"> F < G <">
Bhecing x/ 0"> 7/:<8 x 0"> F < G 2"@
Instrumentation x<"@ 0"? 7<"@:<8 x 0"? F < G <"2?
Impo!erished info" x/ 0"2 7/:<8 x 0"2 F < G <"?
Assessed nomina% %i"e%ihood of fai%ure
0"00/ x <"> x 2"@ x <"2? x <"? G ,-,24
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Conditions affecting human re%ia'i%it#
Uncertaint# 'ounds
eneric !as" +omina% Human Unre%ia'i%it#
as ; 0"00/
Uncertaint# .ounds
0"000> – 0"00.
Assessed nomina% %i"e%ihood of fai%ure
0"00/ x <"> x 2"@ x <"2? x <"? G 0"02?
Uncertaint# .ounds
0"00@5 – 0"05.
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A fundamenta% need
• as nalysis is a !ery important part ofunderstanding the potential for +1MD3)"
• ' opinion suggests that the potential formost error reduction can be achie!ed byactually understanding what the operatorneeds to do
• Mae the Hright way( the Heasy way( – reducingthe incenti!e to do it wrong, tae short cuts$
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!e/as Cit#
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Error Reduction
• Ban ' be changed
• elati!e importance of assessed proportionof affect of the 3&Bs
• Bost:effecti!e measures
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Error Reduction
Bhecing
&rocedures
Impo!erishedinformation
Instrumentation
1nclear roles
*leep cycles
9ow morale
Inexperienced
operator
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&ummar#
• 3xplained why +uman eliability ssessment 7+8 is important
• 3xplained how +uman 3rror ssessment and eduction echni6ue7+38 wors
•)utlined ey principles and e!idence
• Jored through some scenarios to aidunderstanding