reliability and safety: looking at the unique human factors … · factors needed to predict,...
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PTP-Global
Reliability and Safety:
Looking at the unique human factors needed to predict, prevent
and manage incidents
Tim Southam. QCVSA, BSc, FIEHF, FIIRSM, CMIOSH
PTP-Global
Electronics Design 8 Years
RAF Pilot 21 Years – Jaguar /
Tornado – Rae Farnborough
Human Factors Specialist -
Registered Ergonomist and
Chartered Safety Professional
Specialist in Virtual Reality
design, workload, fatigue, Human
Error, Human Factors Integration,
Human Performance. Human
Factors Engineering.
Associate Consultant with:
The Keil Centre
Abbott Risk Consulting
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The Situation is:
• We are very good at saying Human Error is an issue
and plays a part in accidents
– Then do little about it.
• We say “No harm to people, equipment and the
environment.
– Then do not remove the opportunity for it to
happen again or the conditions for human error.
• We investigate accidents and incidents
– Then stop at the person and do not get to the real
root causes of human error.
• What we say we do
– We often don‟t
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What do we do to Prevent or Reduce Human Error?
We do not diagnose the pain
• Safety Critical Task List• Predictive Human Error Analysis (PHEA)• HAZOP including HE Guidewords• Safety Case including Human Factors as
per APOSC and legislation• Human Error Analysis in AI using HFAT• Learn the lessons from experience
The Question
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Reactive Management Optimum Performance
Plan, think and get right first time
Is there a Price for Risk Management?
When do YOU want to Manage the problems?
The Rules Change
We Spend Lots of £ Layout Access / Egress
Signs / Labels Complexity
Control Interfaces
Physical Environment
MaintenanceReliability
Vendor Packages
Stress Fatigue
Workload
Working HoursShifts
Competence
Working Conditions
Physical Demands
Communication
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Organisational
culture
Design, Packages,
Access, signs,
Maintenance
Layout
Alarm Handling
CCRs, Screen Config
Process Visability
Interfaces
Useability, HAZOP
HF Guide-words
EngineeringIssues
Safety Critical
Task Analysis, PHEA
Fatigue
Behaviours
People Issues
Human Failure
Accident Invest – HEA
Safety Critical
Communications
Procedures
Integration
Systems Issues
Man of Change
Leadership &
Supervision
Workload / Time
Training and
Competency
Resources
Performance
Human
Failure
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Engineers Graph
EngineeringAge
I need betterengineering
Systems Age
I need moreprocedures
Human FactorsIntegration
Age
BBS will fix it(Theirs not Mine)X X X
Continuous Improvement
Workforce Involvement
Open, Honest Communication
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Learning The Lessons
Yet do we deal with:
– ensuring adequate resources for tasks,
– reducing “initiative overload”,
– dealing with maintenance backlogs
– and long working hours,
– and have created high workloads, high
fatigue levels in the workforce.
– Stress is High
PTP-Global
Why Address Human Factors
When we addressing human factors, we're aiming to:
• Optimize human performance• Reduce human failures.• Increase Business Performance
Even experienced, highly-trained, well-motivated technicians make simple slips and omissions, mistakes
and
such errors can initiate major accidents, as well as result inpersonal injury to personnel.
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Los Rodeos Airport, Tenerife 27th
March 1977 - 583
Human factors – why bother?
The Herald of Free Enterprise6 March 1987 - 193
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Process Safety Management
… it must be more about insights, recoveries
and adjustments.
Less about sticking to the checklist as the
plane goes down.
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Stress FatigueWorkload
Working Hours
Shifts
ErrorsSlips
Lapses
Mistakes
GENDER
NATIONALITY
PARENTAL LOVE
UPBRINGING
EDUCATION
CULTURE
LIFE’S EVENTS
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Impact on data processing
1 We take in information through our senses
1 We might misread something, we might miss something important, we might choose to focus on certain things rather than others
3 We process the
information and make
decisions …
3 We might make the
wrong connections, we may
not have all of the facts, we
might make the wrong
assumptions
2 … referring to our memory store
2 We might forget or fail to
remember important
information
4 We act accordingly in line with the decision made
4 We might select the
wrong response, we might
set out to act in one way
but get “clumsy”
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Performance Influencing Factors• Task Factors
• Communication Factors
• Procedures and Documentation
• Ambient Environment
• Training and Experience
• Human-Machine Interaction
• Personal Factors
• Social and Team Factors
Number of tasks, Complexity, Time Pressure, Workload, non-standard activities
Communication workload, Phraseology & Standards, Language and accents, information content, method, Quality, equipment quality and reliability
Procedure availability / access / location, No of
Procedures, accuracy, correctness,
completeness, clarity, validity, format, do-ability,
suitability, compatibility
Weather, Noise, Distraction, Lighting,
Temperature, Air quality
Familiarity with Task, experience, time on job, training, quality of training, suitability of training, recency of training, competence testing, mentoring quality.
Information accuracy / correctness, info type and format, info availability / access, Quality, completeness, clarity, complexity, validity, info structure, location, position, equipment reliability, trust in equipment, allocation of tasks between person and systems, health risks, ergonomics, visual display quality,
Alertness / concentration / fatigue, emotional state, stress, anxiety, boredom, confidence, complexity, job satisfaction, Domestic issues, fitness / physical health issues, Mental health, drugs and alcohol.
Team co-ordination, quality, groupthink, handover / takeover, structure & dynamics, Team relationships and trust, Maturity, inter-team co-ordination, Age, Shift organisation, assistance and support, working methods, staff availability, allocation of responsibility
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Human Factors Inspectors Toolkit
Core Topics:
Competence Assurance
HF in Accident Investigations
Identifying Human Failure
Reliability and Use of Procedures
Common Topics
Emergency Response
Maintenance Error
Safety Critical Communications
Safety Culture
Specific Topics
Alarm handling
Managing Fatigue Risks
Organisational Change
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Human ErrorHigh Costs of AccidentsAccident PotentialWorkload and FatigueInefficient systems and proceduresPotential for Major AccidentsNon-compliance with regulationsNon-compliance with current guidelines
High PerformanceHigher ReliabilityOrganisational AlignmentHF Understanding and AwarenessProactive Risk AssessmentsHuman Centred designs and OperationsMore effective Control roomsCommunication and Systems FeedbackMore effective alarm handlingManning levels at correct levelEffective Shift-work and handoversSafety CultureWorkforce Interaction and InvolvementHappy Regulator
COSTS
15-20%
£
PERFORMANCE
Human FactorsIntegration
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Principles of Human Performance
• Humans are fallible . . . Even the best people make mistakes.
•Error-Likely Situations are . . . Predictable, manageable and preventable.
•Individual behaviour is influenced by . . . Organisational processes and values.
•Behaviours are reinforced . . . People achieve higher levels of performance
•Events are avoidable . . . By understanding the reasons mistakes occur. By applying lessons learned
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Conclusion• Processes Need Humans
• Humans are involved in processes from the outset.
• Safety is maximised by optimising the human
involvement, not by minimising it.
• Operators of processes need to be involved
systematically with its design.
• Design Must Accommodate Human Performance…
just like any other component of the system.
• Human Factors Engineering is a mature discipline
that is based on reliable, validated descriptions of
human performance.
• It specifies safe operational limits for human work and
design interfaces with other components.
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Imagine if you are in Court asking yourself:
• „How did we get ourselves in this position?‟
• We have known about Fatigue, Stress, Workload and the Physiology of Shift Work for a long time
• How will you be exonerating yourself?
• „Our management of change procedures failed‟
• We thought we had it controlled
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Imagine if you are in Court being asked:
• Explain why does your Internationally-
operating company does not have Time
available to ensure people work in the
right frame of mind or have adequate rest
periods?
• Please explain why you do not change the
way you operate until something has gone
wrong and people get hurt?