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2006 IChemE Manchester Branch - Human factors & risk management

Introduction to human factors and risk management

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2006 IChemE Manchester Branch - Human factors & risk management

  1. 1. Tel: 01492 879813 Mob: 07984 284642 andy.brazier@gmail.com www.andybrazier.co.uk 1 Human Factors & Risk Management Andy Brazier
  2. 2. 2 Introduction – about me Chemical engineer Human factors consultant for 10 years – oil, chemical, gas industry – COMAH sites Self-employed since January 2005 Recent clients include Shell, Corus, Lucite, Novartis, Jacobs, Centrica, CapitalOne, DTi Health & Safety Executive projects Supervision COMAH evaluation Control rooms.
  3. 3. 3 Purpose of the presentation Give you an appreciation of human factors What is it? Why is it important? How can you apply it to controlling major hazards? Human factors in design Expectations of the Health and Safety Executive Overview of a two-day course Human factors in COMAH.
  4. 4. 4 Human Factors and Ergonomics What are they? Same thing or different? Why are they important?
  5. 5. 5 Ergonomics From the Ergonomics Society website at www.ergonomics.org.uk The job must ‘fit the person’ and should not compromise human capabilities and limitations. The application of scientific information concerning humans to the design of objects, systems and environment for human use. The interaction of technology and people Basic anatomy, physiology and psychology Objective to achieve: The most productive use of human capabilities Maintenance of human health and well-being
  6. 6. 6 Physical demands - musculoskeletal disorders Psychological demands - stress Social conditions - job satisfaction Human error - cause of major 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
  7. 7. 7 Human Factors What 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)?
  8. 8. 8 There is a large overlap Ergonomics Human capabilities Hardware design Work stations User interfaces Working environment Manual handling Personal safety, health and well being Human factors Whole system Organisation Culture Tasks Errors Procedures Training and competence Major hazard
  9. 9. 9 Behavioural safety Tends to be more concerned with Physical activities Personal safety accidents Failures of people at the sharp end The premise is that people are free to choose the actions they make Human factors is based on the principle that people are ‘set up’ to fail Management and organisational root causes.
  10. 10. 10 Major accidents Texaco - Pembroke Herald of Free Enterprise Chernobyl Clapham Junction Esso - Longford Fixborough
  11. 11. 11 Why is human factors important? Up to 80% of accident causes can be attributed to human factors All major accidents involve a number of human failures Human factors is concerned with Understanding the causes of human failures Preventing human failures “Underlying accident causes are faults of management and supervision plus the unwise methods and procedures that management and supervision fail to correct…” (Heinrich 1931).
  12. 12. 12 Causes of human failures Job factors Illogical design of equipment Disturbances and interruptions Missing or unclear instructions Poorly maintained equipment High workload Noisy and unpleasant working conditions
  13. 13. 13 Cause of human failure (continued) Individual factors Low skill and competence levels Tired staff Bored or disheartened staff Individual medical problems Organisational and management factors Poor work planning, leading to high work pressure Lack of safety systems and barriers Inadequate responses to previous incidents Management based on one-way communications Poor health and safety culture
  14. 14. 14 Video
  15. 15. 15 • 1 way to undo • 40,0000 ways to reassemble Procedure Use Not something people like to do! Depends on Task experience Task complexity (Perception of) task criticality Closely related to competency Cannot write a procedure for every task Job aids can be very useful
  16. 16. 16 Training and competence They are not the same thing! Requirements must be specific – define the skill, knowledge and/or understanding to be achieved Must reflect how tasks are performed (based on written procedure) Must be evaluated Competence can degrade.
  17. 17. 17 Human factors in design Human factors considered throughout design Integral not separate activity Requires human factors expertise Based on end user requirements Involved throughout User trials Analyses Task analysis Information needs analysis Communication link analysis Workload assessment.
  18. 18. 18 Critical tasks Operating: Start up and shut down Bulk loading and unloading Complex manifolds and line ups Continuing to operate whilst some elements are inoperable Responding to emergencies. Maintenance Work on live systems Intrusive work Reassembly of items critical to pressure envelope Resetting of safety critical elements.
  19. 19. 19 Man against the machine Humans are better at Detecting small visual or acoustic signals Perceiving patterns Improvising Being flexible in approach Exercising judgement Machines are better at Responding quickly to control signals Applying force smoothly and precisely Performing repetitive tasks Handling highly complex situations Not possible to engineer-out human involvement Automation usually reduces the day-to-day human involvement Reliance on error free maintenance, testing etc.
  20. 20. 20 Control Room Design Give adequate consideration to human factors for normal and abnormal conditions Number of people (more & less than ‘normal’) Man-machine interface is a combination of displays, alarms and input devices Should be designed on a full task analysis Should map activities to controls Recognise potential under & over load of operators Feedback that actions have been successful Opportunity to correct errors Inform of deviations from safe operating levels Frequency, proximity and importance.
  21. 21. 21 Alarms - EEMUA Guide Long term average alarm rate – no more than one every 10 minutes No more than 10 alarms in the first 10 minutes of a major plant upset Prioritise High – 5% Medium – 15% Low – 80%.
  22. 22. 22 Health and Safety Executive Human factors is being seen as a high priority www.hse.gov.uk/humanfactors Specialist team within HID Inspection, investigation, expert witness, advice, guidance and research Provide specialist support Training field inspectors Aim – ‘To drive continuous improvement in the management of human performance in the control of major accident hazards.’
  23. 23. 23 HSE’s concern with current approaches Overoptimistic assumption of what people will do Intervene “heroically” Always follow procedures Well trained, highly motivated & always present Will take immediate, appropriate action Too much emphasis on personal safety rather than how errors can cause major accidents Focus on technician errors - managers, designers etc. don’t make errors! Failure to deal with human factors with same rigor as for process and engineering issues
  24. 24. 24 HSE’s Top Ten Human Factors Organisational change Staffing levels and workload Training and competence Alarm Handling Fatigue from shiftwork & overtime Integrating human factors into risk assessment and investigation Communication/interfaces Organisational culture Human factors in design Maintenance error
  25. 25. 25 What the HSE is looking for Knowledge Understanding Application Do you know what human factors is? Do you understand human factors? Do you know your limitations? Do you have the available guidance? Do you have access to competent help? Is there a ‘competent person’ on site? Is there evidence of human factors in your systems? Do you monitor and review?
  26. 26. 26 Have enforced because of Organisational change Hours of work Workload and staffing Competence assurance Human factors risk assessment for batch process No appeals on noticed issued to date
  27. 27. 27 Specific requirements Task analysis Competence assurance program Ergonomic standards Procedures Interface design Staffing level assessment Fatigue assessment and management Design and procurement procedures Shift handover.
  28. 28. 28 Task Analysis Separator tasks Start up unit Start/stop individual pumps Open/close wells Water wash separator Respond to unit trip High Low Medium Medium High Criticality Offshore Technology Report OTO 1999 092 http://www.hse.gov.uk/research/otopdf/1999/oto99092.pdf
  29. 29. 29 Hierarchical Task Analysis Water wash production separator 2.1 Put override on 2.2 Start wash water pump 2.3 Open wash water inlet valve 2.4 Put flow control valve on manual 2.5 Open flow CV to maximum SS CRFO CRFO 1. Line-up water to separator 2. Start washing 3. Monitor water outlet for oil 4. Return to normal Plan: Do 1 then 2 Do 3 until water is clear Then do 4
  30. 30. 30 Staffing Arrangements Assessment Not calculate minimum or optimum number of staff Enough people to detect, diagnose and respond to potential or actual emergency situations More people not always the solution Staffing arrangements + technology YES YES NO NO Physical assessment decision trees Individual/organisational ladder assessment Energy Institute User Guide ww.energyinst.org.uk/humanfactors/staffing
  31. 31. 31 HSE RR 292/2004 www.hse.gov.uk/research/rrhtm/rr293.htm Supervision Management function Performed by one or more people, within and/or external to the team Has been overlooked in recent years Many control room operators perform supervisory activities. Rotating leadership Coach / mentor Team appointed leader Management appointed leader Traditional hierarchy True SMT Supervision is team led Supervision is management led
  32. 32. 32 ALARP As Low As Reasonably Practicable Presumption is that you will implement ‘good practice’ risk reduction measures Need to demonstrate sacrifice is grossly disproportionate to the benefit Risk reduction would be minimal Would lead to greater risk else-where Holistic approach Risk of the whole facility.
  33. 33. 33 Demonstrating ALARP Answer these two questions What more could be done? Why have we not done it? For example, could you: automate more? – Ironies of automation have more automatic protection? – Over-reliance have more procedures? – Usability concerns do more training? – Only (small) part of competence employ more people? - ???
  34. 34. 34 Costs of Accidents Piper Alpha - $2.5 billion Exxon Valdez - $3.5 billion Grangemouth - $100 million
  35. 35. 35 Benefits of Addressing Human Factors Integration during design 1 Improved safety = less accidents Improved working conditions = less health problems More efficient operation and maintenance Less down time In some cases lower CAPEX Less than 1% of engineering costs 2 1 - MW Kellogs - Presented at Petroleum Institute 2001 2 - Shell - Presented at Houston 2002
  36. 36. 36 Risk Reduction Strategy Always look to remove or reduce hazard first Specify hardware controls – but ensure does not affect operability Procedural controls and rules – must be practical and realistic under all conditions PPE and mitigation are secondary, in addition to the above
  37. 37. 37 A changing world New technology More automation Less people More remote Different team structures Evolving jobs More passive More lonely More responsibility.
  38. 38. 38 “An airline would not make the mistake of measuring air safety by looking at the number of routine injuries occurring to it staff” A. Hopkins - Lessons from Longford
  39. 39. 39