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2007 North Wales OHS - Human factors overview

Presentation to the North Wales Occupational Health and Safety Group. Introduction to human factors

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2007 North Wales OHS - Human factors overview

  1. 1. Tel: 01492 879813 Mob: 07984 284642 andy.brazier@gmail.com www.andybrazier.co.uk 1 Human Factors North West Wales Occupational Health and Safety Group 28 March 2007
  2. 2. 2 A bit about me Chemical engineer 10+ years working as a risk and safety consultant Specialising in human factors Most work in major hazard industries Self-employed for 2 years Live in Llandudno Registered member of the Ergonomics Society Nebosh General Certificate.
  3. 3. 3 My aim for today Introduce human factors’ and its role in safety Tell you what we have learnt about human factors in major hazard industries Give some ideas of how this applies to lower hazard activities.
  4. 4. 4 Physical demands - musculoskeletal disorders Psychological demands - stress Social conditions - job satisfaction Human 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
  5. 5. 5 Audience participation Has anyone recently made an error? Has anyone recently violated a rule or procedure You knew the rule or procedure But decided to do it differently. Human factors is impotent when your asessing tge risks in your organization
  6. 6. 6 Major accidents involving human factors Piper Alpha Herald of Free Enterprise Chernobyl Clapham Junction Esso - Longford Fixborough
  7. 7. 7 Errors in lower hazard industries Inland revenue – record deleted Australian immigration – deported wrong person Nasa Polar Lander to Mars – crashed Sunday Mirror – photos of wrong person DWP – 40,000 PC out of action for 5 days PC World – fned for selling old computers as new IVF clinic – mixed race twins for white couple Barclay’s Bank – 62,000 people’s wages late $30 billion loss for errors in patent UK industry – errors cost £9.3 billion per year NHS - 30,000 deaths per year
  8. 8. 8 Piper Alpha Very big event Series of quite small errors Initial explosion = gas release equivalent to 10kg
  9. 9. 9 Chernobyl Operators not told about poor reactor design Given instructions - assumed must be safe Fatality of Mark & Luke Wells – working as contractors for British Waterways Not told about previous accident Given a job that had not been assessed
  10. 10. 10 Esso Longford (Australia) Operators given training - but did not understand what it meant Cecil Kumar lost his hand in a hydraulic press He had been trained but the light curtain around the machine was not set up properly
  11. 11. 11 Flixborough Plant modification designed by someone without necessary competence Q Carpark in Glasgow Large concrete slab fell 4 floors Project manager ignored advice because was not competent in structures
  12. 12. 12 Hence interest in human factors Up to 80% of accident causes can be attributed to human factors All accidents involve a number of human failures Human factors is concerned with Accepting that errors and violations are not random ‘acts of God’ They are predictable and preventable Different circumstances create different types of errors.
  13. 13. 13 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)?
  14. 14. 14 Simple errors Competent and experienced people Minor lack of precision or attention to detail Training won’t help – or telling people to “be more careful” Procedures won’t be read Need to design systems to that they are Arranged in a logical way Labelled clearly Can be used without thinking.
  15. 15. 15
  16. 16. 16 More complex errors Making the wrong decisions or choices People don’t understand how the system works Presented with confusing or misleading information Training can help Procedures can help in some circumstances Letting people concentrate Minimise fatigue and distractions.
  17. 17. 17 Made in China
  18. 18. 18 Violations Deliberate deviations from rules & procedures Most are motivated by trying to get the job done Like errors, they are caused Difference between policies and practices Impractical recommended practices Inappropriate priorities Lack of understanding hazards and risks Lack of feedback Group or peer pressure Frustration Feeling that it doesn’t matter.
  19. 19. 19 Taking short cuts
  20. 20. 20 What should you do? Have a clear view of: Errors and violations that can cause accidents Risk control measures that rely on human actions Consequences of human failure Consider human factors when: Carrying out risk assessments Investigating incidents Buying new equipment Developing systems Make sure working arrangements help people work reliability.
  21. 21. 21 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
  22. 22. 22 Risk assessments Confusing equipment controls Illogical or inconsistent layout Poor labelling Illegible, missing or hand written Complex tasks Possible short-cuts People working when fatigued or stressed Distractions and poor working conditions Reliance on communication.
  23. 23. 23 Incident investigation Human error is NOT a root cause You need to understand why errors or violations occur Telling people to be more careful is not a solution Neither is writing more procedures Or 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.
  24. 24. 24 Buying new equipment Try to make sure controls are consistent with current equipment or normal conventions Identify specific training needs Don’t rely on the manufacturers instructions Include ergonomics in your purchasing specifications.
  25. 25. 25 Stress People pay less attention They do not communicate so well As well as being bad for health, stressed people make more errors.
  26. 26. 26 Communication . There were 20 sick sheep, one died, how many were left? Error is an integral part of communication.
  27. 27. 27 What are your procedures like? A – Clear, concise and comprehensive B – Clear, concise, some gaps C- Wordy and complex
  28. 28. 28 Procedures - 80% rule Page 1 Page 2 Page 3 Page 4 Page 5 0 10 20 30 40 50 60 70 80 90 100 % Whole read procedures
  29. 29. 29 Better procedures Procedures can assist in risk control Different types – depending on risk of activity Mandatory – few where step-by-step instructions are necessary Job aids – summarise key information Guidelines – primarily for training Only write the procedures that are really needed Aim them at experienced people Not someone off the street.
  30. 30. 30 Training Only a small part of people becoming competent The following affect how people work Knowledge Skills Attitude Habits Most learning is done ‘on the job’ Often very unstructured.
  31. 31. 31 Something to beware of Any of these sound familiar? Forgetting to take your change Forgetting to take your receipt Leaving headlights on when getting out of the car Leaving the gas on when finished cooking Leaving the original in the photocopier Forgetting the attachment on an email All examples of where there is an extra step after the main task is complete.
  32. 32. 32 Where does ergonomics fit in? 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 Accidents
  33. 33. 33 And what is 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.
  34. 34. 34 Where does human factors fit with ‘Traditional’ Health and Safety Management responsibility Safety culture.
  35. 35. 35 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).
  36. 36. 36 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”
  37. 37. 37 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)
  38. 38. 38