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Behaviour-based safety (BBS) is the “application of science of behaviour change to real world problems”. BBS “focuses on what people do, analyzes why they do it, and then applies a research-supported intervention strategy to improve what people do
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Behaviour-based safety (BBS) is the “application of science of behaviour change to real world problems”. BBS “focuses on what people do, analyzes why they do it, and then applies a research-supported intervention strategy to improve what people do

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  • 1. Safety, Health & Environment Consulting, Training & Testing HUMAN FACTOR ANALYSIS www.indohaan.com Contact +91 981 0081 140 1
  • 2. Safety, Health & Environment Consulting, Training & Testing       Bhopal Gas Tragedy Flixborough Explosion Sevaso Gas Release Minamata Mercury Release IPCL, Nagothane Explosion Several others www.indohaan.com Contact +91 981 0081 140 2
  • 3. Safety, Health & Environment Consulting, Training & Testing       Out of the total 91 accidents (property loss/fatality/loss of 800MH/led to plant SD ), 66% were fire accidents 47% accidents happened during operational jobs Causes of accidents: 71% human error 11% Failure of plant 18% Presence of ignition source www.indohaan.com Contact +91 981 0081 140 3
  • 4. Safety, Health & Environment Consulting, Training & Testing HUMAN FACTOR www.indohaan.com Contact +91 981 0081 140 4
  • 5. Safety, Health & Environment Consulting, Training & Testing ACCIDENT Man Environment TASK Machine www.indohaan.com Contact +91 981 0081 140 5
  • 6. Safety, Health & Environment Consulting, Training & Testing     An injury occurs only due to an accident An accident occurs only as a result of unsafe action or an unsafe condition Unsafe actions/conditions exists only because of fault of persons Faults of persons are inherited or acquired through environment www.indohaan.com Contact +91 981 0081 140 6
  • 7. Safety, Health & Environment Consulting, Training & Testing  Anatomical or physiological characteristics  Improper psychological conditions  Lack of knowledge/skill  Improper physical or mechanical environment www.indohaan.com Contact +91 981 0081 140 7
  • 8. Safety, Health & Environment Consulting, Training & Testing       Behavior Model Human Factors Model Peterson Accident-Incident Causation Model Epidemiological Model Decision Model Systems Model www.indohaan.com Contact +91 981 0081 140 8
  • 9. Safety, Health & Environment Consulting, Training & Testing    Safety performance of an employee is dependent on his level of motivation and his ability to perform Ability is a function of selection and training Motivation depends on; Climate Style of organization Personality Peer group State of mind www.indohaan.com Contact +91 981 0081 140 9
  • 10. Safety, Health & Environment Consulting, Training & Testing  Human error is caused by; Overload: Mismatch of human capacity and the load to which he is subjected Incorrect response: By the person in a situation which is due to basic incompatibility Improper activity: Performed because he did not know or deliberately took a risk www.indohaan.com Contact +91 981 0081 140 10
  • 11. Safety, Health & Environment Consulting, Training & Testing  • • • Goals and objectives of the human Long term goals Short term goals Conflicting goals Contradictory and Different behavior Combination of goals and behavior is known as personality www.indohaan.com Contact +91 981 0081 140 11
  • 12. Safety, Health & Environment Consulting, Training & Testing  3 basic types of factors; Genetic factor Environmental or Learned Factors Situational Factor www.indohaan.com Contact +91 981 0081 140 12
  • 13. Safety, Health & Environment Consulting, Training & Testing       Height Built Color Body Personality Intelligence www.indohaan.com Contact +91 981 0081 140 13
  • 14. Safety, Health & Environment Consulting, Training & Testing  Extra uterine influence  Family and early upbringing  Education  Working environment and social group  Culture www.indohaan.com Contact +91 981 0081 140 14
  • 15. Safety, Health & Environment Consulting, Training & Testing   Changing physical and social environment of individuals Changing goals and objectives which an individual is seeking  New work method  Change in allocation of job www.indohaan.com Contact +91 981 0081 140 15
  • 16. Safety, Health & Environment Consulting, Training & Testing  Saving time  Saving effort  Seeking comfort  Getting attention  Asserting independence  Acceptance of group ethos www.indohaan.com Contact +91 981 0081 140 16
  • 17. Safety, Health & Environment Consulting, Training & Testing         Attitude and Aptitude Frustration and Conflict Morale Individual difference Skill and Training Motivation Aspiration Fatigue www.indohaan.com Contact +91 981 0081 140 17
  • 18. Safety, Health & Environment Consulting, Training & Testing      A kind of mental set up Change in attitude may radically change opinions Knowledge of attitudes helps find the real cause of an accident Attitudes are generally associated with likes and dislikes Methods of evaluation are interviews, surveys, suggestion schemes and safety committee www.indohaan.com Contact +91 981 0081 140 18
  • 19. Safety, Health & Environment Consulting, Training & Testing    Means inclination or fitness Ability related to the capacity to develop proficiency on specific jobs Aptitude tests during selection;  Mental ability  Mechanical ability  Psychomotor ability  Visual skills  Specialized ability www.indohaan.com Contact +91 981 0081 140 19
  • 20. Safety, Health & Environment Consulting, Training & Testing  Caused due to;  Characteristics;  Response ◦ Defeat or disappointment towards success ◦ Interference with the achievement of goal ◦ Aggression ◦ Regression ◦ Fixation ◦ Adaptive ◦ Maladaptive www.indohaan.com Contact +91 981 0081 140 20
  • 21. Safety, Health & Environment Consulting, Training & Testing  Physical and Mental  May arise due to; Attitude Jealousy Bad behavior Working conditions Environment www.indohaan.com Contact +91 981 0081 140 21
  • 22. Safety, Health & Environment Consulting, Training & Testing     Exploitative authoritative: Fear/Threat/Punishment/Occasional rewards. Information flows only downwards Benevolent authoritative:Uses rewards and also some punishment. Information flows only downwards Consultative: uses rewards, some punishment and some involvement in decision making. Information both up and down Participative: uses entire group in setting goals. Information flows both up and down www.indohaan.com Contact +91 981 0081 140 22
  • 23. Safety, Health & Environment Consulting, Training & Testing           Operator input limitations Operator decision limitations Operator output limitations Workplace environment limitations Inadequate decision aids No training needs analysis Training needs oversights Training needs not delivered No refresher training Incomplete refresher training www.indohaan.com Contact +91 981 0081 140 23
  • 24. Safety, Health & Environment Consulting, Training & Testing              No retraining linked to change Inadequate competence assurance Procedures fail to cover normal operations Procedures fail to cover abnormal operations Procedures fail to cover maintenance Implementation of procedures difficult/impractical Organisation of procedures difficult/impractical Ill-defined channels of communication Excessive levels of communication Authoritarian culture Limited manning Inadequate change-over procedures Inadequate mix of experience www.indohaan.com Contact +91 981 0081 140 24
  • 25. Safety, Health & Environment Consulting, Training & Testing              Ill-defined roles and responsibilities Shift friction Excessive hours (fatigue/stress) Crew compatibility Supervisory pressure Peer pressure No/poor safety leadership Poor safety communications Unresponsiveness to complaints Blame culture No safety audit procedures in place Safety audit procedures poor Safety audits not carried out www.indohaan.com Contact +91 981 0081 140 25
  • 26. Safety, Health & Environment Consulting, Training & Testing          Actions not carried out No transfer of knowledge across departments Inconsistent monitoring of personnel Poor feedback on performance Limited accident investigation (fails to identify root causes) Lessons from past accidents not learnt No/poor awareness of hazards No update of risk assessment following change Poor provision/use of PPE www.indohaan.com Contact +91 981 0081 140 26
  • 27. HUMAN FACTOR ANALYSIS MODEL Safety, Health & Environment Consulting, Training & Testing A B A B Inadequate Operator Information Workplace Environmental Limitations Inadequate Decision Information Hazard Assessment not linked to design 1.3 Alarms 1Design 1.1 Man –Machine Interface 1.2 Process/System Design A B Alarm Handling Problem Poor Provision/consideration of Alarms A B C A B C A B A No Training Needs Analysis Training Needs Oversight Training Needs not Delivered No Refresher Training Incomplete Refresher Training No Retraining linked to change No competence assurance Inadequate Competence assurance Training course inadequate/Inappropriate B On-job Training Inadequate/Inappropriate C No Formal Training Program 2.1 Training Needs Analysis Training/ Competence 2.2 Refresher / Retraining 2.3 Competence Assurance 2.4 Training Needs Analysis www.indohaan.com Contact +91 981 008127140
  • 28. Contd…. Safety, Health & Environment Consulting, Training & Testing A Falls to cover Aspects of Normal Operation B Falls to cover Aspects of Abnormal Operation C Falls to cover Aspects of Maintenance D Insufficient Operator Procedure A Implementation Difficult/Impractical B Organization Difficult/Impractical C Procedures Not updated following changes A Ill-defined Channels of Communication B Excessive Hierarchy C Authoritarian/Submissive Culture A Incomplete Refresher Training B Inadequate Change-over Information A Key Information retained by Senior Personnel B Poor Clarity in Transfer of Information 3.1 Comprehensiveness 3Procedures 3.2 Practicality 4.1 Interpersonal 4.Communic ation 4.2 Practicality 4.3 Information Availability www.indohaan.com Contact +91 981 008128140
  • 29. Contd…. Safety, Health & Environment Consulting, Training & Testing A B No Training Needs Analysis Training Needs Oversight Endemic Pressure B Transient Pressure C Supervisor Pressure eg. Bonus D Peer Pressure eg Bonus A No/Poor Safety Leadership B 6.2 Safety Culture Crew Compatibility A 6.Attitudes Excessive Hours-Fatigue/Stress B Poor Safety Communication C Unresponsive to Complaints D 6.1 Performance Pressure B A 5.3 Record Keeping Shift Friction/Over Competitiveness C 5.2 Shift work/Roasters Ill-defined roles/Responsibilities A 5.Organization Inadequate Manning-mix-Experience C 5.1 Manning–Roles/ Responsibilities Inadequate Manning Blame Culture www.indohaan.com Contact +91 981 0081 140 29
  • 30. Contd…. Safety, Health & Environment Consulting, Training & Testing No Audit in Place Audit in Place – Poor Audit in Place – Not carried out No/Sporadic Inspection Actions not carried out 7.2 Inspection No Transfer of Knowledge Inconsistent Monitoring of Personnel 7.3 Supervision Fails to feedback Performance Fails to Identify Root Causes 8.1 Accident Investigation Lessons from past not learnt No/Poor Awareness of Hazards No update linked to change 8.2 Hazard Awareness Poor provision or use of PPE, Safeguards etc. D No Assessment/ Analysis of Risk A Inadequate Control of Hazards B Inadequate Procedures 9.1 Emergency Management C No off-site Liaison D No/Inappropriate Training E Poor On-Site/Off-site Plans A No Regular Practice/Drills 9.2 Fitness for Response B Implementation Impractical981 0081 140 www.indohaan.com Contact +91 7.1 Audit 7 Monitoring 8 Risk Assessment 9 Emergency Response A B C A B C A B A B A B C 30
  • 31. Safety, Health & Environment Consulting, Training & Testing Plant upset conditions (caused by an electrical storm) were poorly handled, leading to 20 tonnes of hydrocarbon liquid being continuously pumped into a process vessel with a closed outlet. Once full, the liquid escaped through the pressure relief system to the flare line, which was not designed to cope with such quantities. As a result 20 tonnes of hydrocarbon was released and subsequently ignited leading to a major fire and a number of secondary fires.The investigation identified that the operators were not sufficiently aware of how the plant operated to be able to take control. Training had not addressed dealing with any similar scenarios. The poor information relating to plant conditions provided in the control room exaggerated the problem. www.indohaan.com Contact +91 981 0081 140 31
  • 32. Safety, Health & Environment Consulting, Training & Testing 1.1A DESIGN Inadequate Operator Decision Information Operators in the control room were unaware that valve B, which should have allowed fluid from debutaniser into naphtha splitter, remained closed after the initial upset trip. 1.2A DESIGN Inadequate decision information The system was operating on a single control loop leaving the operator unaware that the outflow was not greater than the input from the deethanizer. 1.3A DESIGN Alarm Handling Problems During the incident, alarms were being presented to operators at the rate of one every two to three seconds www.indohaan.com Contact +91 981 0081 140 32
  • 33. Safety, Health & Environment Consulting, Training & Testing 1.3B DESIGN Poor Provision/Consideration of Alarms The high level alarm for the flare drum was activated. There is no evidence that it was seen.A number of other critical alarms (not directly related to the incident) also appear to have been missed among the many equal status alarms. Warnings of the developing problems were lost in the plethora of instrument alarms triggered in the control room, many of which were unnecessary and registering with increasing frequency, so operators were unable to appreciate what was actually happening. 2.2C TRAINING COMPETENCE No retraining linked to change A key feature of the pump-out modification was reliance on appropriate operator manual action to deal with high drum liquid levels. However, in practice, personnel did not have instructions or experience of reconfiguring the system www.indohaan.com Contact +91 981 0081 140 33
  • 34. Safety, Health & Environment Consulting, Training & Testing 3.1B PROCEDURES Failure to cover aspects of abnormal operations Or TRAINING COMPETENCE Inadequate Competence Assurance The flare knock-out drum’s contents were increased still further by the operators next action which was to try to remove the flooding from the dry end of the interstage drum by draining the liquid directly to the flare line by an impromptu modification which employed steam hoses.’ 3.2C PROCEDURES Procedure not updated following change An earlier modification to the pump out system severely reduced its automatic liquid handling capacity. It overflowed, causing liquid to enter an outlet designed for gas only.It was possible to restore the original pump-out capability, by manually opening a valve, but this procedure had fallen into disuse from lack of practice and written procedures. www.indohaan.com Contact +91 981 0081 140 34
  • 35. Safety, Health & Environment Consulting, Training & Testing 4.3B COMMUNICATION Breakdown of Team Structure Or ORGANISATION Ill-defined roles and responsibilities. Where more than one operator is working, an increased emphasis on communication is required to ensure that each is working with the team. As people at senior level helped out, they took on operating roles rather than taking an overview of the whole process.Some managers and supervisors were involved in ‘hands-on’ operational matters instead of performing a strategic and diagnostic role. 8.1B RISK ASSESSMENT Lessons from past not learnt All the key elements of the incident, and the lessons drawn from it, have been seen and publicized before, in major accidents around the world. www.indohaan.com Contact +91 981 0081 140 35
  • 36. Safety, Health & Environment Consulting, Training & Testing 8.2 B RISK ASSESSMENT No Update Linked to Change There was no recorded safety assessment concerning this modification. 9.1D EMERGENCY RESPONSE No or inappropriate training www.indohaan.com Contact +91 981 0081 140 36
  • 37. Safety, Health & Environment Consulting, Training & Testing      Identify major hazard installations Carry out hazard assessment Report to authorities the result of hazard assessment Set up emergency plans Take measures to improve plant safety www.indohaan.com Contact +91 981 0081 140 37
  • 38. Safety, Health & Environment Consulting, Training & Testing      Component failure Deviation from normal operating conditions Human and organizational errors Outside accidental interferences Natural forces www.indohaan.com Contact +91 981 0081 140 38
  • 39. Safety, Health & Environment Consulting, Training & Testing  Major Accident means an occurrence including any type of emission, fire or explosion involving one or more hazardous chemicals and resulting from uncontrolled developments in the course of industrial activity or natural events likely to cause substantial loss of life and adverse effects on environment www.indohaan.com Contact +91 981 0081 140 39
  • 40. Safety, Health & Environment Consulting, Training & Testing  Legal Requirement : Rule 10, Schedule 8 of MSIHC rules  The occupier shall;  Prepare safety report and send 90 days before the activity starts  Carry out safety audit by independent expert  Send copy of auditors report within 30 days of the audit  Fresh audit every year and updation of report www.indohaan.com Contact +91 981 0081 140 40
  • 41. Safety, Health & Environment Consulting, Training & Testing Safety report should contain; A) Description of installation and process B) Description of process C) Description of hazardous substances D) PHA E) Description of safety relevant units F) Hazard Assessment G) Organization H) Assessment of consequences I) Information on mitigation of major accidents www.indohaan.com Contact +91 981 0081 140 41
  • 42. Safety, Health & Environment Consulting, Training & Testing    Major changes in plant/process New information about hazardous processes Improvements in safety engineering www.indohaan.com Contact +91 981 0081 140 42
  • 43. Safety, Health & Environment Consulting, Training & Testing      Check adherence to safety standard Carry out specific inspection Learn about the hazards Siting of industries Establish contingency plans www.indohaan.com Contact +91 981 0081 140 43
  • 44. Safety, Health & Environment Consulting, Training & Testing 1. 2. 3. Hazid : Types and quantities of hazardous material, location and storage, nature of hazard, What can go wrong ? Risk : How often ? Probability of damage ? Vulnerability : Extent of vulnerable zone, dispersion model, support systems Control can be reestablished Action during the May determine whether first few seconds/ minutes Damage/Injury avoided Accident can develop www.indohaan.com Contact +91 981 0081 140 44
  • 45. Safety, Health & Environment Consulting, Training & Testing    Legal requirement – Rule 13, Schedule 11 of MSIHC Rules Preparation of plan by occupier Conduct mock drill every 6 months for; • Objectives  Familiarity  Confidence  Accuracy  Availability  Statutory requirement  To localize the emergency and eliminate it  To minimize the effects of accidents on people and property www.indohaan.com Contact +91 981 0081 140 45
  • 46. Safety, Health & Environment Consulting, Training & Testing   Name and address of person giving information Key persons with assigned responsibility and duties Outside organization assisting details Details of liaison Information on PHA • Site details • Likely dangers to plants     Type of accident  System elements/events that can lead to major accidents  Hazards  Safety relevant components  Location of dangerous substances  Emergency control centre  Seat of key personnel  Description of hazardous chemicals at site (MSDS) www.indohaan.com Contact +91 981 0081 140 46
  • 47. Safety, Health & Environment Consulting, Training & Testing   Likely dangers to plant Effect of ; • Details of ; • Details of communication facilities Details of fire fighting Details of first aid and hospital services • •  Stress and strain during normal operations  Fire/explosion and secondary hazards  Alarm and hazard control plans  Reliable measuring instruments  Precautions in designing of foundations  General engineering practice www.indohaan.com Contact +91 981 0081 140 47
  • 48. Safety, Health & Environment Consulting, Training & Testing   Overall Co-ordinator  Senior person To decide level of emergency Call key personnel Exercise direct operational control • Action group leader/site incident controller         Assess scale Initiate emergency procedure Direct rescue and fire fighting teams To search for casualties Evacuate Communicate with ECC www.indohaan.com Contact +91 981 0081 140 48
  • 49. Safety, Health & Environment Consulting, Training & Testing           Team A : Plant/ Dept. Head, Supervisor, Worker – To control emergency Team B : Mechanical/Maintenance – To assist Team A Team C: Safety, Firefighting, Security Team D : Medical Team E : None of the above – Reserve team Administration Manager : Arrange for transportation Personnel Manager : Food, Head Count, Liaison with external agencies Telephone Operator : Keep lines free Assembly points : Depends on size of factory and wind direction ECC :  Select so that no effect of emergency Eg. Security, Gate, Control room  Should be equipped with PPE, tel.nos. , details of emergency plans www.indohaan.com Contact +91 981 0081 140 49
  • 50. Safety, Health & Environment Consulting, Training & Testing    Legal requirements – Rule 14, Schedule 12 as per MSIHC rules Mock drill once every year Formation; Central crisis group State crisis group District crisis group Local crisis group www.indohaan.com Contact +91 981 0081 140 50
  • 51. Safety, Health & Environment Consulting, Training & Testing The off – site emergency plan should include;  Types of accident  Organization involved, including key personnel and liaison arrangements between them  Site information  Technical information about substances  Facilities and transport routes  Contact for further advice e.g. meteorology, food, transport, first aid, hospital  Communication links  Fire fighting equipment  Emergency response procedures  Public notification  Evacuation arrangements  Dealing with press  Longer term “ Clean up “ www.indohaan.com Contact +91 981 0081 140 51
  • 52. Safety, Health & Environment Consulting, Training & Testing Local crisis group  Prepare local emergency plan for industrial pocket  Ensure dovetailing of local plan with district plan  Train personnel in accident management  Educate public  Mock drill every 6 months at site and give report to District crisis group District crisis group  Preparation of district off – site emergency plan  Review on – site plans of all MAH units  Continuously monitor every chemical accident  Forward report of accidents to State crisis group  Mock drill every year and report to SCG www.indohaan.com Contact +91 981 0081 140 52
  • 53. Safety, Health & Environment Consulting, Training & Testing CCG SCG DCG LCG Chairperson Member Secretary Secretary Jt. Sec MoEF MoEF Chief Labour Secretary Secretary District Inspectorate Collector of Factories Magistrate Inspectorate of factories www.indohaan.com Contact +91 981 0081 140 53
  • 54. Safety, Health & Environment Consulting, Training & Testing www.indohaan.com Contact +91 981 0081 140 54