Human factors to verify in an incident review

1. Disclaimer: We want to prevent similar incidents occurring. All guidance herein is provided in good faith and Step Change in
Safety nor its member companies accept responsibility for any inaccuracies or omissions contained within this safety moment.

2. HIDE THIS SLIDE
This pack contains examples of events where human factors
contributed to the incident. The applicable Human Factors subtopics
are highlighted on each slide.
Whilst not all the incidents occurred within our industry, the learnings
remain applicable.
You may wish to use this pack during safety meetings or break it up
and use the individual sheets for your toolbox talks.

3. What is Human Factors?
Human Factors is about understanding the interactions between people and all aspects of how work is designed and organised in order
to find ways to improve performance and safety. Investigations from across our industry tell us that human factors lie at the root of
serious incidents. If we can recognise when these factors arise in our activities, we can learn how to manage them and prevent harm.
Human Factors can be broken down into a series of basic subtopics:

4. Awareness of Risk
- Helicopters
• Remember how you felt the first time you heard the roaring
sound, the thunderous vibration & gusting downdraft of a running
helicopter?
• How do you maintain your awareness of risks?
• Helideck Assistant was
performing his duties when
he became unaware of the
helicopter tail rotor and
walked close to it.
• He had used the
correct access stairs 3
times when collecting
life jackets.
• He used the wrong
stairs when delivering
food to the pilots.
Human Factors Learning:
• Eliminating a hazard or providing a physical barrier are more
effective ways of reducing accidents than trying to maintain
people’s awareness of the hazards.
Tail Rotor Close Encounter
Safe
Access
Unsafe
Access
• During a planned crew change flight, the Helideck
Landing Officer (HLO) was one of the passengers.
Hot Swapping
• The outgoing HLO handed over to
the oncoming HLO on the helideck.
• During this handover,
they swapped life jacket
& HLO jacket under the
running rotors of the
helicopter.
How do you ensure hazards are eliminated or
physical barriers are provided rather than trying
to maintain people's awareness of the risks?

5. Loss of well control during
drilling operations
The circumstances: A drilling company was to drill its
first High Pressure High Temperature (HPHT) well.
Staffing & Workload | Competence & Training
• The company found it hard to recruit tool
pushers with HPHT experience.
• They were able to recruit one person with the
rig & UK familiarisation & one person with
HPHT experience.
• The plan was for the one with HPHT
experience to work as day tool pusher and the
one without to work as night tool pusher.
Organisational Change:
• A significant amount of new equipment had
been fitted to the drill rig for HPHT service.
Staffing & Workload | Fatigue
• Once drilling started it soon became clear that the only way
they could work the equipment was for both to be on duty
with one maintaining the drill operations while the other
concentrated on the HPHT equipment.
• They came up with a plan that they would both work 20
hour shifts and take alternate 4 hour breaks.
• They managed this for three days before one fell asleep at a
critical stage and they lost control of the well.
What went wrong?
• People aren’t superhuman. Organisations and
individuals need to understand how mental and
physical limitations can impact on safe activities.
• Manning levels must be properly assessed to ensure
safe operations.
Human Factors Learnings:
How are fatigue & manning levels
managed at your worksite?

6. Leadership & Behavioural Safety
• There were not enough lifeboats to accommodate all passengers.
• The Titanic was the product of intense competition among rival shipping lines. Due to
innovative technology, the liner was deemed ‘practically unsinkable’.
• The owner took the decision not to add additional lifeboats as this would reduce space
on the deck for 1st class passengers and did not see the sense in preparing for a disaster
that would ‘never happen’.
Human Factors in Critical Communication
• The Wireless Officer placed priority on sending personal messages for passengers. While
he did pass on some iceberg warnings, he asked the senders to stop transmitting them.
Leadership & Behavioural Safety / Human Factors in Procedures
• The captain ignored warnings of icebergs ahead and continued to travel at almost full
speed.
Competence and Training / Human Factors in Procedures
• The Lookout was the first to spot the iceberg at 500 yards away. Visibility should have
allowed him to spot the iceberg at 1000 yards or greater but he did not have the
required binoculars.
• Launched lifeboats were loaded to under 50% capacity - more people could have been
saved had Emergency Response training been conducted.
The Unsinkable
The Titanic was a luxury steamship that sank on its maiden voyage 15th April 1912 after striking an
iceberg, leading to the deaths of more than 1500 passengers and crew.
How do you ensure there is enough
emergency response equipment - Lifeboats,
jackets etc. ?
How do you prioritise safety critical
communications at site?
What would you do if you did not have the
right equipment for the job available?
How do you feel an emergency evacuation
would go at your site?

7. Distraction – the right action, wrong equipment
A senior electrician was tasked with performing a multi-point isolation on one of two
gas turbines.
The electrician was familiar with the switch room and layout of the turbines electrical
systems and isolation began on the correct turbine.
What processes are in place at your site to minimize
distraction for those carrying out complex or critical
tasks?
An investigation found that the distraction during an important job had led to the error.
Distraction
• The engineer received a call to attend the Galley over the public address (PA)
system – the call was ignored because the current job was important.
• A second announcement called the engineer urgently to the Galley, he attended to
find a fuse for the fridge had blown.
• Annoyed that an important job had been interrupted with one that could have
waited, the electrician returned to the worksite to complete the remaining isolation
points but on the wrong turbine.
• The error was discovered days later before any harm was caused. How do you ensure you are working on the correct
equipment and completed work is checked?
What processes do you have in place for returning
to a job after breaks or other tasks?

8. Human Factors in Procedures / Critical Communications / Leadership
• The work-pack made only a general reference to removing equipment in the
area.
• Various pieces of steelwork and pipe were marked with red and white tape.
• The team assumed that the tape marked equipment needed to be removed,
when in fact it was to highlight trip hazards.
• The team were instructed to ‘cut all materials in the area’.
• Leadership did not use two-way communication during the TBT to confirm the
work party understood the plan for the task as they intended.
Assumptions
A team was tasked with removing redundant steelwork and pipework.
What processes are in place at your site to
allow you to raise any questions or concerns
about work scopes?
What Happened?
• Shortly after cutting a pipe an oily smell was noticed.
• The team stopped work and it was confirmed they had cut through a live drain line.
How do you confirm you have received a
toolbox talk and understand content?

9. Vessel struck installation
After waiting on standby ~2km from the installation, the vessel was on route
to the installation.
Human Factors in Critical Communications
• Control of vessel was handed over to the Lookout. The Lookout
handed back control whilst the 1st Officer was carrying out a radio check.
• Installation CRO informed vessel they had breached 500m zone when
vessel was 250m from installation.
• Vessel 1st Officer reacts by attempting to take over vessel steering.
Human Factors in Design
• Vessel 1st Officer accidently placed the vessel into emergency steering
mode, which resulted in him losing control of the vessel.
• The switch for taking back vessel steering could also be used to place
the vessel into emergency steering mode. What would you do if you realised a control system
allowed you to breach a safety zone or limit?
Are your emergency response exercises realistic
enough to pick up a design flaw like the emergency
steering switch?
500m
Key:
Vessel Installation
1
2
3
Vessel heading set
for installation
Vessel warned they
had entered 500m
zone when 250m
from installation
Vessel attempted to
avoid collision.
Human Factors in Design
• Vessel heading was set on collision course - auto-pilot software
permitted this, despite it being against procedure.
The vessel Master arrived at the bridge when 30m from the installation, he
managed to turn the vessel, however a glancing contact was made with the
installation. Neither were critically damaged.

10. Knowing that a hazard is there DOESN’T always protect you!
During installation of a temporary piping system a worker sustained serious injuries when
they stepped through an opening in the deck and fell 35 feet to the deck below. The deck
opening was fully enclosed by a scaffold barrier at the time of the accident.
A supervisor was preparing a hose to clean up a spill. He needed help to run the hose
across the barriered area. The worker crossed the scaffold barrier with the supervisor’s
knowledge.
As the work proceeded the employee gradually moved closer to the opening. Whilst the
worker was moving the hose, he took a step backwards and fell through the opening.
Leadership & Behavioural Safety.
• Supervisor permitted employee to cross the scaffold barrier.
• Team members routinely crossed barriers without any intervention from
supervisors.
• The worker crossed the barrier to assist his supervisor. When a supervisor
asks you to do something, some people may not feel empowered to say no.
• What action would you take if a Supervisor was
requesting you to undertake a task you felt was
unsafe?
• How do you manage barriers at your
worksite?
Human Factors in Risk Assessment
• The employee knew the opening was there but believed he could avoid
it.
• When his attention became focused on the job, he stopped thinking
about the hazard. The brain ignores information which is ‘”irrelevant” to
the immediate task, so it can concentrate mental resources on the task in
hand.