This document discusses human factors in major hazard safety and outlines the top ten human factor issues according to a UK regulator. It begins with the author's biography and defines human factors. It then lists and briefly explains the top ten human factor topics, such as managing human failures, procedures, training and competence, and fatigue. It describes how organizations can use the top ten list to assess their capabilities and improve performance. An example is given of how addressing human factors led to a reduction in errors. The document concludes by providing references for further reading on applying human factors in industries like oil and gas.

1. TITLE: Human factors in major hazard safety: the top-ten issues
AUTHOR: R Lardner, AFIChemE, Chartered Psychologist
The Keil Centre
PO Box 7886
Cloisters Square
Perth WA 6850 Mobile 0452 585547
ronny@keilcentre.com.au
BIOGRAPHY
Ronny is a UK and Australian Registered Psychologist, and an Associate Fellow of The British
Psychological Society and the Institution of Chemical Engineers. He holds a Masters Degree in
Occupational Psychology from the University of Sheffield, UK. He is a founder of The Keil Centre, a
Scottish-based firm of psychologists and ergonomists, also recently established in Australia. He
specialises in the human factors which influence health and safety in hazardous industries, and has
worked in this field of applied psychology for twenty years.
KEY WORDS
Safety, human factors, organisational factors, safety culture, safety behaviour, process safety,
major hazards, error, violation, human reliability, ergonomics, psychology, staffing, fatigue,
maintenance error, isolations, human failure
Introduction
There is an increasing emphasis on the importance of managing “human factors” to achieve
improved safety and business performance in the chemical process industries and resource sector.
Major process safety and environmental incidents, including those at Texas City, Varanus Island
and Montara have highlighted the importance of addressing this aspect of performance.
However, many find the term human factors unclear, incorrectly assuming it is identical to
behavioural safety, or synonymous with safety culture.
In the UK, the national health and safety regulator has provided an operational definition of the
key human factors issues relevant to ensuring safety in hazardous industries, including
petrochemicals, oil & gas and others with major accident potential (Reference 1). The author has
found that this practical way of defining the scope of human factors is relatively unknown in
Australia, and therefore the purpose of this paper is to outline key elements of this approach, and
direct the reader to further information, support & resources. This may be timely as in Australia
several regulators (e.g. NOPSEMA; DMP) have announced an additional focus on human factors as
part of their regulatory activities, noting that these factors are relevant to performance across
safety, integrity and environmental management.
What are human factors?
Ten years ago the UK regulator defined the “top-ten” human (and organisational) factors, based
on their experience of inspecting duty-holders, investigating incidents, and taking enforcement
action (Reference 2). Table 1 names the top-ten topics, along with a brief definition of their
content. This list has been refined over the years, and a number of sub-topics defined. For
example, the safety-critical communication topic has two sub-topics: permit to work systems and
shift handover communication.

2. Table 1 : Top-ten human &
organisational factors (HOF)
topics
Brief explanation of HOF content
1. Managing Human Failures Systematic inclusion of influences on human failure
(violations and errors) during design, risk assessment and
incident investigation
2. Procedures Providing user-friendly procedures, developed according to
ergonomic principles, which support error-free performance
3. Training & Competence Developing and ensuring the ability of people to undertake
safety-critical responsibilities and perform related activities to
a recognised standard on demand. This involves the right
combination of skills, experience and knowledge.
4. Staffing & workload Ensuring the right level of skilled people available for tasks,
with a manageable workload, especially during upsets and
emergencies. Experienced supervisors regularly present at
work-site. Competent contractors, properly-supervised.
5. Organisational Change Human aspects of organisational change risk-assessed and
controlled.
6. Safety- Critical
Communications
Structured process for shift and task handover in place and
working as intended. Likewise for permit-to-work & isolations.
7. Human Factors in Design Ergonomic design principles used for control rooms, human-
machine interfaces, alarm management, and prevention of
alarm floods. Human requirements for lighting, thermal
comfort, noise & vibration addressed.
8. Fatigue & Shiftwork Work & shift patterns designed to prevent / mitigate fatigue,
and reduce error.
9. Organisational Culture Programmes exist to target critical behaviours, and include
process & occupational safety. Chronic unease exists, always
looking for system causes of failures, and opportunities to
learn or improve.
10. Maintenance, Inspection &
Testing
Structured process to minimise maintenance errors in place –
coupled with widespread awareness of risk of error. Where
specialist contractors are used, the client organization has
retained a clear understanding and knowledge of the product
or service being supplied.
The focus of this operational definition is on the key HOF topics associated with assuring process
safety and technical integrity, a much broader scope than the typical behavioural safety
programme with a narrow focus on occupational safety (Reference 3).
How can the HOF “top-ten” be used?
Once aware of the scope of human factors which have to be addressed to ensure major accident
hazards are well-managed, organisations can:-
• assess their current HOF capability and arrangements, and focus on areas of vulnerability
• educate key people about HOFs, who can then use this knowledge to improve performance
• build HOF knowledge and capability into operational, HSE and HR management systems
and practices
• recognise that forthcoming organisational or technical change provides an opportunity to
improve safety by additional focus on HOF (for example control room redesign)
• recruit or develop internal HOF specialists, who can translate HOF knowledge into
operational reality, rather than relying excessively on external specialists (References 4 &
5)
• ensure that when incidents occur, the underlying HOFs are recognised and addressed, and
subsequently built into the hazard and risk analysis process, and the management of new
projects.

3. It can be helpful to focus on one HOF topic which is salient for the company concerned, and this
usually brings other relevant topics into focus. What matters is getting started, rather than
spending undue amounts of time identifying ‘the’ issue. If there is nothing immediately obvious
then focusing on safety-critical procedures and improving human factors in investigation are
sensible places to start. This is best done prospectively, but of course much learning can also be
gained from incidents and near-misses, as the following example demonstrates.
An example
An offshore oil and gas platform experienced a series of errors during process isolations (HOF topic
10). Initial investigations were superficial, and focused on blame, revealing a lack of capability in
managing human failure (HOF topic 1) and an immature safety culture (HOF topic 9). Thorough
human factors analysis revealed the person involved in the most recent electrical isolation incident
was trying to do their best for their company under difficult circumstances, being overloaded
covering for an absent colleague (HOF topic 4). The permit-to-work system did not allow for
human error (HOF topic 6). Recommendations focused on addressing these human and
organisational factors led to a 66% reduction in isolation errors. This and other HOF case studies
can be found in recent oil and gas industry guidance (References 6 & 7). In the more recent past,
the author has conducted several studies in different companies to identify the potential for human
failure in their permit to work and isolation procedures. This has resulted in a method which can be
used by industry (Reference 8).
Further reading
There are many examples of industry-specific, freely-available, high-quality research, guidance,
tools and improvement techniques which can be used by Australian oil and gas operators to
improve human reliability and improve health and safety performance. A brief selection are
provided in references (1) to (7) below.
UK regulator HOF guidance
(1) Health and Safety Executive’s HOF web-site
http://www.hse.gov.uk/humanfactors/index.htm
Background to top-ten development
(2) Anderson, M (2003) “Human Factors and COMAH: a regulator’s perspective” in IChemE
Hazards XV11 Symposium Series No 149, pages 785-792
(3) Anderson, M (2003) Behavioural safety and major accident hazards: magic bullet or
shot in the dark? www.hse.gov.uk/humanfactors/topics/magicbullet.pdf
Developing internal HOF capability
(4) Novatsis, E. et al (2012) “Developing Internal Human Factors Capability In An
Australian Oil And Gas Company”, paper presented at the SPE/APPEA International
Conference on Health, Safety, and Environment in Oil and Gas Exploration and Production
held in Perth, Australia, 11–13 September 2012
(5) IChemE Human Factors Professional Development programme
http://www.icheme.org/humanfactors
Selected oil & gas industry HOF guidance
(6) Energy Institute HOF briefing notes
http://www.energyinst.org/technical/human-and-organisational-factors/human-factors-
briefing-notes

4. (7) Step-Change HOF guide – Human Factors: How to take the first steps
http://www.stepchangeinsafety.net/about/workgroups/FirstSteps.cfm
Preventing human failure during control of hazardous work
(8) Lardner, R. (2013) “Human Failure In Control Of Work: Plugging Holes In The Swiss
Cheese?” Paper presented at IChemE Australia Hazards Conference, Perth, Western
Australia, November 2013