This document discusses the top 10 human and organizational factors issues relevant to high-hazard industries according to the UK Health and Safety Executive. It provides an overview of these issues and examples from the UK oil and gas industry of improvements made in these areas. A case study is presented analyzing human errors in isolation incidents using human factors analysis tools. Recommendations are provided for reducing isolation errors and violations.

1. © The Keil Centre 2015
1
Human factors in major hazard
safety: the top 10 issues
Ronny Lardner AFIChemE
Registered Psychologist
ronny@keilcentre.com.au
and organisational
v

2. © The Keil Centre 2015
About your speaker
• 22 years experience as applied
psychologist in high-hazard
industries
• Founder of The Keil Centre Ltd
• Associate Fellow of British
Psychological Society &
Institution of Chemical
Engineers
• Registered Psychologist in
Australia

3. © The Keil Centre 2015
Overview
• Top-ten "human and
organisational factors" most
relevant to high-hazard
industries
• UK oil and gas industry
experience of making
improvements on these topics
• A case study
• Further reading & resources
• Questions / comments
3

4. © The Keil Centre 2015
Why “human factors”?
• UK Health and Safety
Executive
 General guidance on human factors
HS(G)48
 10 key human factors topics for
hazardous sites / installations
• Numerous incidents
 Lost balance between major hazard &
occupational safety
 Many human factors causes
 “behavioural safety” not enough
• Client / partner expectations
 Developing their own expertise
 e.g. Woodside, Inpex, Chevron

5. © The Keil Centre 2015
Human factors
Reducing error and influencing behaviour

6. © The Keil Centre 2015
6
What do we mean by ‘human
factors’ in hazardous industries?
10 Key UK HSE human & organisational factors issues
 Managing human
failure
 Procedures
 Training and
competence
 Staffing, including
supervision
 Organisational change
 Safety-critical
communication
 Human factors in
design
 Fatigue & shiftwork
 Organisational
(safety) culture
 Maintenance,
inspection and testing

7. © The Keil Centre 2015
7
Influences on human reliability & performance
Organisational (safety) culture
Usable procedures Safety-critical communication
Training and competence Human factors in design
Staffing levels, including
supervision
Fatigue & shiftwork
Organisational change
Maintenance, inspection and
testing
GOAL: Managing human reliability &
failure

8. © The Keil Centre 2015
8
Case study: human factors analysis of
five isolation incidents
• Three human errors, two violations of
the control of work / isolation
procedures
• This incident involved a very
experienced electrical technician – a
classic maintenance error
• The investigations identified a number
of performance-shaping factors, which
increased the likelihood of errors
• Control of work system was analysed to
establish if it was “error-tolerant”

9. © The Keil Centre 2015
9
Human Factors Analysis Tools
Specify behaviour(s) to be understood
Behaviour
intentional or
unintentional?
ABC Analysis Human Error
Analysis
Intentional Unintentional
Gather Evidence
Identify Critical Factors
& Causes; Write
recommendations
Assemble
Timeline
CF 1 CF 2 CF 3
Traditional
analysis
Human
factors
analysis

10. © The Keil Centre 2015
10
Human Factors Analysis Tools
Specify behaviour(s) to be understood
Behaviour
intentional or
unintentional?
ABC Analysis Human Error
Analysis
Intentional Unintentional
Gather Evidence
Identify Critical Factors
& Causes; Write
recommendations
Assemble
Timeline
CF 1 CF 2 CF 3
Traditional
analysis
Human
factors
analysis

11. © The Keil Centre 2015
11
Human reliability assessment
- a proactive technique for critical tasks -
Task Probability of failure
Task of similar nature to
process isolation, with some
independent checking of output
?? in 1000
Above, without independent
checking of output
?? in 1000
?? in 1000Above, plus time shortage for
error detection and correction

12. © The Keil Centre 2015
12
Human reliability assessment
- a proactive technique for critical tasks -
Task Probability of failure
Task of similar nature to
process isolation, with some
independent checking of output
3 in 1000
Above, without independent
checking of output
9 in 1000
81 in 1000Above, plus time shortage for
error detection and correction
Performance-
shaping
factors

13. © The Keil Centre 2015
13
Recommendations
• Reducing isolation error rate
• Early detection of isolation errors
• Educate personnel on human error, and performance-shaping
factors
• Share learning with other platforms, and other organizations
using same control of work software
• Reducing isolation violations
• Result: 66% reduction in errors, and remaining errors are of
lower potential consequence

14. © The Keil Centre 2015
14
Swiss Cheese Model
Hazards
Harm&Event
Engineering Process
control
system, safety
devices
Management
system
Behaviour
& culture
Emergency
response

15. © The Keil Centre 2015
15
Scope of COWS human factors review
Human failures
during
hazardous
work
ABC Ltd and
published data
COWS
design
COWS
training
COWS
use
(12 phases)
Performance
shaping
factors
Recovery
Harm&Event

16. © The Keil Centre 2015
16
Safety culture and human factors
• Key points
 Many hazardous industries
need more management
focus, tools & techniques for
identifying and reducing
error, and performance-
shaping factors
 Human error includes
management error
 More traditional behavioural
safety wont help
 Strong Link to Just & Fair
Culture
Maturing
safety
culture
Decreasing
number of
unsafe acts
Unintentional
(Error)
Intentional
(Violation)
Capability
improvement
needed here?
Weak safety culture:
Error obscured by focus
on more obvious
violations, and blame
Strong safety culture: Cannot eliminate
error; ATC = 98% error; 2% intentional
A
developing
safety
culture:
55%
violations;
45% error

17. © The Keil Centre 2015
17
Summary
• A more sophisticated
understanding of scope of
human factors, and the
many & varied influences on
behaviour is required
• Increased development of
internal company expertise
is slowly taking place
• Integration of human factors
into design, operations,
maintenance and
decommissioning is
necessary

18. © The Keil Centre 2015
18
IChemE Human Factors professional development
course
• Joint initiative with The Keil
Centre
• 4 x 2-day modules, spread
over 12 months
• Covers main “top-ten” HF
topics
• Three complete Australian
courses now finished
 80 industry delegates
• Another East Coast course
commences May 2016

19. © The Keil Centre 2015
• Further reading on abstract
• Relevance?
• Questions?
• Comments?
• Thanks