Humanfactors New Guidance presented by Bil Gall May 2008

7/25/2019 Humanfactors New Guidance presented by Bil Gall May 2008

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Investigating and analysinghuman and organisational

factors aspects of incidents

and accidents

Presented by Bill GallNew Guidance published May 2008



The Guidance was

developed by the

Energy Institute’s

Human andOrganisational actors

!or"ing Group

#ee website for detailsof the HO!G’s wor"$

www%energyinst%org%u"&humanfactors



Introduction

This presentation

explains why new

guidance is neededand introduces the

document with some

selected extracts

including generaland specific

examples of problem

areas



Background

• The petroleum and allied industries investigate

and analyse both incidents !near misses"# and

accidents $ whether with ma%or ha&ards oroccupational potential' but(

• )uman and organisational factors aspects are

rarely addressed sufficiently

• That is' investigations*analyses often fail to establish root causes

and thus fail to identify effective

actions in response



Investigation - Analysis

+nvestigation $ gathering information'

reconstructing events' for example' using a time,

line' to ma-e sense of the incident

.nalysis $ thorough and systematic review of the

information to identify root causes



Investigation - Analysis

• The guidance focuses on analysis but also

advises on the investigation process*data

gathering• /aults in the conduct of an investigation can

ma-e subseuent analysis difficult or its results

invalid



“HOF aspects are rarely addressed

sufficiently”

1vidence to %ustify the above statement

3eviewing incident investigation reports for thisstudy and two other studies , one in the

petroleum industry the other in the nuclear

industry , it was not possible to establish

• The type of human failure involved• The basis for the analysts" conclusions



Further Evidence

4everal incident analyses indicated

• +mmediate 5ause $ )uman 1rror

• 3oot 5ause $ )uman 1rror



A Prole! "ith #hecklists

. chec-list provided by a ma%or ha&ard industry to

assist investigators in their tas- proposed the

following !root causes"

• 6ac- of competence• +nadeuate procedures• +nadeuate tools or euipment

These are not root causes: the investigator can

and should continue to ask questions



$uestions

!6ac- of competence" $ 7hy 7hat

organisational processes have failed

• 4election procedures• Methods for identifying training needs

• Training delivery or assessment

!+nadeuate procedures" $ explain !inadeuate"

• .re they difficult to find when they are needed• 9nclear or poorly worded*illustrated

• :ut of date

.gain' what failed here*what do we need to fix



#ase %tudy & a spillage incident

. road tan-er driver refuelling his vehicle left it

unattended with the trigger loc-ed;

Ten litres of diesel spilled onto the forecourt of

the refuelling bay' reuiring clean,up and

causing delay to other drivers

7hy



E'a!ple & analysis of incident 7hy

7hy 7hat was the

!payoff" for violating

7hy 7hat

was so

urgent

The driver did not comply with company

procedures for refuelling; )e had left his vehicle

unattended to spea- to a colleague; )e alsostated that he had done this before without

incident;



E'a!ple & further analysis

The investigation did not seem to explore the

underlying causes of the driver"s violation;

• <id he need something from his colleague• <id he feel under time pressure and could not

stop after refuelling to tal- to his colleague• 7as he simply bored

The analysis also failed to explore the issue of

!safety culture" the role of his colleague and other

observers $ why did no,one else intervene



Proposed solution

rom the incident report

<river was made aware of what can happen whennot ta-ing full care when carrying out any operation

within the terminal

= >?e more careful@



Better solutions(

• <iscipline the driver and warn others about this

ha&ardous practice

• 1xplore the site"s safety culture• 5onsider removing the loc-ing trigger

on filler no&&les or add an automatic cut,off

?9T $ removing the loc-ing trigger could

encourage drivers to improvise; .n automatic cut,

off could create false sense of safety



)earn fro! Incident and Accidents

.n incident or accident has to be seen as a

learning opportunity and one not to be wasted by

unless the true ):/ root causes are established

The more thorough the level of analysis' the

better the response in terms of focused

improvements

This is what

you see

This is what you don"t see $

until you start to dig



I!proving investigation and analysis

7hich investigation*analysis methods are the

most useful in identifying ):/ root causes

The guidance does not tell you

The guidance provides criteria for you to choose

.nd before that' gives some information you will

need to get the best from the methods



Basic *nderstanding of HOF Issues

The Guidance <escribes

• )uman failure types

$ 4lips' 6apses' Mista-es' Aiolations

$ 4afety Management

$ 4afety 5ulture



A *seful Failure +odel

<irection of 1vents

<irection of .nalysis



,he eed for a ./ust0 #ulture

The need for a fair system of sanctions and

rewards

Too punitive $ reporting*cooperation will bereduced

Too lenient $ complacency' low motivation

conform to rules



)ifecycle of an Investigation

The Guidance provides advice and cautions for

each lifecycle stage and advises on how best to

address ):/ issues; The stages are• 3eport

• +nvestigate*analyse

• Ma-e recommendations

• .ssign' trac- and close out actions

• 4hare information



Brief #hecklists1Aides +e!oire

Bey /actors .ffecting )uman /ailure

• 7or-place $ design and layout of wor-spaceand euipment' wor- environment

• Tas- $ poorly designed' wor-load

• Cersonnel $ competence' fitness' motivation

• :rganisation $ supervision*leadership' change

management



%electing an Appropriate +ethod

'autions

• ?e realistic about the team"s expertise in )/D

may reuire training• 5hec-lists $ can help as an initial prompt but

, as shown already , can mislead the user



#riteria for %election of a +ethod

• Training reuirements

• Caper or software,based method

• 3etrospective analysis of incident reports

• 9sed in petroleum industry

• Generates graphical content e;g; timeline

• . complete method for incident analysis

• Crovides solutions

• +ncludes chec-lists or flowcharts



+atri' & #riteria Against +ethods

(ethod Training )e*uired Paper+Based or #oftware

)etrospective ,nalysisOf Incident )eports

-sed inPetroleum Industry

Generates Graphical'ontent .e%g%timeline/

'omplete (ethodfor Incident ,nalysis

Provides#olutions

Includes'hec"listsor low 0iagrams

Paper #oftware



+ethods

28 methods described briefly in the Guidance

+ncluded because they

• 7ere cited by interviewees as methods theyhad successfully used

• /eature prominently in incident investigation

literature or

• 5learly offer a sound approach to identifying):/ aspects



Further +ethods

E additional methods are described but not in

detail because they

• <o not appear to be !mainstream" methods• ?ut they are cited in the literature and

• )ave potential for application in the petroleum

and allied industries and others#



Incident1Accident

Investigation1Analysis +ethods .35. $ .C:66: 3oot 5ause .nalysis

?lac- ?ow Ties

<:3+ $ <efining :perational 3eadiness To +nvestigate

15/. $ 1vents and 5ausal .nalysis 5harting# and 15/.F , 1vents and

5onditional /actors .nalysis

/ishbone diagram

)13. $ )uman 1rror 3epository and .nalysis 4ystem

)13.,.N94 $ )uman 1rror 3eduction in .TM .ir Traffic Management#

)/.54 $ The )uman /actors .nalysis and 5lassification 4ystem)/.T $ )uman /actors .nalysis Tools

)/+T $ )uman /actors +nvestigation Tool

)4H4 $ )uman 4ystem +nteractions and allied industries and others#



Incident1Accident

Investigation1Analysis +ethods+5.M $ +ncident 5ause .nalysis Method

M1<. $ Maintenance 1rror <ecision .id

M:3T $ Management :versight and 3is- Tree

C1.T $ Crocedural 1vent .nalysis Tool

C3+4M. $ Crevention and 3ecovery +nformation 4ystem for Monitoring

and .nalysis

45.TI $ 4ystematic 5ause .nalysis Techniue

4:6 $ 4afety through :rganisational 6earning

4:9351J $ 4ee-ing :ut the 9nderlying 3oot 5auses of 1vents4T1C $ 4euentially Timed 1vents Clotting

4torybuilder

Tap3ooTI

Belvin# Top,4etI



Incident1Accident

Investigation1Analysis +ethodsT3.51r $ Techniue for 3etrospective and Credictive .nalysis of

5ognitive 1rrors

Tripod ?eta

7?. $ 7hy,?ecause .nalysis

K 7hys

7hy Tree

.dditional Methods

5.6M $ 5ombined .ccident ana6ysis Method

+4+M +ntegrated 4afety +nvestigation MethodC3:.5TI

4.5. $ 4ystematic .ccident 5ause .nalysis

4T.MC 4ystems Theoretic .ccident Modelling and Crocess

T:3 $ Techniue of :perations 3eview



2eferences and Biliography

The Guidance describes sources of information

used including useful websites



Otaining a #opy

/ree download C</# available from

www;energyinst;org;u-*humanfactors*incidentandaccident

Crinted copy from 1+ Cublications online section of

the 1nergy +nstitute website L0#

+4?N O8 0 8K2P K2 O



Ackno"ledge!ents

The 1nergy +nstitute gratefully ac-nowledges the valuable contributions that

the following individuals and companies made to this pro%ect

<r Bathryn Mearns .berdeen 9niversity

Crof 3hona /lin .berdeen 9niversity6ee Aanden )euvel .?4 5onsulting

<enise Mc5afferty .merican ?ureau of 4hipping

.ndrew 6ivingston .t-ins Global

ohn Mc5ollom ?.e 4ystems

Crof Graham ?raithwaite 5ranfield 9niversity

6es 4mith <NA

<ominiue van <amme 1urocontrol

<r ?arry Birwan 1urocontrol

3achael Gordon 1urocontrol



Ackno"ledge!ents & continued

Ceter .c-royd Greenstreet ?erman

ohn 5happelow )uman /actors +nvestigations

<r 5laire ?lac-ett )uman 3eliability

1uan <yer Belvin Top,4et3onny 6ardner Beil 5entre

3ichard 4caife Beil 5entre

Crof Trevor Blet& 6oughborough 9niversity

4tuart 7ithington Marine .ccident +nvestigation ?ranch

3ainer Miller Mensch,Techni- :rganisation

6ouise /arrell National Grid

5hris Mostyn National Grid

<r 4teve 4horroc- N.T4



Ackno"ledge!ents & continued

3udolf /rei Noordwi%- 3is- /oundation

Crof .nn Mills 344?

<eclan Bielty Cfi&er

Gerry Gibb 4afetywise 4olutionsMar- Caradies 4ystem +mprovements +nc

T%er- van der 4chaaf Technical 9niversity 1indhoven

Gerard van der Graaf Tripod /oundation

<r 6inda ?ellamy 7hite Queen ?A

4tep 5hange in 4afety :rganisation

The 1nergy +nstitute would also li-e to ac-nowledge the )41 for their

financial contribution to the development and dissemination of this

publication;

Humanfactors New Guidance presented by Bil Gall May 2008

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Transcript of Humanfactors New Guidance presented by Bil Gall May 2008