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Reliability and Safety:

Looking at the unique human factors needed to predict, prevent

and manage incidents

Tim Southam. QCVSA, BSc, FIEHF, FIIRSM, CMIOSH

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Electronics Design 8 Years

RAF Pilot 21 Years – Jaguar /

Tornado – Rae Farnborough

Human Factors Specialist -

Registered Ergonomist and

Chartered Safety Professional

Specialist in Virtual Reality

design, workload, fatigue, Human

Error, Human Factors Integration,

Human Performance. Human

Factors Engineering.

Associate Consultant with:

The Keil Centre

Abbott Risk Consulting

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The Situation is:

• We are very good at saying Human Error is an issue

and plays a part in accidents

– Then do little about it.

• We say “No harm to people, equipment and the

environment.

– Then do not remove the opportunity for it to

happen again or the conditions for human error.

• We investigate accidents and incidents

– Then stop at the person and do not get to the real

root causes of human error.

• What we say we do

– We often don‟t

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What do we do to Prevent or Reduce Human Error?

We do not diagnose the pain

• Safety Critical Task List• Predictive Human Error Analysis (PHEA)• HAZOP including HE Guidewords• Safety Case including Human Factors as

per APOSC and legislation• Human Error Analysis in AI using HFAT• Learn the lessons from experience

The Question

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Reactive Management Optimum Performance

Plan, think and get right first time

Is there a Price for Risk Management?

When do YOU want to Manage the problems?

The Rules Change

We Spend Lots of £ Layout Access / Egress

Signs / Labels Complexity

Control Interfaces

Physical Environment

MaintenanceReliability

Vendor Packages

Stress Fatigue

Workload

Working HoursShifts

Competence

Working Conditions

Physical Demands

Communication

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9 August 19882025 hrs

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Organisational

culture

Design, Packages,

Access, signs,

Maintenance

Layout

Alarm Handling

CCRs, Screen Config

Process Visability

Interfaces

Useability, HAZOP

HF Guide-words

EngineeringIssues

Safety Critical

Task Analysis, PHEA

Fatigue

Behaviours

People Issues

Human Failure

Accident Invest – HEA

Safety Critical

Communications

Procedures

Integration

Systems Issues

Man of Change

Leadership &

Supervision

Workload / Time

Training and

Competency

Resources

Performance

Human

Failure

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Engineers Graph

EngineeringAge

I need betterengineering

Systems Age

I need moreprocedures

Human FactorsIntegration

Age

BBS will fix it(Theirs not Mine)X X X

Continuous Improvement

Workforce Involvement

Open, Honest Communication

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Learning The Lessons

Yet do we deal with:

– ensuring adequate resources for tasks,

– reducing “initiative overload”,

– dealing with maintenance backlogs

– and long working hours,

– and have created high workloads, high

fatigue levels in the workforce.

– Stress is High

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Why Address Human Factors

When we addressing human factors, we're aiming to:

• Optimize human performance• Reduce human failures.• Increase Business Performance

Even experienced, highly-trained, well-motivated technicians make simple slips and omissions, mistakes

and

such errors can initiate major accidents, as well as result inpersonal injury to personnel.

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Los Rodeos Airport, Tenerife 27th

March 1977 - 583

Human factors – why bother?

The Herald of Free Enterprise6 March 1987 - 193

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Process Safety Management

… it must be more about insights, recoveries

and adjustments.

Less about sticking to the checklist as the

plane goes down.

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Ergonomics - Make Safety Achievable

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Stress FatigueWorkload

Working Hours

Shifts

ErrorsSlips

Lapses

Mistakes

GENDER

NATIONALITY

PARENTAL LOVE

UPBRINGING

EDUCATION

CULTURE

LIFE’S EVENTS

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Impact on data processing

1 We take in information through our senses

1 We might misread something, we might miss something important, we might choose to focus on certain things rather than others

3 We process the

information and make

decisions …

3 We might make the

wrong connections, we may

not have all of the facts, we

might make the wrong

assumptions

2 … referring to our memory store

2 We might forget or fail to

remember important

information

4 We act accordingly in line with the decision made

4 We might select the

wrong response, we might

set out to act in one way

but get “clumsy”

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Performance Influencing Factors• Task Factors

• Communication Factors

• Procedures and Documentation

• Ambient Environment

• Training and Experience

• Human-Machine Interaction

• Personal Factors

• Social and Team Factors

Number of tasks, Complexity, Time Pressure, Workload, non-standard activities

Communication workload, Phraseology & Standards, Language and accents, information content, method, Quality, equipment quality and reliability

Procedure availability / access / location, No of

Procedures, accuracy, correctness,

completeness, clarity, validity, format, do-ability,

suitability, compatibility

Weather, Noise, Distraction, Lighting,

Temperature, Air quality

Familiarity with Task, experience, time on job, training, quality of training, suitability of training, recency of training, competence testing, mentoring quality.

Information accuracy / correctness, info type and format, info availability / access, Quality, completeness, clarity, complexity, validity, info structure, location, position, equipment reliability, trust in equipment, allocation of tasks between person and systems, health risks, ergonomics, visual display quality,

Alertness / concentration / fatigue, emotional state, stress, anxiety, boredom, confidence, complexity, job satisfaction, Domestic issues, fitness / physical health issues, Mental health, drugs and alcohol.

Team co-ordination, quality, groupthink, handover / takeover, structure & dynamics, Team relationships and trust, Maturity, inter-team co-ordination, Age, Shift organisation, assistance and support, working methods, staff availability, allocation of responsibility

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Human Factors Inspectors Toolkit

Core Topics:

Competence Assurance

HF in Accident Investigations

Identifying Human Failure

Reliability and Use of Procedures

Common Topics

Emergency Response

Maintenance Error

Safety Critical Communications

Safety Culture

Specific Topics

Alarm handling

Managing Fatigue Risks

Organisational Change

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Distraction

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Human Error

- Situational Awareness required!!!?

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Most Organisations……..

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Human ErrorHigh Costs of AccidentsAccident PotentialWorkload and FatigueInefficient systems and proceduresPotential for Major AccidentsNon-compliance with regulationsNon-compliance with current guidelines

High PerformanceHigher ReliabilityOrganisational AlignmentHF Understanding and AwarenessProactive Risk AssessmentsHuman Centred designs and OperationsMore effective Control roomsCommunication and Systems FeedbackMore effective alarm handlingManning levels at correct levelEffective Shift-work and handoversSafety CultureWorkforce Interaction and InvolvementHappy Regulator

COSTS

15-20%

£

PERFORMANCE

Human FactorsIntegration

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Principles of Human Performance

• Humans are fallible . . . Even the best people make mistakes.

•Error-Likely Situations are . . . Predictable, manageable and preventable.

•Individual behaviour is influenced by . . . Organisational processes and values.

•Behaviours are reinforced . . . People achieve higher levels of performance

•Events are avoidable . . . By understanding the reasons mistakes occur. By applying lessons learned

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Conclusion• Processes Need Humans

• Humans are involved in processes from the outset.

• Safety is maximised by optimising the human

involvement, not by minimising it.

• Operators of processes need to be involved

systematically with its design.

• Design Must Accommodate Human Performance…

just like any other component of the system.

• Human Factors Engineering is a mature discipline

that is based on reliable, validated descriptions of

human performance.

• It specifies safe operational limits for human work and

design interfaces with other components.

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Imagine if you are in Court asking yourself:

• „How did we get ourselves in this position?‟

• We have known about Fatigue, Stress, Workload and the Physiology of Shift Work for a long time

• How will you be exonerating yourself?

• „Our management of change procedures failed‟

• We thought we had it controlled

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Imagine if you are in Court being asked:

• Explain why does your Internationally-

operating company does not have Time

available to ensure people work in the

right frame of mind or have adequate rest

periods?

• Please explain why you do not change the

way you operate until something has gone

wrong and people get hurt?

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Let us Co-Invent the Future