The Contribution of Human Factors in Getting Safety ... - IOSH
Transcript of The Contribution of Human Factors in Getting Safety ... - IOSH
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The Contribution of Human Factors in Getting Safety Right
Simon Skinner MBA BSc (Hons) DPS C.ErgHF MIEHFIOSH 4th July 2016
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What am I going to talk to you about?
What does NATS do?
NATS Strategy
Human Factors
Human Performance
Safety Culture Case Study
Airports Case Study
So how have we done it?
2
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Slide 3
SCOTTISH AREA CONTROL CENTRE
LONDON AREA CONTROL CENTRE
SHANWICK AREA CONTROL CENTRE
Two Control Centres- Prestwick & Swanwick
NATS
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London Terminal Control Operations
Slide 4
Controls low level
traffic around London
and South East England
Including aircraft
making approaches and
departures to and from
the main London airports
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En-route ATC
PrestwickHandles on average 2,500 flights/dayScottish Oceanic Control Centre
Scottish Area Control Centre
Manchester Area Control Centre
SwanwickHandles on average 5,500 flights/dayLondon Area Control Centre
London Terminal Control Centre
London Military Air Traffic Control
WhiteleyCorporate & Technical Centre
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NATS Airports
EDINBURGH
BELFAST
GLASGOW
ABERDEEN
MANCHESTER
LUTON
STANSTED
LONDON CITY
HEATHROW
SOUTHAMPTON
FARNBOROUGH
CARDIFF
BRISTOL
Heathrow has over 1,300 flights per day,
90 aircraft per hour
Heathrow is the busiest 2 runway airport in the world
+ GIBRALTAR
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NATS Strategy
04.07.16
NATS7
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The NATS Safety Strategy
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The NATS Safety Strategy
People are our strength not our weakness
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There are 3 elements to how we help people to do their jobs
› How well the person is supported by the things they use to do their job (HMI, technology, airspace, procedures etc.)
› How well the person is prepared for the task (selection, training, confidence, competence etc.)
› How well the person is supported by the organisation (leadership, culture, motivation, reward etc.)
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There are 3 elements to how we help people to do their jobs
› How well the person is supported by the things they use to do their job (HMI, technology, airspace, procedures etc.)
› How well the person is prepared for the task (selection, training, confidence, competence etc.)
› How well the person is supported by the organisation (leadership, culture, motivation, reward etc.)
Provide the right TOOLS
Provide the right CAPABILITY
Provide the right ENVIRONMENT
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All 3 elements of Human Performance have to work together
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Strategy, HP & HF
People create safety Safe, effective systemperformance
TheSafety
StrategyBusiness Performance
People need support
Selection, Training, Procedures, Tools & Equipment, Teamwork, Roles & Responsibilities,
Wellbeing, Leadership,Change Management,
HP Assurance
The key Human Performance areas that deliver safety
Human Performance
Support needs expertise
The discipline that deals with the underlying
Human Factors in work situations and their
optimisation
Human Factors
Situation Awareness,Workload, Human
Centred Design, Fatigue, Training
Effectiveness,Change Management, Controller Confidence
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Human Factors in NATS
A team of 23 highly experienced professionals – and growing
Reports to the Director of Safety
Fully embedded into the NATS change process and the Safety Management System (SMS)
We spend most of our time in ops rooms / towers solving real problems
Our vision is to “Optimise Human Performance”
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How Human Factors supports Human Performance in NATS
TOOLS
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Provide the right TOOLS
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Provide the right TOOLS• Understand the
Requirement
• Remove Risks through Human Centred Design
• Identify and Mitigate sources of Human Error
• Support Transition and Change• Competency and
Confidence
• Provide HF Validation and Assurance
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Provide the right TOOLS
Swanwick Centre / Visual Control Towers
• Make sure you
comply with the
regulations
• Or that you can
make a really good
case as to why you
are deviating from
them
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Provide the right TOOLS
iFACTS, SwanwickCentre
• Apply ergonomic
standards and best
practice – they help
to avoid future
issues
200mm
Hand / Wrist / Arm
Support
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Provide the right TOOLS
Manchester Control Tower
• Identify design
options before
expensive
decisions are
made.
An Early Design
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Provide the right TOOLS
Manchester Control Tower
• Human Factors
staff have to be
very “hands-on”
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Provide the right TOOLS
Electronic Flight Data, Prestwick Centre
• Involving the users
helps to win their
“hearts and minds”
The Final Design
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How Human Factors supports Human Performance in NATS
CAPABILITY
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Provide the right CAPABILITY
Electronic Flight Data, Prestwick Centre
• Train the
controller how to
use the tools
And
• Train the
controller how to
control using the
tools
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Provide the right CAPABILITY
HF Training is provided for ATCOs, Managers and Safety Specialists in NATS.
Also provided externally to Regulators, Airport Operators, Airlines and other ANSPs
Training available includes:
Introduction to Human Factors
Incident Investigation
Visual Scanning in the Operational
Environment
Fatigue Risk Management
Team Resource Management
Building Personal Resilience &
Confidence to Achieve Success
Train the trainer
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Provide the right CAPABILITY
Building Personal Resilience and Confidence to Achieve Success
• There is a peak in trainee ATCO failures when they reach the very last stages of training
• By this stage, 98% of the training cost has been spent
• 40% of failures are related to “non-technical skills”
The Approach
• Training Course8 modules delivered over 2 daysSelf reflection and analysisTailored and bespoke approach
• 1:1 CoachingThree 1.5 hour sessions over a number of cyclesBespoke support using workbook, exercises, training materials, andInstructor and Training Manager support
“I have been involved in many aspects of training, but the 1-2-1 coaching and resilience courses have been (in my opinion) the biggest cultural shift to training during my thirteen years in NATS.”
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How Human Factors supports Human Performance in NATS
ENVIRONMENT
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Provide the right ENVIRONMENT
Heathrow Control Tower
• Don’t forget the
personal issues
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Provide the right ENVIRONMENT
Fatigue Awareness Training
Mandatory for ALL Controllers, Assistants and Operational Engineers in NATS
Mandatory for ALL Managers of Controllers, Assistants and Operational Engineers
Advisory for all other staff
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Provide the right ENVIRONMENT
Safety Culture
0
10
20
30
40
50
60
70
80
90
100
MANAGEMENT COMMITMENT
RESOURCING
JUST CULTURE, REPORTING &
LEARNING
RISK AWARENESS & MANAGEMENT
TEAMWORK
COMMUNICATION
RESPONSIBILITY
INVOLVEMENT
Unfavourable
Neutral
Favourable
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Content
Attributes of the Initiative Being Implemented
Context
Attributes of the Environment
Where Initiative is Implemented
Process
Steps Taken to Implement the
Initiative
Individual Attributes
Attributes of the Employees Where
Initiative is Implemented
Perceived Change
Readiness
Perceived Stage of Change
Individual Impacts
Team Impacts
Organisation Impacts
ANTECEDENTS PSYCHOLOGY OF CHANGE
CONSEQUENCES
Provide the right ENVIRONMENT Change Management
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Provide the right ENVIRONMENT Leading Indicators
Open Reporting
Incident Investigation
Day 2 Day Safety Observations
Measures events that go wrong
Measures the positive
things people do
More data = greater ability to proactively
manage safety risk
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To optimise Human Performance, ALL aspects of the framework have to beconsidered
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HP and HF in the Safety Management System (SMS)
“It is critical that HF is fully integrated into Safety Management Systems (SMS) as the human remains at the heart of the ATM system, and therefore HF is a key enabler for ATM safety.”
(Eurocontrol)”
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HP and HF in the Safety Management System (SMS)
“HF awareness increases efficiency, reduces error and can provide significant returns on investment. These cost savings, along with an obligation towards safety and a robust Safety Management System should provide an incentive for organisations to develop their Human Factors programmes.”
(UK CAA)
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HP and HF in the Safety Management System (SMS)
Considerations
• How will Human Performance risks
be identified and how will they be
mitigated? How do people create
safety?
• Are Human Factors activities
effective? Do they add value?
• Are the Human Factors activities
proportionate to the risk faced within
the organisation?
• What else could the organisation do
to improve their Human Performance
or to reduce their human risk?
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HP and HF in the Safety Management System (SMS)
Key Areas for HF Integration
• System Design (people,
procedures & equipment)
• Managing Change
• Hazard Identification
• Risk Management
• Safety Behaviours
• Safety Culture
• Safety Reporting
• Incident Investigations
• Training
• Competency
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Human Factors plays a key role in optimising Human Performance and delivering the Safety Strategy
TheSafety
Strategy
Business Performance
The key Human Performance areas that deliver safety
Human Performance
The discipline that deals with the underlying
Human Factors in work situations and their
optimisation
Human Factors
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Case StudySafety Culture
04.07.16
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What is Safety Culture
A “Just Culture” is an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.
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Safety Culture Model
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The Process
Plan to
Improve
Questionnaire
Workshops
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Who does it apply to?
Operational
Technical
Management
Other Staff
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Safety Culture
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Questions, more questions…
44. Team meetings are used to communicate concerns and collect ideas
for improvements.1 2 3 4 5 na
45. Engineering knows the importance of systems failures (in order to
maintain provision of safe services).1 2 3 4 5 na
46. Engineers get sufficient training, prior to major changes being made. 1 2 3 4 5 na
47. The other people in the organisation do not understand our job and the
safety roles we fulfil.1 2 3 4 5 na
What other topics (safety or otherwise) do you feel you would like more information on?
Role Watch Manager Normal working hours
Watch Staff Watch Supervisor Day staffSystems ManagerSystems Engineer Number of years experience in
current role?Other
Please tick as appropriate:
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Example Metrics
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Radar Diagram
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Sequence of Events
Dip test
› Action plan
› Roll out
Safety Culture Survey
› Questionnaire
› Workshops
› Report
› Action
› Learn
Repeat….
Airside Community Safety Culture Gap Analysis Study
Version 0.3 | 19th October 2015NATS Private
Prepared by:Nic Turley
NATS - PRIVATE
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Case StudyHF in Air Traffic Control Towers
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What is an ATC System?
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None of this works without….
PeopleATCOs
› Air Traffic Controllers
› Licenced by the Government
Air
› Arrivals
› Departures
Ground
› Ground Movement Controllers
Support
› Lighting Panel Operators
› Engineers
› Managers
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Heathrow Tower –Why did it need to be replaced?
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What was HF involvement?
Design of the interior and layouts
HMI design for components
Human Error Risk Analysis
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Then….. Its not just a new Tower
It’s a:
New way of working
New strip management system
New location
New entry and exit procedures
New watch organisation
New training requirements
New orientation
New Terminal (5)
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Action Plan
Growing rift between actors
Identify Concerns
Identify potential Errors
Evaluate impacts
» Manage potential risks
» Training plans
» Training Effectiveness
» Competence
» Shadowing
» Confidence
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Go Live! Heathrow’s new tower handled its first flight early on Saturday 21 April 2007.
Post implementation monitoring
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Workload, Culture and Safety
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How have we done it?
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HumanFactors in Design: Why is it important?
• We rely on control room operators
• Physical interface design & cognitive interface design
• A Eurocontrol study of accidents across aviation and nuclear industries concluded that approximately 50% of all accidents or incidents had a root cause in design – Roelen, 2004
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What if HF isn’t involved in the design process?
• Efficiency: business• Complex issues discovered later• Less able to represent customer
need • Fewer options considered • Less value from evaluation • More uncertainty • Less user buy in/ momentum • More expensive changes • Human error
NATS
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Adding value through incorporating HF into the design process
• Efficiencyo Supports human operatoro Increases productivityo Business
• Time & Costo Reduces trainingo Reduces development costso Reduces maintenance costs
• Qualityo Improve user experienceo Provides competitive advantage, for
example by improving brand image
00.00.00
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Adding value through incorporating HF into the design process:
Return on investment
• Metricso Business
o HSE aspects
• Shell international (Van Uden 2003)o 0.25 - 5 % reduction of capital
expenditure,o 1 - 10 % reduction of the total
engineering hourso 3 - 6 % reduction of operational and
maintenance life-cycle costs of facilities
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How do we incorporate HF into the design process?
1) Getting involved
• Formal process
• Building relationshipso Managerialo Supplierso End users
• Clear, pragmatic communication in multidisciplinary teams
• Show value added o To the businesso To safetyo To the end user
00.00.00
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How do we incorporate HF into the design process?
1) Getting involved
• Formal process
• Building relationshipso Managerialo Supplierso End users
• Clear, pragmatic communication in multidisciplinary teams
• Show value added o To the businesso To safetyo To the end user
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How do we incorporate HF into the design process?
2) Incorporation of HF at different design stages
• The ideal: contribution at the early stages
• Later stages in the design cycleUndesired but can still add value
• Contribution for a commercial ‘off-the-shelf’ system
Overarching principle: Apply robust, scientific, HF principles, in a
pragmatic way
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and FinallyYou know when you’ve arrived when….
04/07/16
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The Contribution of Human Factors in Getting Safety Right
Simon SkinnerIOSH 4th July 2016