why do we do what we do? - Tank Storage Association€¦ · HSE Assurance: Leading Indicators. From...
44
Human performance – why do we do what we do? The business of sustainability © Copyright 2018 by ERM Worldwide Group Limited and/or its affiliates (‘ERM’). All Rights Reserved. No part of this work may be reproduced or transmitted in any form or by any means, without prior written permission of ERM.
Transcript of why do we do what we do? - Tank Storage Association€¦ · HSE Assurance: Leading Indicators. From...
Human performance – why do we do what we do?
The business of sustainability
© Copyright 2018 by ERM Worldwide Group Limited and/or its affiliates
(‘ERM’). All Rights Reserved. No part of this work may be reproduced
or transmitted in any form or by any means, without prior written
permission of ERM.
Safety Moment
Safety Moment
Design of the environment using Affordances and Constraints
The ghost in the machine We are amazing…But the powerful information processing machine in our heads can sometimes yield unexpected results…
43%
20%
11%
21%Poor HFE design
Weaknesses inCompetence
Errors inCommunications
Failures inProcedures
Human factors in incidents
Data based on recent studies reported by UK
HSE and Shell Oil Company.
But what is the probability that
he will get it wrong?
Reaction protection - In-line pH test
Sources:IEC 61511 - Functional safety - Safety instrumented systems for the process industry sectorReliability, Maintainability and Risk - Practical methods for engineers, David J Smith, 2001
Human error probability
Cognitive capabilities/error modes
• Perception and Vigilance– Visual search failure– Monitoring failure– Expectation bias– Association bias– Spatial, visual or auditory information confusion– Discrimination problem– Information overload– Vigilance problem– Distraction or preoccupation– Tunnelling– Out of sight bias
• Response Execution– Problem of habit– Spatial confusion– Lack of manual precision– Acting on similar-looking objects– Failing to speak clearly– Timing error– Positioning error
• Planning and Decision Making– Incorrect knowledge– Lack of knowledge– Prospective memory failure– Misunderstand communication– Information integration failure– Fixation– Incorrect assumption– Incorrect priority of task– Denial of risk– Failure to recognise risk– Inadequate/incomplete mental model
• Memory– Similarity of information– Memory capacity overload– Negative transfer of information– Mis-stored, not learned information– Rarely used information– Long-term memory failure– Short-term memory failure– Prospective memory failure
INPUTS
PROCESSING
OUTPUTS
VISUAL STIMULI
PERCEPTION
DETECTION
COGNITION &
WORKING
MEMORY
RESPONSE
SELECTION
RESPONSE
EXECUTION
AUDITORY STIMULI
LONG TERM
MEMORY
EXPECTATIONS
AUTOMATICITY
LEARN
VOCAL
MANUAL
ATTENTIO
N
8
Our brain is amazing, but…
It’s fast
but lazy
It’s
prehistoricIt plays
tricks
It’s analytical
It’s slow
It takes mental effort
System 2 - SLOWSystem 1 - FAST
Baguette
Roll
Crust
RyeSandwichPitta
ButterToast
LoafWholegrain
Memorise this?
10
Input: Perception
A or B, which is darker?
Say out loud the
colour of the following
words
(not what is written, but what colour
the text is!)
Say “red”
Say what you see…
RED ORANGE YELLOW
PURPLE BLUE GREEN
BLUE RED YELLOW BLUE
GREEN ORANGE PURPLE
RED ORANGE YELLOW
BLUE GREEN RED BLUE
PURPLE ORANGE GREEN
Cognitive biases 1Anchoring
•A tendency to rely on the first piece of information provided
•The information provides a reference or frame
$2.99
$9.99
$8.99
Nudge in action!
Cognitive biases 2
Representativeness
• We assume things follow predictable patterns
• Gamblers’ fallacy: luck will change soon
Cognitive biases 3Availability
• Emotional salience affects our recall and actions
• We rely on recent experience, or exaggerate low probabilities (never happened to me)
• Prior successful performance increases risk taking (getting away with it)
Cognitive biases 4Loss aversion
• The ‘pain’ of loss is twice as great as the reward from a gain.
• So a certain loss of convenience is valued over a possible increase in risk.
Cognitive biases 5Confirmation bias
• We over-emphasise information that supports what we think
• We diminish the importance of information that contradicts what we believe
• We stick with a flawed plan
The facts
Things you
already believe
Cognitive bias normalises risk
Spot Prize
23
Bread
Car
TreeHouse
24
Baguette
Roll
Crust
RyeSandwichPitta
ButterToast
LoafWholegrain
25
Drift into failureFailure to recognise human performance weaknesses in organisations can lead to a steady decline in standards of integrity and practice…
Case Study – nitric acid release
Nitric Acid Tanker Release
Drift into failure
The story of the slow erosion of technical and procedural barriers designed to maintain the safety of a nitric acid storage tank.
Tanker failure and NOx emissions due to Acid Corrosion
Tanker failure and NOx emissions due to Acid Corrosion
Improper Behaviour that is Unintentionally Condoned
Improper Behaviour that is Unintentionally Condoned
Inadequate Preventative Maintenance
Improper Behaviour that is Unintentionally Condoned
Inadequate Preventative Maintenance
Inadequate Contractor Management
Improper Behaviour that is Unintentionally Condoned
Inadequate Preventative Maintenance
Inadequate Contractor Management
Inadequate Communication
Improper Behaviour that is Unintentionally Condoned
Inadequate Preventative Maintenance
Inadequate Contractor Management
Inadequate Communication
Poor Hazard Recognition
Improper Behaviour that is Unintentionally Condoned
Inadequate Preventative Maintenance
Inadequate Contractor Management
Inadequate Communication
Poor Hazard Recognition
Failure to Manage Risk
Case Study – nitric acid release consequenceNitric Acid Tanker Release
Event DescriptionFollowing a routine inspection of the bund around an external nitric acid tank, the sub-contractor in charge of this area noticed that the bund was 30% full. He ordered a tanker from a cleaning agency, which came onto site and pumped out the liquid. Within 15 minutes of emptying the bund a significant emission of orange toxic fumes (NOx) suddenly occurred from the tanker’s exhaust valve. There was also some liquid spillage from holes in the metal walls of the road tanker. The alarm was sounded and the site emergency plan put in place. There were no injuries to personnel and no loss of liquid off site. There was some short term local press interest.
Tanker failure and NOx emissions due to Acid Corrosion
People as barriers – safety critical tasks
36
Threat
Threat
People act as the barrier
People maintain the barrier
36
Detailed AnalysisPlotting the distribution of tasks across the site and any associated risks or inefficiencies
Human & organisational factors
Human & organisational factors affecting barrier reliability
The Barrier Management Plan
HSE Assurance: Leading IndicatorsFrom the Barrier Management Plan we will be able to define Leading Indicators for the successful
management of the availability and reliability of safety critical elements. Leading indicators will be defined
for people, plant and processes that will be part of the safety performance standards.
• Manpower levels
• Responsibilities
• Accountabilities
• Skill and competence
• Etc.
People
• Availability
• Reliability
• PM Targets
• Calibration and certification
• Etc.
Plant
• Records of compliance
• Audit results
• Improvement actions
• Closure of open actions
• Etc.
Process
The safety fulcrum
Continuous operations Bang!BBSOrganisational
Integrity
Safety Managementeffort
SafetyGain
Thank you – further reading 1
