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© The Keil Centre, 2016V1.0 0116
www.keilcentre.co.uk @TheKeilCentre
Human Factors in
Incident InvestigationColin Munro
Consultant Ergonomist
Mobile: +44 (0) 7432 720979
Direct Dial: +44 (0) 131 221 8272
Email: [email protected]
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© The Keil Centre, 2016V1.0 0116
About The Keil Centre…
• Chartered Ergonomists & Psychologists
• Applying ergonomics and psychology to promote
organisational success
• Human and organisational factors in health and
safety
• Management development
• Psychological health
• International client base
• High Hazard / Safety Critical Industries
• Edinburgh & Australia offices
• Invited member of the Chartered Institute of
Ergonomics and Human Factors (CIEHF)
‘working party’ - to produce a white paper
detailing the integration of human factors into
health and social care
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• 12 years in healthcare (NHS)
• MSc Ergonomics (Human Factors)
• Consultant Ergonomist
– Human Error Analysis
– Energy Institute Briefing Notes
– Ergonomics Essentials (BOHS/OHTA)
– Ergonomic analysis for control rooms
– Procedures
– Ergonomics and Human Factors in design
• Healthcare, oil & gas, animal & plant laboratory
biohazards and transport (rail)
© The Keil Centre, 2016V1.0 0116
Objectives
• high level overview of human factors
• high level overview of human failure
• human factors in incident investigation
– reactive approach…..human factors analysis tools (HFAT®)
– proactive approach…..human reliability analysis
– case study
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© The Keil Centre, 2016V1.0 0116 4
The Health and Safety Executive (HSE)
defines human factors as:
“environmental, organisational and job factors,
and human and individual characteristics which
influence behaviour at work in a way which can
affect health and safety.
Human factors are all those things
that affect performance in the
workplace
Human Factors – What is it…?
www.hse.gov.uk
© The Keil Centre, 2016V1.0 0116 5
‘HSE Top Ten’
human factors
issues
Procedures
Training and competence
Staffing
Organisational change
Safety-critical communication
Human factors in design
Fatigue and shift work
Organisational culture
Maintenance, inspection and
testing
Managing human failure
www.hse.gov.uk
© The Keil Centre, 2016V1.0 0116 6
Understanding Human Failure
Human Error
Violation
Accident
Latent Failures Active Failures
Management
Decisions
Organisational
Processes
Barriers
Performance Shaping Factors
Triggers for Non-Conformances
© The Keil Centre, 2016V1.0 0116 7
• Skilled people usually get it right
• PSFs help explain what shaped
performance on the day
• PSFs are conditions which
make errors more likely
• PSFs can be external and
internal to the individual
• Must be taken into account
when developing solutions
Performance Shaping Factors (PSFs)
© The Keil Centre, 2016V1.0 0116
• Active
– Occur in operation – they are immediate where
there is no room for error, such as when driving
• Latent
– Occur in design – setting people up to fail at a
later time / space e.g. designers, managers,
maintainers
– e.g. poor design of the car systems
– inadequate maintenance of the car
Human Failures can be…
© The Keil Centre, 2016V1.0 0116
Human Factors Analysis Tools
(HFAT®)
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…….a reactive approach to incident investigation
© The Keil Centre, 2016V1.0 0116 10
Typical Incident Analysis Process
Specify behaviour(s) to be understood
Unintentional
ABC AnalysisHuman Error
Analysis
Gather EvidenceIdentify Critical Factors
& Causes
Assemble
Timeline
CF 1 CF 2 CF 3
Intentional
© The Keil Centre, 2016V1.0 0116 11
Intentional or Unintentional
Behaviour ?• Intentional (violation)
– Person announced their
intention to behave in that
way, prior to behaviour
– It can be demonstrated that
the person knew what
should be done
– Their behaviour led to some
positive consequences for
them
• Unintentional (error)
– The person can explain
how the error occurred, but
not why - they are puzzled
by their own actions.
– Colleagues have done
similar things
unintentionally
© The Keil Centre, 2016V1.0 0116 12
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ABC analysis
• First step in changing behaviour is to understand why people
are currently behaving as they are
• ABC analysis helps you to understand behaviour from the
other person’s perspective
• Antecedents get us going, consequences keep us going
ANTECEDENT BEHAVIOUR CONSEQUENCE
© The Keil Centre, 2016V1.0 0116 13
Model of information processing
Sensory
Decision
Memory
Action
Unintentional Behaviour
© The Keil Centre, 2016V1.0 0116
Human Error
Classification Scheme
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Le
ve
l o
f D
eta
il
Error
Type
Error
Mechanism
Performance
Shaping Factors
e.g. Clarity of information,
equipment ergonomics,
workload…
© The Keil Centre, 2016V1.0 0116
Human Reliability Analysis
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…….a proactive approach to mitigate against incidents
© The Keil Centre, 2016V1.0 0116
Human Factors Roadmap
Major Accident Hazards
Human Factors in Design HF in safe systems (e.g.
procedures, training,
supervision)
Safety Critical Tasks
Task Analysis
Human Error Analysis
© The Keil Centre, 2016V1.0 0116
Human Error AnalysisPrevent, or improve
detection / recovery
Human factors in design
Human factors in safe
systems, e.g.
procedures, training,
supervision,
communications…
Safety
Critical
Task
© The Keil Centre, 2016V1.0 0116 18
Case Study18
Processing facility
Summary of analysis
Multiple risk control measures
were identified from the analysis
and grouped:
Equipment changes
(improved engineering controls)
Additional procedural steps
identified
Alterations to the procedure &
schematic diagram
Procedure steps to be removed
Issues for further review
Multiple risk control measures
were identified from the PSFs
reviewed
© The Keil Centre, 2016V1.0 0116 19
Thank you for your time…
Any questions…?
For further information, please visit
our exhibition stand
Colin Munro
Consultant Ergonomist
Mobile: +44 (0) 7432 720979
Direct Dial: +44 (0) 131 221 8272
Email: [email protected]
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