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Energy Institute ME branchHuman and organisational factors: Preventing the causes of incidents before they happen? 13 October 2014Stuart King, Technical Products Managersking@energyinst.org

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MSc Social AnthropologyWorking for the EI since October 2009Manage a portfolio of human factors and process safety related activities:Human and Organisational Factors CommitteeHearts and Minds programmeStichting Tripod FoundationProcess Safety Management Framework

Production of resources, e.g. guidelines, tools, research, focusing on various aspects of improving health and safety, by tackling the human element of risk.

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The Energy Institute (EI) is the chartered professional membership body for the global energy industryServes society with independence, disseminating knowledge, skills and good practice towards a safe, secure and sustainable energy system. Licensed by: the Engineering Council to award Chartered, Incorporated and Engineering Technician status, the Science Council to award Chartered Scientist status, and the Society for the Environment to award Chartered Environmentalist status. Technical work programme funded by EI Technical Partner Companies

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19,000 individual EI members350 company membersTechnical work programme funded by EI Technical Partner Companies:

MembershipBG GroupBP ExplorationBP Oil UK LtdCentricaChevronConocoPhillipsDana PetroleumDONG EnergyEDF EnergyENIE.ON UKExxonMobil InternationalInternational PowerKuwait Petroleum AviationMaersk Oil North SeaMurco Petroleum LtdNexenPhillips66Premier OilRWE npowerSaudi AramcoScottish PowerSGSShell E&PShell Oil Products LtdSSEStatoilStatkraftTalisman EnergyTotal E&P UK plcTotal UK LtdValeroVattenfallVitolWorld Fuel Serviceswww.energyinst.org

Todays topic:Human and organisational factors: Preventing the causes of incidents before they happen?www.energyinst.org

Contentious topic title, but deliberately so.5

Tripod BetaTripod DeltaHearts and MindsBow TieShell and OGP Life Saving RulesResearch: 1980-2000 (and beyond)www.energyinst.org

Think back to late 1970s, ICI (HAZOPS, SMS) has changed the way risk is being managed.Shell began period of research into behavioural aspects of risk management.Several well-known tools and techniques have come from that research.6

Answer: Yes!Original research question: Can you predict the causes of accidents before they occur?Jop GroenewegPatrick HudsonJim Reasonwww.energyinst.org

The original research question.Several key names were involved in that research.Others include:Dianne ParkerRon Westrum

The answer is Yes.7Swiss cheese modelOrganisations manage risk using barriers

Barriers use of equipment, design of plant (redundancy, overflows, etc.), following rules, procedures, standards usually barriers are people doing a jobBarriers are functions

Why incidents happen (1)www.energyinst.org

Out of that research came The resident pathology model of how incidents happen.Popularised by James Reason in 1992 as the Swiss cheese model.

Explain Swiss cheese model.8Why incidents happen (2)Incidents happen when barriers fail.

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Why do barriers fail? The Tripod causation path

An organisationError / violation promoting conditionsThat influences the person

CreatesTo take action or inaction

That causes barriers to failThat result inAccidents, incidents and business upsets

SMSLeadershipCulture

Performance influencing factors (PIFs)CompetenceFatigueEnvironmentSupervisionTaskEtc.

Human action or inactionslips, lapses, mistakes, violations

Underlying causes

Immediate causes

Preconditions

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- But why do barriers fail?- Barriers may be human-based (e.g. Op. shuts off vale) or technological (automatic shutoff), but barriers almost always fail due to human failure either in the barrier enactment, its maintenance, or planning.

- The problem: many incident investigations stop here.- Going further, we find that people do things for a reason. We can never be 100% sure why, but certain things make error and violation more likely Performance influencing factors.PIFs are sometimes created by the organisation (its culture, its SMS, it leaders), or are not controlled by the organisation effectively.

So we say: (read words).Barriers: related to the specific incident (but learning can be shared if similar barriers in place elsewhere).UCs: related to PCs, and so the causes of all incidents. 11 BRFs.

Where to focus on to make improvements to prevent incidents?Where not to focus? Why?

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Knowledge.energyinst.org

Why do barriers fail? The Tripod causation path

An organisationError / violation promoting conditionsThat influences the person

CreatesTo take action or inaction

That causes barriers to failThat result inAccidents, incidents and business upsets

SMSLeadershipCulture

Performance influencing factors (PIFs)CompetenceFatigueEnvironmentSupervisionTaskEtc.

Human action or inactionslips, lapses, mistakes, violations

Underlying causes

Immediate causes

Preconditions

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- Human and Organisational Factors11

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What is human and organisational factors (HOF)?environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work. 1Piper Alpha (1988)

Texas City (2005)

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Human factors are, in my opinion, the key to preventing incidents. It is the key to the kingdom. Technical aspects are important too, HOF provides to means by which to manage.12Types of human failure the immediate causeIntended actionsUnintended actionsViolationsMistakeSlipLapseErrors

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At the hearts of HF, we are trying to prevent barrier failure.Barrier failure due to human action:Either intended actionsUnintended actions.

Important that this is identified, as different types of action have different causes, and different solutions.

Violations: Bad procedureTime poorCulture or supervision

MistakeDidnt recognise the situationCompetence/trainingSlip/LapseEnvironment, working on edge of human performance, control layout, distractions (mental, physical).13Human factors the PIFs (two similar models)JobIndividualOrganisationTask complexity.Facilities.Environment

Culture, leadership, supervisors, rules and procedures

Personality, psychology, height, weight, competency, fatigue

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Peoples performance is influenced by the interplay between the individual (their personality, competencies, height, weight, psychology etc.), the job they are being asked to do (the complexity of the task, the equipment, the environment, etc.) and the organisation (its culture, leaders, supervisors, procedures, rules, management system).

These are performance influencing factors as they make errors and violations more or less likely.

These are the things that the organisation should be managing.

14Organisational change (and transition management) Staffing arrangements and workloadTraining and competence (and supervision)Fatigue (from shiftwork and overtime)Human factors in design: (a) General(b) Alarm handling(c) Control rooms(d) Ergonomics design of interfaces(e) Ergonomics health ergonomicsProcedures (especially safety critical procedures)Organisational culture (and development)Communications and interfacesIntegration of human factors into risk assessment and investigations (including Safety Management Systems)Managing human failure (including maintenance error)Human factors Top 10 issueswww.energyinst.org

There are 10 main topics that15IndividualsManagement systemsDesign of facilities and equipment Current?ALARP?Best possible?Burden of risk management Adapted from OGP, Human factors engineering in projectsThe organisation the underlying causewww.energyinst.org

The point of this slide:- The organisation needs to manage risk. It needs to design out risk as much as possible, and have management systems in place to actively manage risk that cant be designed out. However, too much risk is managed by individuals, and in the best scenario it will always be. We need to manage the individuals in the same we manage risk.16Todays topic:Human and organisational factors: Preventing the causes of incidents before they happen?

Tools to help uswww.energyinst.org

Investigationwww.energyinst.org

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Tripod Beta user guideTripod Beta: Guidance on using Tripod Beta in the investigation and analysis of incidents, accidents and business losses

The current manual on Tripod BetaStep-by-step process, along with detailed guidanceAlso good introduction to human factors causes of incidents

Purchasable, or included in some Tripod Beta training courses.

www.tripodfoundation.com

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An example of an investigation methodology. There are many others out there.

It may sound lie a cop out, but investigation and analysis is still the primary way we prevent future incidents.

A good investigation is a human factors investigation.

Tripod Beta is one such methodology (see next page) that help you uncover the barriers, the immediate cause (the human failure), the performance influencing factors, and then the underlying organisational causes that allowed those PIFs to exist.

If an investigation uncovers the underlying causes, it can prevent many more incidents, as UCs cause all incidents.19EventFailed barrierEventEvent - AgentEventObjectAgentObjectFailed barrierFailed barrierImmediate causePreconditionUnderlying causeInvestigation (e.g. Tripod Beta)www.energyinst.org

Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents (May 2008) ISBN 978 0 85293 521 7Developed by Kingsley Management ServicesLaunched at EPSC Learning from accidents and Ergonomics Society Human factors in oil, etc conferences (November 2008)Tackles deficiency that human error as investigation end point. Promotes better investigation of human and organisational factors aspectsReviews attributes of toolswww.energyinst.org.uk/humanfactors/incidentandaccident

Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents www.energyinst.org

EI also have a guide on human factors investigation, lists 28 investigation tools.21Risk assessmentwww.energyinst.org

Tripod DeltaQuestionnaire surveyTries to uncover performance influencing factorsDetermines the underlying causes before they cause an accident

Bow Tie- Promote barrier-based thinking

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Safety critical task analysisGuidance on human factors safety critical task analysis , 2011.Defines a methodology and introduces the most common techniques for conducting human factors safety critical task analysis.Topics include:Introduction to SCTASCTA good practice dos and don'tsCase studies, examples of good and bad SCTASCTA methodologies.Launched at IChemE Hazards XXII (April 2011)

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Quantified human reliability analysis (QHRA)Guidance on QHRAMethodologies, e.g. Heart, Cream, Spar-HPitfallsUses and abuses of HEPsCompetencies requiredChecklistsIllustrative examples

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Human factors managementwww.energyinst.org

Awarenesswww.eihoflearning.org Human factors awareness: web-based training course

Human factors briefing noteswww.energyinst.org

Basic

Human and organisational factors professional development: complete training resourcehttps://www.energyinst.org/technical/human-and-organisational-factors/complete-training-resource

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Established

https://www.energyinst.org/humanfactors www.energyinst.org

Hearts and Minds Safety culture improvement toolkit

Shell E&P Winning hearts and minds toolkitUnderstanding your culture Managing rule breakingRisk assessment matrixMaking change lastImproving supervisionAchieving situation awareness Seeing yourself as others see youWorking safely Driving for excellencePublished by Energy Institute since 2004

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FatigueManaging fatigue using a fatigue risk management plan (FRMP)Advocates the management of fatigue using a management system, in the same way other risks are managed.Ultimately it is about ensuring the workforce can sleep, and carrying out high risk activities during periods of alertness (or building in safe guards so that fatigue cannot cause major incidents.

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Hearts and Minds: Learning from incidents

LFI-engage follow-up study to 2009-2012 PhDFunded by Hearts and Minds research fundGlasgow Caledonian University, will run until June2013.

The project aims to address two main problems that limit the impact of LFI initiatives: Frontline employees tend to engage with learning from incident initiatives in limited waysFrontline managers and supervisors are not fully equipped to engage staff in learning in ways that maximise reflection and sense making.

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Crew resource management (non-technical skills)Contracted to Aberdeen University.Develop guidance for managers on implementing crew resource management (non-technical skills) training, as pertains to major incidents.Focus on:What is CRMIts benefitsHow to identify CRM skills needed in the organisationHow to implement CRMRelevance to safety culture and management systemsSynergies with OGP project to develop a Well Operations Crew Resource Management training syllabus, due end 2012.Highly relevant to major incidents e.g. Macondo, Montara.Situation AwarenessDecision MakingLeadershipTeam WorkCommunicationFatigueStressCognitiveSocialPersonal

Know the situation. Know the solutionwww.energyinst.org

33Measurementwww.energyinst.org

Human factors performance indicatorsResearch report: Human factors performance indicators for the energy and allied process industries, 2010.Joint industry project:EIHSELloyds Register

Methodology for developing HF performance indicators for each HSE top 10 human factors issues.Example performance indicators suggested by or being used in industry.NB: OGP IPIECA: Performance Indicators for Fatigue Risk Management Systemswww.energyinst.org

RCS = Risk Control System35SummaryIncidents are caused by barrier failures.Barriers almost always fail due to human action.Humans do not behave in a vacuum. Performance influencing factors make human failure more or less likely.Managing these performance influencing factors is the purpose of the organisations leadership, management system and culture. The underlying causes of incidents are failures to manage PIFs.Performance influencing factors are basically what we call Human and organisational factors.Preventing incidents before they happen = managing PIFs.Underlying causes can be identified through:good accident investigation. Underlying causes are the cause of all incidents.Risk assessment, e.g. Tripod Delta.EI has many freely available resources on managing human and organisational factors.

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Thank you

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