Tel: (+44) 01492 879813 Mob: (+44) 07984 284642andy@abrisk.co.ukwww.abrisk.co.uk

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Summing up

Andy Brazier

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Overview

Where to go from here

Learn from accidents and incidents.

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Required approach

Policy – includes human factors aims

Organising – responsibilities and competence

Developing procedures

Competency assurance

Management of change

Planning – ensure degree of effort is

commensurate with risk

Monitor, audit and review

Ensure human failures are properly considered

Ensure root causes are identified

Ensure human factors solutions to human factors problems

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Develop a task analysis report

Identify critical tasks

Task analysis and HAZOP

Risk control measures

ALARP demonstration

Referred to from the COMAH report

As you may do for a QRA report.

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Specific requirements

Competence assurance program

Ergonomic standards

Procedures

Interface design

Staffing level assessment

Fatigue assessment and management

Design and procurement procedures.

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Demonstrate human factors risks are

ALARP

As Low As Reasonably Practicable

Presumption is that you will implement ‘good practice’ risk reduction measures

Need to demonstrate sacrifice is grossly disproportionate to the benefit

Risk reduction would be minimal

Would lead to greater risk else-where

Holistic approach

Risk of the whole facility.

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Good practice

Examples:

HSC Approved Code of Practice (ACOP)

HSE guidance

Publications from other government departments

Standard (e.g. B.S. & ISO)

Trade association publications

Need to take into account

Individual and societal risks and concerns

Inherent safety, eliminate hazard, avoid risk

Minimal use of procedures and PPE

Clearly defined scope

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Demonstrating ALARP

Answer these two questions

What more could be done?

Why have we not done it?

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Could you automate more tasks?

May prevent operator errors

Reduces operators’ opportunities to maintain an understanding of how the plant operates

Introduces opportunities for maintenance errors.

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Could you provide more automatic

protection?

Can mitigate effects of operating and maintenance errors

Operators can become over-reliant

Increases complexity of operation

Can create a culture where overrides and

inhibits are tolerated

Vulnerable to errors in calibration and failure to

reactivate after maintenance.

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Could you employ more people?

Increases what can be done in high demand situations

May reduce pressure on teams under normal conditions (less violations?)

Makes training people easier

Increases opportunities for covering absence

You need to demonstrate that:

You have enough people to avoid and respond to major accidents

Staffing arrangements are optimum.

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Could you provide more procedures?

Writing a procedure does not reduce risk

More procedures increases the likelihood that procedures are not used

For some tasks, a good procedure is a good way of minimising the likelihood of errors

A holistic system of good quality procedures and job aids is likely to be the best solution.

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Could you provide more training?

More of the same or different

Increase understanding of the plat

More opportunities to practice infrequent tasks

You need to demonstrate that:

You know what competencies people need

That your staff have the necessary competencies.

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Basis for enforcement

Significant gap between necessary measures and controls in place

Risk of recurrence following incident or near miss

Evidence of potentially serious risk from human factors issues

Lack of expertise where there is a substantive human factors issue.

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Have enforced because of

Organisational change

Hours of work

Workload and staffing

Competence assurance

Human factors risk assessment for batch process

No appeals on noticed issued to date

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Expectations

Appropriate balance between hardware and human issues

Ensure human contribution to major accidents is considered, not just personal safety

Include management, technical and support staff, as well as operators

Consider systems.

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Process safety performance indicators

Effectiveness of training programme

Frequency of accidental releases

Process disturbances

Activations of protective devices

Time taken to detect and respond to events

Component malfunctions

Outstanding maintenance or inspection

Procedure reviews

Occurrences of staffing levels below minimum

Non-compliance of maximum working times

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“An airline would not make the mistake of measuring air safety by looking at the

number of routine injuries occurring to it staff”

A. Hopkins - Lessons from Longford

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Learn from accidents and incidents

Investigate, analyse and share

Cannot learn everything from your own Not

many significant events

Limited resources to investigate

Internal mindset

Look at one incident at a time

Don’t

Dismiss because hazards, equipment, controls are different

Skim through the headlines only

Focus on the last big one.

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All major accidents

One or more ‘fatal errors’

Conditions that made the error likely

System failures contributing to the accident’s

likelihood and consequence

All accidents preceded by similar near misses

Management did not recognise the warning signs.

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BP Texas CityProcess industry has, quite rightly, looked carefully at this accident

It seemed as if, to some people, the causes were novel and unheard of in the industry

I believe the reports actually reflect the current consensus of what causes major accidents.

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Piper Alpha

Permit to work failures

Well established system

Compliant

Not working in practice

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Procedures are essential but…

It is easy to be reassured that written systems and procedures are being used

No news is good news?

People think they are following the procedure but have not actually understood what is required

People think the procedure is only a guide

People daren’t say they don’t follow the procedure

Assume people will adapt & take short cuts

Audit what people do, not just the paper.

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Chernobyl

Communication failures

Management secretive about design weaknesses

Operators did not challenge instructions.

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Error is a natural part of communication

It is not what you say, it is what people think you mean

Some messages are taken literally

Other times people ‘read between the lines’

If people are not told about problems

They will make the wrong decisions

Will not understand why they need to follow procedures

More/better communication is required when unusual events are happening.

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Clapham Junction

Technician errors

Highly trained

Experienced.

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Training ≠ Competence

Training courses have limited impact

Most learning is achieved ‘on the job’

Needs to be planned

Trainees need to be supervised

Time served does not replace the need for competence assessment

Competent people still make mistakes

Given more complex and demanding tasks

Indispensable means less able to take a break.

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Herald of Free Enterprise

Door left open

Ship’s Master did not know

Vulnerable design

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Layers of protection

Understand

How many?

Are they independent?

Don’t assume they will work

Always obtain positive indications of operation

Make sure people understand their safety responsibilities

Learn from near misses

Not just failures, but also what prevented an accident

If you don’t act, people will assume all is safe.

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Bhopal

Methyl Isocyante

Runaway reaction

Unable to contain vapours

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Reduced throughput does not mean

reduced risk

Delaying maintenance

Reduced budget or staff

People get used to systems being inoperable

People are more interested in plants that make money

High rate is more likely to be steady state.

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Mexico City

Fractured pipe

Slow response

Too late to prevent escalation

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Detect → Diagnose → Respond

Have to succeed in all three stages

AND not OR gate logic

Prompt alarms

Competent people

Plant knowledge and understanding

Decision making

Resources

People

Equipment.

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BP Texas City

People in the wrong place at the wrong time

Trailers in plant area

Area not cleared during start up

Slow to raise the alarm

A good safety record has its downside.

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Generic Learning

Big accidents start small

Accidents occur most during unusual circumstances

If you haven’t got it, it can’t hurt you

Keep people away from hazards

Written systems & procedures provide poor risk control

Most learning is on the job

Error is a natural part of communication

People who are tired make more mistakes

Safety devices can create complacency

Don’t assume safety devices are working.

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Generic Learning (cont.)

Everyone needs to act if they know something is unsafe

You need to challenge your emergency arrangements

People must be prepared to raise the alarm

Anyone who may have to deal with the consequences of an accident has to know what they are dealing with

Make sure you learn from near misses

All incidents have multiple causes and this should be seen in your investigations

Don’t overlook sabotage

Non-operational parts of the business can be hazardous

Don’t believe your safety is good (enough).

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Conclusions

Before major accidents most managers didn’t

have particular concerns about safety

Not perfect, but did not foresee the risk

Reassured that systems were in place without having good evidence that they were effective

Only heard or listened to good news

The biggest risks occur because of the errors and poor judgements made by those managers

High reliability organisations expect failures High reliability organisations expect failures

and so work hard to avoid themand so work hard to avoid them

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