Integrating human factors within MAE control measures: Error and - - PowerPoint PPT Presentation

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Integrating human factors within MAE control measures: Error and - - PowerPoint PPT Presentation

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Integrating human factors within MAE control measures: Error and ALARP in offshore petroleum activities Joelle Mitchell APPEA HSE Conference, Perth, September 2015 Human Factors and MAEs Humans interact with control measures Error can

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Integrating human factors within MAE control measures: Error and ALARP in

  • ffshore petroleum activities

Joelle Mitchell

APPEA HSE Conference, Perth, September 2015

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  • Humans interact with control measures
  • Error can be a barrier-defeating factor
  • Error risk can be addressed through adapted

traditional risk management approaches

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Human Factors and MAEs

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Reducing error risk

Error Prevention Error Management

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Typical approach

Hazard Hazard Hazard Hazard Hazard

Consequence Consequence Consequence Consequence Consequence

EVENT

Prevention Controls Mitigation Controls

Elimination Prevention Reduction Mitigation

Training & competency

Error

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A more accurate approach

Control Control Control Control Control Control Control Control Control Control Control

! Error ! Error ! Error

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A deeper exploration

Performance shaping factor Performance shaping factor Performance shaping factor Performance shaping factor Performance shaping factor

Prevention Controls Mitigation Controls

ERROR

Control measure failure

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  • March 23, 2005

– Isomerization unit start-up – Operators overfilled the raffinate splitter tower – Pressure relief devices activated – Flammable liquid spurted from a blowdown stack – No flare installed – Ignition, explosion and fire – 15 deaths, 180 injuries

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Example – Texas City Refinery

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Error analysis

Knowledge- based mistake

Incorrect knowledge Fatigue Misleading HMI Poor handover Insufficient personnel Control measure failure Overfilling tower

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Possible controls

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Tower overfill Tower Overfill

Knowledge- based mistake

Incorrect knowledge Fatigue Misleading HMI Poor handover Insufficient personnel

Training Simulation Drills FRMS HF in design Maintenance Procedure Comms conventions Planning rules Risk indicators HF in design Maintenance Error training Drills Trip

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Benefits of error analysis

  • Classify potential high-risk errors
  • Identify critical PSFs
  • Develop targeted control measures
  • Focus on prevention and mitigation
  • Facilitate risk reduction to ALARP

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Which errors?

  • “Critical human tasks”
  • Activities people are expected to perform:

– as barriers against an incident – to prevent incident escalation – to support or maintain barriers during an incident

  • OGP (2011). Human factors engineering in projects.

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Identify critical human tasks Identify error potential Identify PSFs Evaluate existing controls Develop additional controls

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A suggested process

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  • Tasks where:

– a procedure is a single point failure – people interact with control measures – error can lead to barrier failure – barrier failure can lead to MAE

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Identify critical human tasks

Identify critical human tasks Identify error potential Identify PSFs Evaluate existing controls Develop additional controls

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  • Task analysis can help

– What errors are possible? – Classify errors by a taxonomy – What are the potential consequences? – What are the high-risk potential errors?

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Identify error potential

Identify critical human tasks Identify error potential Identify PSFs Evaluate existing controls Develop additional controls

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  • People-level

– Knowledge, skills, experiences – Health

  • Job-level

– Procedures – Equipment – Supervision

  • Organisation-level

– Culture & climate – Corporate strategy

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Identify PSFs

Identify critical human tasks Identify error potential Identify PSFs Evaluate existing controls Develop additional controls

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  • Prevention controls?
  • Mitigation controls?
  • Is error risk ALARP?

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Evaluate existing controls

Identify critical human tasks Identify error potential Identify PSFs Evaluate existing controls Develop additional controls

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  • Layered defences targeting error:

– Eliminate the opportunity – Prevent the error – Reduce the impact – error identification and recovery – Mitigate the consequences

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Develop additional controls

Identify critical human tasks Identify error potential Identify PSFs Evaluate existing controls Develop additional controls

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Where to start?

  • Evidence of uncontrolled error:

– Events and dangerous occurrences – Existing controls have failed to mitigate error risk

  • Performance-shaping factors:

– Latent conditions – Broader implications

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  • Human error can facilitate barrier failure
  • Error is most significant within

critical human tasks

  • Layered defences can reduce error risk
  • Effective risk reduction includes:

– error prevention – error mitigation

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Summary

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Online resources

www.nopsema.gov.au

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Questions