We are all human Graham King Health and Safety Executive We are - - PowerPoint PPT Presentation

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We are all human Graham King Health and Safety Executive We are - - PowerPoint PPT Presentation

Nov 05, 2023 270 likes •837 views

Health and Safety Executive We are all human Graham King Health and Safety Executive We are all human Need we be unduly concerned about human factors and human reliability? What is the worst that can happen if it is not managed it

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Health and Safety Executive

We are all human

Graham King

Health and Safety Executive

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We are all human

  • Need we be unduly concerned about

human factors and human reliability?

  • What is the worst that can happen if it is

not managed it well?

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“It will never happen to us”

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How is this relevant to cutting the toll of machinery accidents?

Typical immediate causes of machinery accidents

  • Safeguards of inadequate design or construction.
  • Safeguards removed or fallen into disrepair.
  • Safety systems overridden or defeated.
  • Inadequate systems of work.
  • Individual inadequately trained.
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The challenge

  • Identify & understand the

underlying causes.

  • Involves answering the why?

questions.

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Underlying causes

  • Not just technical.
  • Human factors play a key part.
  • Technical solutions must take account
  • f human factors.
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What Do We Mean by ‘Human Factors?’

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Interaction between people, their

  • rganisation, and physical and

psychological factors in their work Direct effects on health Human reliability Mental health Mental health Musculo- skeletal disorders Personal injury frequency P r

  • b

a b i l i t y

  • f

d i s a s t e r Unclear procedures Unclear procedures Dysfunctional culture Poor Poor interface design design

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Human Human reliability

Performance Performance Influencing Influencing Factors Factors

Personal injury injury frequency frequency P r

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a b i l i t y

  • f

P r

  • b

a b i l i t y

  • f

d i s a s t e r

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Incident Unsafe act

Latent

  • rganisational

failures

Fail to recover situation Unsafe plant/ condition Accident

Accident Model

Risks from Risks from human failure human failure

Injury

Person

Organisation

Job

Performance Performance Influencing Influencing Factors Factors

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Key messages

  • Human failures…

– Not random – Different patterns/types – Different influencing factors – Different means of prevention/reduction

  • You and your managers and supervisors

need to understand them

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Key messages

  • Many human failures can be predicted.
  • Most active human failures are

predisposed by factors remote from the individual (blaming the individual gets us nowhere).

  • You can take action to prevent/reduce

human failures.

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Human Failure Types

Errors Violations A simplified view

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Errors

Human error is far too vague a term to be useful. We should ask “What sort of error?” because different sorts of error require different actions if we are going to prevent the errors happening again. Trevor Kletz. An Engineer’s View of Human Error.

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Kegworth

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h f h f

H ID H U M A N F A C T O R S T E A M
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‘Human error”

Who was to blame for Kegworth?

Two equally true, and equally (un)helpful statements about the Kegworth air crash…

“The disaster was due to pilot error “(public enquiry). “The disaster was due to gravity” (me).

Neither conclusion would help to prevent a repeat.

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Fact or myth?

  • “Human errors are usually caused by

carelessness on the part of the individual”

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Fact or myth?

  • “Errors are random and cannot be predicted”
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Fact or myth?

  • “By definition all errors are bad”
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Conscious and automatic behaviour

Automatic Conscious Knowledge-Based

No routines or rules available for handling situation

Rule-Based

IF symptom X THEN cause is Y IF the cause is Y THEN do Z

Skill-Based

Automated routines with little conscious attention

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Errors

Skill-Based

Automated routines with little conscious attention “action not as planned”

  • Simple slips
  • Lapses of memory
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Errors

Skill-Based

Automated routines with little conscious attention “action not as planned”

  • Simple slips
  • Lapses of memory
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Example - omissions in aircraft maintenance

5 10 15 20 25 Left undone Not rem oved Caps missing I tem s loose I tem s m issing Tools not moved No lubrication Panels left off

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Errors

Slips and lapses on “autopilot” e.g. missing a step in a procedure Operating the wrong valve

Checking critical work (isolation permits) Solutions, e.g; Error-avoiding & error- tolerant design.

Skill-Based

Automated routines with little conscious attention Not prevented by more training!

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Knowledge-Based

No routines or rules available for handling situation Knowledge- based mistakes Competence assurance Solutions, e.g; Provide procedures & good communications Working from first principles wrong assumptions

  • r choices
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You are chief aircraft washer at the company hanger and you…..

(1) Hook up the water hose to the soap suds machine. (2) Turn the machine "on". (3) Receive an important call and have to leave work to go home. (4) As you depart for home, you yell to Don, your assistant, "Don, turn it off.“ (5) Assistant Don thinks he hears, "Don't turn it off”. He shrugs, and leaves the area right after you. Result……..

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Technology may change but…..

……humans still make the same mistakes

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Rule-based mistakes E.g. assuming everything ‘normal’ – alarm is at fault

Rule-Based

IF symptom X THEN cause is Y IF the cause is Y THEN do Z Procedures for abnormal but foreseeable situations Solutions, e.g; Enable good situational awareness

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Design

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Human Failure Types

Errors Violations

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Violations

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Violations

  • Probably more significant than errors when it

comes to accidents

  • Can be routine – “everybody else ignores the

rule, so do I” – 30mph limit. – closing bow-doors on Herald of Free Enterprise (Zeebrugge disaster). – Are normal behaviour. – Have to be anticipated and managed.

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Violations

  • Can be situational – perceived benefits of

ignoring outweigh perceived penalties. – Time/deadline pressure. – Staff shortages. – Discomfort/inconvenience. – e.g., skimping permit to work procedure.

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Violations

  • Can be exceptional, only happen when

things go wrong. – To solve the problem employee feels

  • bliged to break the rule/take a risk.
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Performance Influencing Factors – Violations – a few examples

Job factors,

  • Procedure a pain or doesn’t fit situation

Person factors:

  • Stress
  • Risk perception

Organisational factors:

  • Likelihood of getting caught
  • Lack of compliance monitoring/enforcement
  • Blind eye turned/walked by
  • Organisational culture…
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Solutions

  • Design of rules and procedures

– Relevant, practical, useable – Owned & valued by users (involve the users in writing them!)

  • Monitoring/measuring compliance

– Audit – Behaviour observation

  • Dealing effectively with violations disclosed

– Addressing root causes – ‘Fair’ or ‘just’ blame

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Solutions

  • Tackle the culture

Is there really zero tolerance of rule breaking? Is there committed management leadership in H&S that is “visible” and “felt”?

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Human Factors - Do we learn from incident investigations?

Often focus on error or rule-breaking & put down to: – “Insufficient care” – “Competence” – “Supervision” i.e. the easy explanations!

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Board of Enquiry – Challenger Space Shuttle Disaster….. “Many accident investigations make the same mistake in defining causes. They identify the widget that broke or malfunctioned, then locate the person most closely connected with the technical failure: the engineer who miscalculated an analysis, the operator who missed signals or pulled the wrong switches, the supervisor who failed to listen, or the manager who made bad decisions. When causal chains are limited to technical flaws and individual failures, the ensuing responses aimed at preventing a similar event in the future are equally limited: they aim to fix the technical problem and replace or retrain the individual responsible. Such corrections lead to the misguided and potentially disastrous belief that the underlying problem has been solved”.

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Incident Unsafe act Latent

  • rganisational

failures Fail to recover situation Unsafe plant/ condition Accident

Accident Investigation Model

Human Human reliability reliability

Person

Organisation

Job

Performance Performance Influencing Influencing Factors Factors

Injury

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What to remember

  • All humans are prone to failure.
  • Often they are predisposed to fail.
  • Blaming the individual does nothing to

solve the problem.

  • Organisational factors are critical.
  • If you understand why errors and

violations happen you can prevent/reduce them.

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How?

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“Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that

  • f adding the final garnish to a lethal brew whose

ingredients have already been long in the cooking” James Reason, Human Error,1990

A final quote

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