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Human factors seminar Applied human factors: Hazard analysis Gareth Hughes, Manager Human Factors zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA December 2015 Agenda ASA Human Factors team who we are Hazard analysis


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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

Human factors seminar

Applied human factors: Hazard analysis

Gareth Hughes, Manager Human Factors

December 2015

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 2

Agenda

  • ASA

Human Factors team – who we are

  • Hazard analysis

general principles

  • Specific

tools, techniques, methods and models

  • Exercise
  • Q & A
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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 3

Who we are…

The ASA SQER Human Factors (HF) team are:

  • Gareth Hughes
  • Manager HF
  • Airdrie Long - Snr HF Specialist
  • Stuart Hughes
  • HF Specialist
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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

Asset Standards Authority

Purpose, priorities and progress

Nick Berry, Manager Industry Engagement

December 2015

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 5

Emergency evacuation

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 6

Emergency evacuation

Figure 9 - Main fire evacuation assembly area

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 7

Consulting and advising across asset life cycle

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 8

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

New engineering drawings and CAD requirements standard

Potential benefits ✓

Consistency across transport organisations in TfNSW cluster Alignment with AS1100 and industry best practices First step toward digital engineering (BIM) No constraint on using a specific software Common title block formats for all disciplines including tagging and file naming conventions and other metadata requirements (pictured)

✓ ✓ ✓ ✓

Asset Standards Authority Applied human factors: Hazard analysis | 9

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 10

Nick Berry

Manager, Industry E ngagement 02 9422 7356 Nicholas.Berry@transport.nsw.gov.au

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 11

Human factors seminar

Applied human factors: Hazard analysis

Gareth Hughes, Manager Human Factors

December 2015

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 12

This seminar

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 13

CHAIR – Application currently has limitations

Construction Hazard Assessment Implication Review = CHAIR CHAIR 1

  • is

performed at the conceptual stage of a design, which is the best opportunity to make fundamental change, even though much of the design is still to be determined. CHAIR 2

  • focuses on construction and demolition issues and is

performed just prior to construction, when the full detailed design is known. CHAIR 3

  • focuses on maintenance and repair

issues and is performed at the same time as the CHAIR 2 study. Developed in the late 1990’s CHAIR is construction focused. CHAIR 3 studies do consider some issues regarding maintainability

  • f the asset but

not operability. Note: CHAIR is no longer supported on the NSW Work Cover website.

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 14

Safety In Design (SiD)

Focuses

  • n safety

interventions early in design. This is the most cost effective opportunity to do this. SiD involves the use of:

  • Hazard identification registers

(HAZID)

  • Risk

registers

  • Risk

is eliminated or controlled so far as is reasonably practical (SFAIRP) levels

  • Any

residual risk is identified and managed by the client

  • SiD

workshops that involve stakeholder representatives especially the client

  • Stakeholder

consultation should include actual end-users!

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 15

SiD in practice - example

Exterior flood light at the top of a three story building Light fixture rotates inwards to facilitate safe access for maintenance

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 16

Lessons learnt – Human factors integration and safety in design

  • For projects at the simpler

end, broadening the Safety in Design (SiD) process can be sufficient for Human Factors Integration (HFI) – SiD (under the WHS Act 2011) requires consideration of the safety

  • f people

during:  Construction  Maintenance  Operations  Disposal – Broadening the process to include:  Operability  Maintainability (the ease with which the asset can be operated and maintained) Note: CHAIR is

  • ften provided as evidence of SiD.

(Heavily biased towards construction, no longer

  • n WorkCover NSW

website) (see T MU HF 00001 GU for further information)

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 17

The ASA

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 18

The ASA’s objective

The Asset Standards Authority’s

  • bjective:
  • Is

to develop standards to enable AEO’s to deliver: – Assets are both operable and maintainable – Are safe to operate and maintain – Deliver required performance

  • Human factors

and human interaction is significant in these activities

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 19

What are human factors?

  • It

is the scientific discipline concerned with the understanding of the interactions among humans and

  • ther elements
  • f a system

and the profession, that applies: – theory – principles – data – methods to design in order to optimise human well- being and system performance.

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 20

Human factors

Overall system performance improves when human capabilities and limitations have been addressed in the design

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Human factors at the ASA is…

“Human Factors is about ensuring the delivered asset is both operable and maintainable, safe to operate and maintain as well as deliver required levels

  • f

performance” Key points:

  • It’s

about the delivered asset

  • r

service (lifecycle)

  • It

starts with good design (at least HF considerations in design)

  • It’s

not

  • nly

about safety, it’s about delivering to required design expectations – getting value

  • To achieve a good asset

HF should be incorporated at concept and design

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 22

Human factors in the asset lifecycle

Good asset performance begins at design Good design Leads to good asset performance

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Human factors in delivered assets

Making operable:

  • The finished asset

works well for end-users

  • The needs
  • f

the end-user been properly assessed during the concept and design stages Making it maintainable:

  • The finished asset

enables maintainers to keep it working well

  • Access

for maintenance been considered

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 24

Hazard analysis – general principles

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 25

Hazard analysis – definitions

Hazard – AS 61508 ‘Potential source of Harm’ Hazard ‘A potential source of harm. A condition that could lead to an accident. A hazard should be referred to a system

  • r product’.
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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 26

Why perform hazard analysis

  • To stop people getting killed
  • r injured
  • To enable the development
  • f a SFAIRP design
  • To enhance the performance

level of the final product

  • To provide assurance in the
  • verall quality of the design
  • To demonstrate compliance

with legislation

  • As

an afterthought when we have done the design

  • Because it

says so in the contract

  • To keep people happy!
  • To tick

the box

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 27

What are the goals of hazard analysis

  • Completeness
  • Full list of hazards
  • Knowledge-based
  • Take account
  • f past accidents

and current knowledge and previous work (previous projects etc)

  • Enable lateral thinking and
  • Reflect multi-disciplinary

understanding of interactions experience between system elements

  • To provide robust justification for
  • Auditable

decisions and content

  • Structured
  • To help completeness
  • Efficient
  • To enable best and appropriate use of

resources

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 28

What makes for good hazard analysis?

Documentation Scoped Facilitation People Preparation Technique

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 29

Exercise – What types of hazards should be identified?

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 30

Scope

  • Design or redesign
  • Like for Like
  • Off the Shelf
  • Simple human interactions or

complex

  • Predictable or uncertain system

behaviour

  • System boundary clear or

unclear

  • Influence of external factors
  • Influence of related system

elements To address the requirements

  • f the ASA Human Factors

standards you MUST have sufficient focus on Operability and Maintainability

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Which technique?

Simple projects

  • Past

experience (in industry)

  • Codes

and standards

  • Checklists
  • Hazop
  • Brainstorming

Complex project

  • Program
  • f

Hazard Analysis

  • Failure Modes Effects

and Criticality Analysis (FMECA)

  • Fault

Tree Analysis (FTA)

  • Event

Tree analysis (ETA)

Asset Standards Authority Applied human factors: Hazard analysis | 31

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

Engineering codes and standards

Advantages

  • Simple

to understand and follow

  • Legally enforced
  • Apply to all installations

Disadvantages

  • Based only on

experience (no prediction)

  • Consensus documents

(minimum acceptable standard)

  • Basis

is arbitrary (no risk analysis)

  • Other?
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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 33

Checklists

Advantages

  • All issues
  • n list will be

addressed

  • Can be done at

any stage in the life cycle

  • Minimal manpower
  • Standard checklists

available Disadvantages

  • May not

be comprehensive

  • Rely
  • n past experience

(not predictive)

  • May

be very lengthy

  • Can be a box

ticking exercise

  • Need to be kept up to

date

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 34

Preparation

  • Understand the context and determine the scope of

the assessment

  • Research past events
  • Site visit
  • Understand the human activities required
  • Identify who should attend (what skill

sets/experience is required)

  • Prepare documents for meeting
  • Develop briefing note for participants
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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 35

Understanding human activities task analysis

Simple Complex

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 36

People

  • Get the right people
  • Give people sufficient notice
  • Confirm attendance close to the day
  • Try to get as good a room as possible
  • Limit number to 6 – 8 people plus yourself
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Facilitation – basics

  • Do the housekeeping
  • Explain the purpose
  • Set the ground rules
  • Explain the process
  • Try to get everyone involved
  • Encourage positive

behaviour

  • Discourage negative

behaviour

A great way to get everyone involved is to start by going round the table and ask people of the known hazards

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 38

Facilitation – best practice

  • Use a means of recording

that is visual to the whole

  • group. You can then agree

wording etc right then and there

  • If possible get someone

else to do the recording (the better the recording at the time the less effort later)

  • Make sure that

explanations are explicit and understandable

Tip for participants, if you have something to say don’t just blurt out, it could interrupt the other persons thoughts. If it’s not the right time jot it down and say it later. It will actually have more effect!

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 39

People – end-user consultation

Have I got the right end user? Who are my end users? Have I consulted with them? How can I make it better for them to do this? What are they trying to do?

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 40

Exercise - Identifying end-users…

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Documentation

  • Use predefined format for collecting information at the
  • workshop. This can provide input into the project

hazard/risk register

  • Include hazard, cause, consequence, current controls, and

potential actions required

  • Copy of report/results sent to participants for review
  • The test of good documentation is that the information

should be clear to someone who was not at the meeting

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 42

Post Workshop Process

  • The final output of the workshop

then needs to be reviewed and the proposed actions subject to some form of governance process

  • In some cases this may require

further analysis such as cost benefit analysis

  • Agreed actions then need to be

tracked through to completion including any validation & verification activities

The output of the workshop represents the view

  • f

a group of people at a specific time

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Hazard analysis in practice

Hazard analysis is the process

  • f

recognising hazards that may arise from a system

  • r

its environment. This includes:

  • documenting undesirable consequences
  • analysing their

potential causes The hazard analysis process commences with a Preliminary Hazard Analysis (PHA) in the early stages

  • f

a project and continues throughout the system product's life cycle. A good hazard analysis session is well scoped and prepared, well facilitated, structured and well documented.

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 44

HAZOP

  • Process industry had poor record in 1950-60’s
  • Developed by ICI in the UK in the mid 1960's
  • Hazard reviews were unstructured and discipline oriented
  • Aim was substantially improve safety and operability
  • “Structured Brainstorming”
  • Based on identifying functional/manageable chunks referred

to as ‘nodes’

  • Guideword driven - explore ALL possible deviations
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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 45

HAZOP – Basic Guidewords

A hazard and operability study, abbreviated HAZOP, uses guidewords systematically to identify deviations from normal conditions to be further examined by skilled personnel.

Basic Guidewords

NO No part of design intent achieved, eg: NO flow, NO level MORE more of a quantitative property, eg: MORE temperature LESS less of a quantitative property, eg: LESS pressure AS WELL AS more of a qualitative property, eg: contamination PART OF less of a qualitative property, eg: additive present in reduced amount REVERSE reverse of design intent, eg: REVERSE flow OTHER THAN something completely different to design intent, eg: product delivered to wrong tank

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 46

HAZOP – extended guidewords

Basic guidewords Extended guidewords

NO NO FLOW COMPOSITION CHANGE MORE REVERSE FLOW CONTAMINATION LESS MORE FLOW RELIEF PART OF LESS FLOW INSTRUMENTATION AS WELL AS MORE LEVEL SAMPLING REVERSE LESS LEVEL CORROSION/EROSION OTHER THAN MORE PRESSURE SERVICE FAILURE LESS PRESSURE ABNORMAL OPERATION MORE TEMPERATURE MAINTENANCE LESS TEMPERATURE INGNITION MORE VISCOSITY SPARE EQUIPMENT LESS VISCOSITY SAFETY

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 47

HAZOP – characteristics

  • Extremely thorough
  • Systematic, structured approach
  • Not most intuitive system for new teams
  • Multidisciplinary approach
  • Relies on expert input... team size
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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 48

HAZOP – flowsheet

Describe design intention, operating conditions etc. Consider first or next guide word Identify all causes and record Identify all consequences and record List existing safeguards and record Take next section Agree any actions necessary and record Yes No Last guide word?

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HAZOP - Documentation

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 50

Study

  • f procedures
  • HAZOP can be applied to procedures
  • Modification of standard guideword set
  • Apply these guidewords to

– actions – sequence – time – information

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 51

Study

  • f procedures

Guideword Issue No action Step is missed or

  • mitted operation did not
  • ccur

/ action impossible / equipment not ready Operator does more than intended /

  • ther

actions More action

  • ccur

affecting this

  • peration

Operation does less than intended / equipment Less action does not perform as required / not enough time to complete the step Wrong action Operator pulls wrong lever, reads wrong instrument / closes instead of

  • pens

/ performs different

  • r
  • ut
  • f

date procedure / performs two

  • r

more steps at

  • nce
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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 52

Study

  • f procedures

Guideword Issue No information No feedback from system / procedure does not specify expected performance / no actions for emergencies

  • r

results specified Too much information Step is confusing / too much detail / too many alarms or signals / contains unnecessary information / too many tasks / information overload Less information Insufficient information to perform properly / expected result not specified / no start or end conditions / insufficient information to cope with emergency

  • r

unusual r esults Wrong information Information provided is wrong or out of date / typo / written instructions contradict oral,

  • r
  • ther procedures,
  • r steps in this procedure
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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 53

Study

  • f procedures

Guideword Issue More time Operator takes longer than necessary

  • ver

action/starts next action later than expected Less time Insufficient time allowed/operator carries

  • ut

action too quickly/insufficient time to warm up

  • r

cool down/equipment limitations Out

  • f

sequence This step occurs too soon or too late/operator performs step at wrong time/equipment not in proper state

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Example – HAZOP results

Asset Standards Authority Applied human factors: Hazard analysis | 54

Guideword Deviation Cause Consequence Current safeguards Recommendations Action by No Flow Valve stuck in closed position Operational delay Potential damage to pump Pump design Provide positive feedback of flow to

  • perator

GJH Operator fails to open valve Operational delay Potential damage to pump Operator to develop procedure and training Provide positive feedback of flow to

  • perator

Aide memoir to be provided on site Valve position to be clearly indicated to

  • perator

GJH DVX DVX

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Brainstorming – SWIFT

Structured What If Technique

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SWIFT characteristics

  • Appropriately thorough
  • Systematic
  • Multidisciplinary team
  • Analytical approach
  • Relies on expert input
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Development of checklist questions

The key inputs to the development

  • f

checklist questions:

  • Task analysis
  • Review of past

incidents

  • Review of

relevant: zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA

  • Codes
  • Standards
  • Legislation
  • Other checklists
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SWIFT procedures

  • Pick a section
  • Discuss regulatory issues
  • Determine design intent
  • Choose a question category
  • Ask What If questions
  • Answer What If questions
  • Use checklist to prompt questions
  • Select next question category
  • Discuss other regulatory issues
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Brainstorm a list of hazards

  • What if?
  • How?
  • Is it possible?
  • Has it even happened?
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SWIFT documentation

The recorder would list the findings under the following categories:

  • Question
  • What-if Question
  • Consequences
  • Safeguards
  • Recommendations
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SWIFT example – filling a car

Question Category What if Consequences Safeguards Recommendations Action by Human Factors What if the driver puts diesel in a petrol car Clogging of fuel system Costly repairs Divorce! Make entry to fuel tanks different sizes Clearly label diesel pump Separate diesel pumps from petrol pumps Don’t own a diesel and petrol car Only fill up own car Self

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Exercise – SWIFT

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Exercise What do you see as the main differences between HAZOP and SWIFT

Think…

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Exercise – Lifecycle

Where do you think the list of techniques fits on the life cycle diagram?

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zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Asset Standards Authority Applied human factors: Hazard analysis | 65

Conclusions

  • It IS worth doing well
  • Scale of exercise appropriate to the project
  • Several available techniques from simple to complex
  • Some are team-based (HAZOP) and individual (FMEA)
  • Must be structured and documented
  • You MUST ask the questions about what the people need

to do to operate and maintain the system. Best source of information is from end users