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The ‘top 10’ common issues:. Fatigue Organisational culture Human factors in design Communications/interfaces Integration of HF into risk assessment & investigations. Organisational change Staffing levels/workload Training & competence Procedures Managing human failure. /.

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slide1

The ‘top 10’ common issues:

  • Fatigue
  • Organisational culture
  • Human factors in design
  • Communications/interfaces
  • Integration of HF into risk
  • assessment & investigations
  • Organisational change
  • Staffing levels/workload
  • Training & competence
  • Procedures
  • Managing human failure

/

  • Behavioural safety = human factors*

No PPE, No slips and Trips!

Its all about HAZARD

*No it does not

organisational change
The BAD

Objectives not clear

Not communicated

Under-resourced

Lack attention to detail:

PTW and ISSOW

SAP / MAXIMO

The GOOD

Additional supervision

Staff hot-line for tech support

Clear communication

Employee involvement

TA’s offshore

Organisational change
  • Tip;
  • Go to Waterstones,
  • Buy a book on “Managing Change”,
  • Do what it says.

It should be impossible for HSE to advise the oil industry on change!

staffing levels workload
The BAD

Skills shortage

Old equipment in poor condition

Auto operation not working – obsolete

Breakdown Maintenance

New hires not mentored (it takes 10% + time)

Cost cutting not thought though

Lack of risk assessment for work-load

No monitoring of workload and stress

The GOOD

Increasing manning levels

Workload monitoring

Improvement schemes

Roving supervisor posts

Staffing levels/workload

Not being there is

a major cause of

serious incidents!

training competence
The BAD

Too many new hires

Commitments to mentor not met

Training unrelated to tasks

Training is too generic

Competence framework seen as training

Competence not related to hazards

Supervision used as a “quick fix”

The GOOD

Training supervisor offshore

Competence framework relates to hazards assessment

Mentoring is included in work plans

Training is theory and practice – knowledge based

On the job training

Independent verification and audit

Apprenticeships

Innovative hiring, ie marine engineers

Training & competence
procedures
The BAD

Unworkable

Out of date

Missing

Too long

“Nannying”

Conceal hazards

Obsessed with procedural compliance

Prefer B-mod to task design

The GOOD

Include operator involvement in preparation

Regularly reviewed as part of continuous improvement programme

A good way to do the job

Balance between procedures and competence

Linked to training and competence

Are part of the SMS

Linked to ISSOW, risk assessment

  • Behavioural safety = human factors*

/

Procedures

*No it still doesn’t

procedures1
The BAD

Unworkable

Out of date

Missing

Too long

“Nannying”

Conceal hazards

Obsessed with procedural compliance

Prefer B-mod to task design

The GOOD

Include operator involvement in preparation

Regularly reviewed as part of continuous improvement programme

A good way to do the job

Balance between procedures and competence

Linked to training and competence

Are part of the SMS

Linked to ISSOW, risk assessment

  • Behavioural safety = human factors*

/

Procedures

EASY WIN, LOOSE:

  • Have procedures that are unworkable.
  • Bring in a B-Mod programme.
  • Punish non-compliance firmly.
  • (if that fails talk about how “people are our greatest asset” then bring in contractors to do the job…)

*No it still doesn’t

managing human failure
The BAD

Ignore human performance imitations : ie “the risk of an accident will keep them alert”!)

High consequences for failure

Assume unrealistic error rates

No error correction plan

The GOOD

Error tolerant systems

Assume error and plan for it

Alert to error

“Defences in depth”

High reliability systems are automated

Managing human failure
fatigue
The BAD

Long hours

Overtime!

No monitoring

No plan for no-shows

Call-outs

Manning too low

Poor shift pattern

Do not record hours (WTD)

Not included in risk assessment and planning

No policy

The GOOD

A clear policy on alertness

Alertness seen as part of safe system of work

Part of the SMS

Monitored and linked to improvement programme

12 hour shifts, overtime in exceptional situations

Risk assessment for every task beyond 12 hours

Hours worked a management measure

Fatigue
organisational culture
The BAD

Management never go onto the plant (do they mean me?)

Two class system

Say one thing, do another (surely not!)

Hire and fire

Secretive

Treat the employees as a hazard

The GOOD

Open (and brave)

“Management by walkabout”

Long term employment

Lead by example

Engage employees in delivering safety and performance; the employee as a benefit to the organisation

Organisational culture
human factors in design
The BAD

Usability not in spec

Lots of in-service modification

Irrational interfaces

Overdependence on vendors for design

No user feedback

Impossible to maintain

Lead from the beach

High error tasks blamed on operator not equipment

No evidence of corporate learning

The GOOD

Operators included in design

Incidents reviewed a as design resource

Investigations include design

Vendors engaged proactively and able to meet field operators

Maintenance and access included in design

Part of an “aggressive” continuous improvement process

A man-machine system

Human factors in design
communications interfaces
The BAD

Fail to identify high hazard situations

Use ambiguous terms

Fail to verify understanding

Directive style

Do not listen: is is very rare that the cause of an incident has not previously been raised to management

Time for communication not included in task plans (ie shift handover)

The GOOD

Recognise communication as important

Proceduralize or design out ambiguity

Open and engaging style

Look for two way interaction

Treat communication as a learnable skill / competence

Include in task planning

Communications/interfaces
integration of hf into risk assessment investigations
The BAD

Everything is “operator error”

“Proforma” risk assessments!

Blame-based investigations

No HF in risk assessments

Investigations stop before reaching a root cause

Investigation outcomes do not prevent a reoccurrence

The GOOD

HF is seen as a positive risk reduction strategy

The objective of Investigations is to prevent reoccurrences

“Operator error” is not seen as an explanation

Risk assessment includes HF as does hazard recognition

HF risk assessment uses realistic and sympathetic mitigation

Integration of HF into riskassessment & investigations
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