The ‘top 10’ common issues:

1. 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

2. 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!

3. 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!

4. 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

5. The BAD Unworkable Out of date Missing Too long “Nannying” Conceal hazards Obsessed with procedural compliance Prefer B-mod to task design The GOOD Include operator involvement in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

6. The BAD Unworkable Out of date Missing Too long “Nannying” Conceal hazards Obsessed with procedural compliance Prefer B-mod to task design The GOOD Include operator involvement in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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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