How to avoid mistakes

Episode 3 of the latest series of BBC’s Horizon, How to avoid mistakes in surgery, provides a fascinating insight into attempts to reduce human failure in the medical and aviation industries and fire service.

In particular, it focuses on crew resource management-type initiatives – a topic of a current EI Human and Organisational Factors Committee project – and successes in preventing human error using simple techniques, such as checklists.

Click the link to watch (availability may be limited depending on your country).

Do you have any simple successes to report as good as the improvements mentioned in the programme regarding the use of checklists or other simple techniques?

Human factors training courses – May 2013

The EI is hosting two human factors training courses in May 2013, to be delivered by Bill Gall.

Bill is a member of the EI’s Human and Organisational Factors Committee and a Chartered Psychologist.  He is the author of the EI’s new Human factors briefing notes and Guidance on investigating and analysing human and organisational factors aspects of incidents and accidents.  By his own admission, Bill’s personal goal is ‘to eradicate the terms ergonomics and human factors and convince management that the principles involved are part of good management practice.’  Attendees of the courses should therefore leave equipped with good management processes to share within the workplace.

The courses:

Basic human factors – 7 May 2013
This one day training course provides an essential overview of the role of human and organisational factors in the energy sector and allied industries.  The course will examine the environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work in a way which can affect health and safety outcomes.  Delegates will learn how they can improve procedures, conditions and performance in their own workplace.

Accident and incident investigation – 8-9 May 2013
This two day training course will focus on the analysis of incidents and accidents and will clarify the process of identifying root causes using practical examples.  The course will provide an overview of available analysis methods and the application of these to identify the underlying management and organisational deficiencies responsible.

If you are interested in attending either or both of these courses, please contact Will Sadler e: wsadler@energyinst.org.

Quantitative over quality?

In January, EI Netherlands Branch member Arend van Campen posted a thought provoking piece in response to the publication of EI Guidance on quantified human reliability analysis (QHRA) (see “Can humans be quantified?”).

Author of Guidance on quantified human reliability analysis (QHRA), Jamie Henderson, has written a response clarifying the purpose of the guide:

“Arend van Campen’s response raises some important points – issues for which we have a deal of sympathy.  One of the reasons for writing the guidance was that human reliability analyses (HRAs) are often undertaken without a proper understanding of the context in which people work, and of the limitations of the available techniques and data.  There are several potential dangers with this, not least complacency that human factors issues are being adequately managed when they are not.

Thirty years ago, when these techniques (e.g. THERP, HEART) were first being developed, the prevailing approach to engineering risk analysis was, and to some extent still is, primarily deterministic.  When people were considered, if at all, it would typically be as components in a system, that reduces people “…to the same level as if he were a valve or pump that can be tested on reliability and sent back to the manufacturer if it does not work properly”.  Now, for many reasons, some of which are set out in Arend’s response, this approach is lacking.  However, at the time, despite an increasing recognition of the role that people play in ensuring safety, human factors was still finding its feet as a discipline and needed systematic ways of ensuring that human factors issues were considered.  Understandably, these attempts focused on developing tools and techniques that could be integrated with existing approaches to engineering risk management.

In the intervening years, individuals working in this area have made many criticisms of these techniques (for example, the basic concept of human error has been challenged by numerous authors) and sought to develop new approaches to understanding why systems succeed or fail.  One well-known example is research into high reliability organisations (HROs) which, instead of failure, focuses on identifying the characteristics of organisations that appear to manage safety in high-hazard environments particularly well.  Resilience engineering, another relatively recent development, seeks to create flexible, robust processes in the face of real world complexity (e.g. responding to resource issues, revising risk models as situations change).  The issues raised in Arend van Campen’s response (e.g. HSE goals, trust, motivation) are also important factors in the ability of an organisation to manage safety and risk.

However, despite the known issues with their application, and the development of new approaches to understanding why systems succeed or fail, these HRA techniques are still used, often by people without a background in human factors, and without a realistic understanding of the operating context in which tasks are performed.  Until new approaches are developed, operationalised and tested, the existing techniques, which are after all designed to work within the context of an engineering risk analysis, will continue to be used.  Therefore, the aim of the guidance, and the supporting article, was not to endorse these techniques, but to ensure that anyone considering using them, in particular individuals without a background in human factors, understands their limitations.”

We thank both Arend and Jamie for their contributions.

Perhaps something to add is to consider not just how QHRA should be done (if done at all), but why?

Is QHRA being used simply to justify the safety measures we have put in place? Or is it being used to better understand the tasks people are expected to perform, in order to improve the measures in place?

Turnover rate as a measure of safety culture?

Blogger Dave Weber, a former Safety and Environmental Manager and founder of Safety Awakenings makes an interesting observation:

Companies with low staff turnover tend to have good safety records and excellent safety cultures.

Having a good culture means they are good places to work.  They are profitable, so treat staff well.  Lower turnover also means there is better retention of safety knowledge.

Could staff turnover (and the factors that affect staff turnover) potentially be used as one measure of safety culture?  If there is a correlation, does this correlation apply to both occupational safety culture and process safety culture?

Can humans be quantified?

The November 2012 edition of Petroleum Review featured an article on EI Guidance on quantified human reliability analysis (QHRA) (both the Petroleum Review article and publication are available for download from the link).

QHRA can be a contentious topic, and the article solicited a response from EI Netherlands branch committee member Arend van Campen.  Arend is a Business Ethicist and writes:

“When I read the article ‘Quantifying human reliability in risk assessments’, I was flabbergasted.  In the article ‘man’ (you-me) was declared ‘unreliable’, meaning: undependable, untrustworthy, irresponsible, etc.

QHRA reduces people to a quantifiable risk statistic, as if people were machines. The philosophical question ‘are people and their conduct indeed quantifiable?’ rose to mind and a second, ethical question: would morality, or virtuous conduct, become obsolete if we could quantify people’s reliability?

In a number of abbreviations and statistical charts, people seem to be reduced to an unreliable entity and we had better know these faults before we employ someone or have him or her operate expensive machines or installations!

But to answer why and to whom this article and the publication it discusses is intended, some first questions need to be answered to analyse: who is at risk?

• Is it the corporation and its management at risk?
• Is this programme intended to control and minimize liability exposure or to prevent reputation damage?
• Is the checklist designed to make the person whose reliability was analysed safer?
• Can one expect that by creating checklists on human reliability, human behaviour can be controlled and risks reduced?
• Does the checklist allow for ethical, moral and social input?

At the Oil Terminal 2012 conference I gave a master class on HSE and operational profit.  It was not aimed at technical aspects such as wearing a hard hat, steel toe boots, etc. but at the need to revise thinking about safety by asking the correct questions. These questions were not found in the new EI publication as they are founded on corporate social responsibility policies and codes of ethics. The lessons were aimed at human safety, happiness, trustworthiness, joy, because these human factors are unfortunately overlooked, but do form the fundamentals of human reliability.  Only when we address these simple human needs, we can reduce people’s unreliability, but not by reducing management and personnel, share or stakeholders to mere statistical and unreliable risk factors.

• What are true HSE goals of the corporation and the individual?
• Can a corporation and its management be trusted?
• Measure human motivation – by investing in concern and compassion.
• Look at social cohesion – at home and at work.
• Prime basic principle: trustworthiness.
• Golden rule principle: Do not do to others what you would not like others to do to you.
• If it is not true, don’t say it. If it is not right, don’t do it.

These simple points / questions would be a good start, whilst in a second stage the following questions are to be asked:

• Is humanity itself the product of rules and regulations?
• Does everyone realize that rules or actions must be based on the universal law that humanity is the product and cannot be the means?
• The most important rhetorical question: would you like to live in a world where wrong actions are followed?
• Is everyone aware that the principle for human action is free will, which gives them a moral value?
• Are guidelines and regulations based on good will?
• Are they based on duty or out of inclination? (Deontology)
• Is everyone aware that moral action becomes an objective necessity of obeying this as a duty, which comes before legality of action?

When addressing safety, people should not be reduced to the same level as if he were a valve or a pump that can be tested on reliability and sent back to the manufacturer if it does not work properly.

Trust, justice, respect, enjoyment, happiness are the key factors, but they are unfortunately often overlooked by technicians who believe in technical control – including of people – by mechanistic tools based on physics, mathematics, economics and statistics. This is an error, but can be balanced by allowing philosophy, in the form of ethics and logic, back into industry.

Just start with the first question before all else: ‘is it good or bad?’”

We thank Arend for his contribution to this debate.

What do you think?  Is QHRA a useful technique for understanding risk, or is it fundamentally flawed?

EI publishes guidance on quantified human reliability analysis

The EI has published Guidance on quantified human reliability analysis (QHRA), freely downloadable from the EI website, or as a priced hard copy publication.  An article featured in the November 2012 edition of Petroleum Review discussing this publication, also available for download from the EI website.

Major accidents in the energy and kindred process industries have illustrated the influence of people upon the performance of safety (and environmental) critical systems. Consequently, there is an increasing requirement for major accident hazard installations to demonstrate that human factors is being properly managed.

Many of the risk assessment techniques used in industry involve quantification, and the value of their outputs relies heavily on the quality of the data they used. Whilst there are some human reliability analysis (HRA) techniques and human error probability (HEP) data available to support the integration of human factors issues in these analyses, their application can be difficult. In particular, HEPs are often used without sufficient justification.

EI Guidance on quantified human reliability analysis (QHRA) focuses primarily on techniques that provide support for quantification. It aims to reduce the instances of poorly conceived or executed analyses by equipping organisations that plan to undertake, or commission, HRAs with an overview of important practical considerations. It promotes the real value of an HRA coming not from the generated HEP, but from the in-depth understanding of task issues that results from analysis.

This publication is intended for three main audiences:

1. Plant managers or general engineering managers, responsible for commissioning HRA studies

2. Risk analysis practitioners who need to undertake HRA studies on behalf of their clients and who wish to refresh their knowledge.

3. Senior managers looking for a concise overview of the main issues associated with HRAs.

For example, a particular use of this publication is to assist those needing to quantify human reliability in safety integrity level (SIL) determination studies.

EI Guidance on quantified human reliability analysis (QHRA) builds on the qualitative approach to task analysis set out in Guidance on human factors safety critical task analysis, which purposefully excludes from quantification from its scope.

Review of EI ‘Delivering safety culture change using the Hearts and Minds toolkit’ training course

The EI piloted a 3-day Delivering safety culture change using the Hearts and Minds toolkit training course in September.  This 3-day course was designed to take attendees on a ‘journey’ of the process by which a safety culture improvement programme may be implemented, beginning with discovering what safety culture is all about, assessing the company’s safety culture and gaining management support, and then building a plan and implementing it (using the Hearts and Minds tools).

Attendees were assessed on two fronts:

• their efforts to run an exercise from either Managing Rule Breaking or Improving Supervision Hearts and Minds tools, and
• the development of a plan to implement a culture programme in their own company.

But the assessment was not for its own sake – when the course was devised it was intended that participants could leave with a practical plan for moving forward with their culture programmes, learning from two prominent safety culture specialists, Prof. Dianne Parker and Dr. Mathew Lawrie, who helped develop the Hearts and Minds toolkit and developed and delivered the 3-day course.  How will their plans work out?  Only time will tell.

Was the training course a success?  Absolutely!  At the beginning of the course participants were asked to list what they hoped to get out of the course, what they would consider a success (i.e. what they needed to learn in order to successfully implement a culture programme) and what particular issues they faced in their organisations:

• Participants hoped for a plan to roll out a programme; they wanted to know how to create drive for improvement, how to sustain a programme and how to use the Hearts and Minds tools; they wanted to grasp the fundamentals of Hearts and Minds and they wanted to network with other Hearts and Minds users.
• Participants would consider success as being able to create ambassadors for managing culture; becoming equipped to implement a culture programme; to move from compliance to conformity; to gain buy-in from senior management.
• Issues faced in their organisations included: leaders not leading the safety culture; people not having the courage to intervene in improving behaviour; many safety programmes with little follow-through; motivating non-production departments to get involved in safety; getting management buy-in; and involving contractors in a culture change programme.

The course met the majority of participants’ hopes, and more than touched upon many of the more specific issues people had (such as contractor involvement)  – in a large part due to the experiences of the trainers themselves, and because, in listing what participants wanted to get out of the course, they were able to shape the discussions that took place.

Did it cover everything?  Of course not – and we learned some important lessons about the course and the Hearts and Minds tools.  For example, whilst fairly general, the tools do have a personal safety bias, making their application to long-term hazard management (such as in the design of a nuclear facility) a challenge.  Participants were also required to role-play or run workshop exercises, which some people found more difficult than others.

But in some cases participants’ expectations were completely blown away, as they realised everything they thought they knew about safety culture improvement was wrong.  (You could almost hear the paradigm shifts happening in their minds.)

One powerful memory involves a participant working in the Middle East.  After day 1 he said “If I go back to my bosses and say ‘we should run a culture programme’, they won’t accept it and I’ll likely get the sack”.  By day 3 he was confident that he had developed a plan to get senior management buy-in (“I’ll make it out that it was their idea”).

The next Delivering safety culture change using the Hearts and Minds toolkit course is schedule to run 4-6 February 2013.  Contact Will Sadler wsadler@energyinst.org for more information.