The next rung on the ladder in staffing arrangements – does HSE CRR348/2001 need updating?

January 27, 2012

In 2001, the UK HSE published Contract Research Report (CRR) 348/2001 Assessing the safety of staffing arrangements for process operations in the chemical and allied industries.  This report sets out a 2-part methodology for assessing whether staffing levels and arrangements are adequate to maintain the safety of operations in high hazard industries, using:

  • Physical assessments – which assess the ability of staff to successfully detect, diagnose and recover hazardous scenarios.
  • Ladder assessments – which benchmark organisational factors in relation to industry best practice.  CRR348/2001 provides ladders on eleven staffing issues.

In 2004, the Energy Institute launched a guidance document setting out a best practice approach to the CRR348/2001 methodology that captures learnings from its use, and provides an additional ladder for the use of automated systems.  This guidance document was authored by Dr. Andy Brazier, now an independent consultant.

A recent independent paper by Andy Brazier provides a ten year review of the CRR348/2001 methodology.  It offers some personal observations of common human factors issues still prevalent within many organisations and makes some recommendations.

Of particular interest, the paper also suggests an improvement to the ladder assessments provided in CRR348/2001.

Ladder assessments can be described as a hierarchy of statements and keywords that describe typical practice on how organisations manage (or fail to manage) particular activities, in this case those associated with managing staffing arrangements (including situational awareness, team working, alertness and fatigue, etc.).  These make up the ‘rungs’ on the ladder, with each successive rung representing better practice than the last.

As well as a method to benchmark performance, ladder assessments provide a series of checkpoints for improvement, with the top rung representing ‘best practice’.  Teams must be confident that they fully meet the expectations of one rung before they can meet the next one up.  As such, CRR348/2001 provides an overview of good and best practice (as of 2001) and a route to achieve that.

However, Andy makes the suggestion that the top rungs in these ladder assessments no longer represent best practice – “I believe the concept of High Reliability Organisations, that has developed over the last decade, gives us a good reference point for what may be considered as best practice now” – and proceeds to suggest an additional rung for each ladder detailing practices commonly found in high reliability organisations (HROs).

Does this mean CRR348/2001 is now out of date or no longer valid?

This is unlikely.  In 2009 the EI’s Human and Organisational Factors Committee (HOFCOM) reviewed and reaffirmed the EI guidance document, believing it (and the CRR348/2001 methodology it supplements) to still be valid and useful.

When using ladder assessments, we should remember that companies must fully meet the requirements of the rung below before they can move up, so until they have reached the top rung CRR348/2001 is still useful.  However, for those companies approaching the top rung, or with serious ambitions of becoming a HRO, would adding an additional rung to the ladder be beneficial?

The health and safety information gap

January 19, 2012

In September 2011, Robert Gordon University published a research report titled: The health and safety information gap.  374 individuals (HSE managers, senior managers and engineers) working in the energy sector responded to an online questionnaire, which asked them to give their views on the importance of safety and which issues they felt were most important to them.

75% of respondents said that they felt HSE performance in their companies had improved.  The top 5 drivers of this were:

  • Increased safety training (83%)
  • Increased focus on safety behaviours (73%)
  • Increased internal communication (68%)
  • Improved sharing of information with contractors (60%)
  • Increased senior management championing of safety (59%)

When asked what their priorities were for improving safety, many felt that management commitment to safety needs to be improved, and that there needs to be greater accountability and individual responsibility for safety.  Particular priorities included:

  • Changing employee safety behaviours (66%)
  • Changing the safety culture of the organisation (61%)
  • Improving employee awareness of safety (53%)
  • Recording and auditing improvements (51%)
  • Meeting regulatory compliance (50%)
  • Improving information systems (45%)
  • Demonstrating employee competency (35%)
  • Addressing new/changed regulations (31%)

When asked what the major challenges were in enhancing safety, by far the two standout challenges were ‘developing a culture of personal responsibility’ and managing ‘Human behaviours’.  These two are fairly general challenges, linked strongly to developing safety culture and competence, but also leadership and managing human failure.  Other challenges included making HSE a priority over production, management of change, issues around training (lack of resources, time, inadequate training), and various issues around information systems (limited sharing of best practice across industry, variations in procedures and standards, missing or poor quality information, etc.).

Much of the report focuses on the ‘Improving information systems’ issue (probably given the provenance of the research funding) and this discusses where gaps in HSE information systems are.  Gaps identified included the need for more employee feedback (64%), better competency assessment (57%), and better documentation of levels of competency (56%).  At the EI Human Factors conference held in December 2011, panel and audience discussions also surfaced competency assurance as a key issue for further development.

Other gaps in information systems included the need for better recording of auditing and performance indicators (40%).

So what, if anything, can we take from this report?

More generally, the top priorities for HSE improvement seem to be around safety culture, e.g. ‘improving culture’, ‘changing behaviour’, ‘developing a culture of personal responsibility’.  Safety culture improvement is clearly still a strong focus for industry.  However, safety culture is something of a paradox: in one way, it is the climate in which an organisation, its employees, and its management system operate, but in another way it is a measurement of how well these aspects work, as well as how well they work together.

When we put the more specific priorities and challenges listed in the report into context an interesting (but perhaps not unexpected) pattern emerges: they fall into these three broad aspects of safety culture, with no clear indication of which aspect is of most concern:

  1. Organisation: management of change and organisational priorities (38%).
  2. People: competency and training (30-36%).
  3. Management systems: information systems, procedures, standards and regulations (29% and below, but divided into many more sub-issues).

At a very general level, then, it seems that people are interested in seeing improvements in all facets of safety; however, no clear priority emerges from this report. Maybe it’s more apposite for individual organisations to identify which is their key weakness and tackle that within their organisation.

Costa Concordia cruise liner capsizes – Captain held for questioning

January 18, 2012

Luxury cruise liner the Costa Concordia capsized off the coast of Giglio Island, Italy, after running aground on 13 January 2012.  At the time of writing the search and rescue operation has been suspended, with 11 confirmed dead and 28 people unaccounted for.

The ship’s owner has accused the Captain of “significant human error”, taking the vessel too close to shore, not following evacuation procedures, and abandoning ship whilst the evacuation was still underway.  Furthermore there has been speculation as to why the captain took the vessel so close to shore, suggesting it was to ‘salute’ a friend onshore or provide a ‘nautical fly-by’ of the island for the entertainment of islanders and on-board guests.

These allegations are denied by the captain claiming that the rock which the ship hit was not marked on maps and that the ship was taken into shallower waters to aid in evacuation, possibly after the ship encountered electrical problems interfering with the navigation systems.

As on-going emergency procedures draw to a close, the next stage will be a full investigation into the circumstances leading to this incident. As human factors specialists and ergonomists recognise, ‘human error’ should not be an adequate cause of the incident: root causes should be identified, whether organisational arrangements, safety culture, compliance with safety critical procedures, etc. or other key human and organisational factors or process safety issues, as detailed within the UK HSE key human factors topics and the EI’s High level framework for process safety management (PSM framework).