Learning from incidents seminar 5: Linking research and practice in learning from incidents, 11 June 2015, London

April 30, 2015

‘Interdisciplinary Perspectives on Learning from Incidents’ (IP-LFI) ESRC Seminar Series

11 June 2015, 10am-5pm (registration from 9:30am)

British Safety Council, 70 Chancellors Road, London W6 9RS (Hammersmith)

http://lfiseminars.ning.com/

You are invited to join an interdisciplinary group of researchers, practitioners and policy-makers from across Europe to explore how organisations can learn effectively from incidents across different sectors: energy, health, finance, construction and further afield.

So far this seminar series has explored key issues and gaps in the field of learning from incidents and has devised a set of preliminary research questions for an interdisciplinary R&D agenda (Seminar 1); examined various theoretical perspectives (Seminar 2) and methodological approaches (Seminar 3) to learning from incidents, from a range of disciplines across Engineering, Social and Life Sciences; and discussed examples and issues from policy and practice perspectives (Seminar 4).

In this fifth seminar we shall discuss how to strengthen the link between research and practice in learning from incidents (LFI). How could researchers, practitioners and policymakers collaborate to advance learning from incidents? What models and frameworks could effectively facilitate cooperation between these different stakeholders? What are the key priorities in learning from incidents and what could researchers do to help practitioners and policymakers improve LFI? How can LFI research be best communicated to practitioners and policymakers?

These questions will be addressed through the keynote talks and group discussions at this seminar. The keynote speakers are:

  • Dr Ritva Engeström, Senior Researcher, Centre for Activity Theory and Developmental Work Research, University of Helsinki, Finland: “Change Laboratory and Developmental Work Research”
  • Professor Eve Mitleton-Kelly, Director of the Complexity Research Group, London School of Economics and Political Science, UK: “Addressing complex problems through collaboration: A complexity theory approach”
  • Professor Lasse Gerrits, Chair in Governance of Complex and Innovative Technological Systems, Otto-Friedrich University, Bamberg, Germany: “Back to normal: Generating resilience in complex systems”

Participation is free. A buffet lunch will be provided.

Registration is required. To register for the seminar, please go to: https://eventbrite.co.uk/event/16547197112/

To join our LFI seminars community and to be kept up to date about the forthcoming events sign up at lfiseminars.ning.com http://lfiseminars.ning.com


Call for abstracts: Human factors application in major hazard industries, 6-7 October 2015

April 2, 2015

The deadline has been extended to submit an abstract for this biennial two-day conference, which returns in 2015 and will explore the practical application of human factors in the management of major accident hazards (MAH) in the energy and allied process industries. The event will focus on two key themes:

  • Assuring human factors performance: How can we ensure high performance through human and organisational factors?
  • Preventing incidents before they happen: How can we effectively investigate and analyse incidents and embed learning. How can we prevent incidents before they occur?

This conference, organised by the Energy Institute (EI)’s Human and Organisational Factors committee and the Stichting Tripod Foundation, will enable the learning and sharing of good practice between companies and industries, and offers excellent networking opportunities with delegates from around the world representing operating companies, suppliers, consultancies, and academia.

Call for abstracts

The deadline for submitting an abstract has been extended until 30 April 2015. Don’t miss this final opportunity to put forward your submission for an oral or poster presentation on the following key topics:

Assuring human factors performance:

  • Competence assurance
  • Non-technical skills and crew resource management (CRM)
  • Alarm handling
  • Risk analysis
  • Fatigue management
  • Other topics will be considered

Preventing incidents before they happen:

  • Safety culture
  • Human and organisational factors in Bow Tie diagrams
  • Embedding learning from incidents
  • Quality incident analysis
  • Other topics will be considered

To submit your contribution you will need to:

  • prepare an abstract of up to 500 words on the topic you intend to present in Microsoft Word format
  • indicate the presenter and co-authors with their affiliation and contact details
  • submit the abstract to Stuart King: e: sking@energyinst.org;

Submissions will be evaluated by the organising committee and successful entrants will be notified shortly after the submission deadline. Final deadline for abstract submission is Thursday 30 April 2015.

Sponsorship

A range of sponsorship opportunities are available for this event. For details please contact Luigi Fontana: e: lfontana@energyinst.org;


EI appearing at Hazards 25 conference – 13-15 May 2015, Edinburgh

April 1, 2015

The EI will be speaking at the IChemE Hazards 25 conference in May.  Steve Sharwen (ABB, member EI Area Classification Working Group) will provide an overview of key changes in the 4th edition of EI’s hazardous area classification publication (‘EI 15’); whereas Dr Ed Smith (DNV-GL, author to EI Human and Organisational Factors Committee) will describe work to prepare comprehensive guidance on learning from incidents.

EI will also have an exhibition stand, so come over and find out more about the technical work we are doing.

For full details on the conference programme, and to book your delegate place, visit the main conference website:

http://www.icheme.org/hazards25


EI issues invitation to tender on project S1502 ‘Guidance on control room alarm rationalisation’

March 23, 2015

The EI has issued an invitation to tender for a new project to produce guidance on how to conduct a human factors-oriented rationalisation of control room alarm systems.  This guidance aims to help companies bring the numbers of control room alarms down to a more manageable level (e.g. in order to meet EEMUA 201), to add in new alarms as the results of SIL/LOPA studies, and more generally to ensure that the alarms in place optimise operator situation awareness.

Consultants with experience in conducting control room alarm rationalisation/optimisation, and who are potentially interested in bidding for this project, are encouraged to contact Stuart King, Technical Products Manager, at e: sking@energyinst.org

 

 


New EI Guidance on ensuring control room operator (CRO) competence

January 13, 2015

Control room operators (CROs) perform a critical role in running normal operations, infrequent activities such as process shut downs, and handling abnormal events and emergencies. Ensuring a sufficient number of competent CROs are available on site is a key element of safety, and can contribute positively to productivity.

This new publication from the EI provides specific guidance on how to assure competence of CROs, particularly how to define competence standards, select training and development methods, assess CROs and maintain their competence once in post.

Challenges

The first challenge to training new CROs is in achieving an adequate pool of candidates from which to select CROs.  As CROs are often selected from field operators, this has a major implication; the recruitment of field operators should foresee the subsequent requirement for CROs.  This guide therefore advises that at least some field operators are recruited based on their potential to be CROs. Methods of assessing underpinning skills are cited in the guide to help identify potential CROs amongst current or candidate field operators.

The second challenge is that training someone to become a CRO is a long process involving the identification of the tasks a CRO needs to undertake, the competencies required, and how to best train and assess those competencies (e.g. using classroom or on-the-job training).  Given that people do not become established CROs overnight, an incremental approach to competence development is needed, progressing from beginners to established and then to advanced CROs. Guidance is provided on the formulation of an incremental approach to development, combining taught and structured on the job learning.

As the training of CROs is an expensive undertaking, the third challenge is retaining CROs once they are in post.  There are many aspects of retaining people. This guide firstly focuses on providing CROs with a structured route for advancement, providing people with the scope for further development once they are in post. Learning and further qualification opportunities may be provided and CROs encouraged and enabled to make use of these opportunities. In addition, creating a positive working environment through practical procedures, ergonomic equipment, supportive supervision and change management all contribute to staff retention as well as help reduce operator error.

The guidance is consistent with common models of competence management, but offers guidance that is specific to CROs.  This guide presents a full lifecycle view of CROs, from the creation of a pool of candidates to advancement of their competence when in post.  Extensive annexes provide practical tools, such as checklists for assessing the organisation’s arrangements for managing CRO competence, job aids for identifying CRO competencies, as well as example CRO competencies (and methods for training and assessment of those competencies) for routine, infrequent, abnormal and emergency operations.

This publication will be of interest for those who have a responsibility for ensuring the competence of CROs, including managers and supervisors of CROs and relevant members of human resources, talent management and learning and development teams.

How to access this publication

Guidance on ensuring control room operator (CRO) competence (1st edition, December 2014), available as a free download, or priced hard-copy publication.  After following the link, sign in to the energypublishing.org website to download.


Understanding the causes of accidents using Tripod Beta

October 30, 2014

This article first appeared in the October 2014 edition of Petroleum Review as ‘Who causes accidents?’.

With the publication of the new Tripod Beta user guide, the Stichting Tripod Foundation and Energy Institute look at how industry can get to the root causes of incidents. Stuart King, EI Technical Products Manager – Human Factors and Safety Management, explains…

Between 1980 and 2000, Shell funded world-class research into the behavioural aspects of risk management. During that period research tools like Tripod, Bow Tie, and Hearts and Minds were developed, which today are used by a large number of organisations worldwide.

The first task was to answer a seemingly impossible question: Can the causes of incidents and accidents be predicted before the incident occurs? Startlingly, the answer is, at a high level, ‘Yes’. The management of risk can best be thought of as the implementation of ‘barriers’ that block the potential negative consequences of a hazard. Incidents are caused by the failure of these barriers and are almost always due to ‘human error’.

This concept was popularised by James Reason’s Swiss cheese model of incident causation in 1991. Today, barrier-based risk management is the foundation on which our industry manages its operations.

However, people do not ‘err’ in a social vacuum. Their behaviour is heavily influenced by the situation and their state of mind. These situational and psychological preconditions are in turn created by, or have never been identified and managed out of the system, by the organisation. Organisational deficiencies are often the true underlying causes of incidents. If we can identify the organisational deficiencies, we can try to prevent incidents before they happen.

By 1996 this concept had been developed into the Tripod Delta survey tool, which is still being used successfully to help companies understand the underlying causes before incidents occur (contact the tripod@energyinst.org for more information).

Following Piper Alpha, it was realised that an investigation and analysis tool was required that would help the investigator uncover the underlying causes of incidents. Tripod Beta was born, alongside the Bow Tie methodology (in fact, both tools were developed by the same team) and with the advent of Microsoft Windows 3.1, incidents could be easily modelled graphically on a computer.

What is Tripod Beta?

Tripod Beta is a visual methodology for analysing incidents and accidents, helping the investigator to consider the human factors and directing them towards the underlying causes. Tripod Beta is now 20 years old, and since 1998 has been publicly available. Furthermore, following a partnership between the EI and the Stichting Tripod Foundation, Tripod Beta is more visible globally. The methodology is used in The Netherlands as the investigation technique of choice for the regulator, the Dutch Safety Board. Tripod is also used by major organisations in the Far East, Canada and other parts of the world, as well as by Shell globally. It is estimated that over a third of all incident and accident investigation methodologies in use today are Tripod Beta or Tripod derived.

Tripod Beta is one of the few incident analysis methodologies to be scientifically validated. Furthermore, the ‘Life-Saving Rules’, which were adopted and expanded by the International Association of Oil and Gas Producers (OGP) based on their annual occupational safety data, were originally based on Tripod Beta analysis of fatal incidents (http://www.ogp.org.uk/ publications/safety-committee/ life-saving-rules).

At the heart of Tripod Beta is the Swiss cheese model of incident causation. Incidents can be modelled as a series of events, each one leading to the next. Each event is the coming together of two things – a hazard/agent (eg a source of energy) acts on and changes an object (a person, fuel, equipment). This agent/object/ event combination is called a ‘trio’ and each trio leads to the next, creating a simple tree of what happened. Most incidents can be modelled in only two to five trios. However, organisations should have identified ‘barriers’(the layers of Swiss cheese in Reason’s model) to prevent each trio from having taken place. In a ‘typical’ incident modelled by three trios, there are at least three barriers to prevent the incident – each representing an opportunity to stop the incident in its tracks.

Tripod tree magazine illustration

Barriers are functions that, if enacted, would have prevented the next event from happening. They are not always human actions (eg, an automatic cut-off valve) but they often are.

For example, a high level alarm is not a barrier; but an operator reacting to a high level alarm and shutting off the flow into a tank is. Even if a barrier is purely mechanical, humans are responsible for designing, installing and maintaining them.

How an incident happened is ‘because the barrier failed’ and the barrier failed almost exclusively due to a ‘human failure’ – an error (such as a slip, lapse or mistake) or a violation of a rule or procedure.  Sometimes these human failures are made by designers or managers months before the incident. But usually errors are made at the front line, immediately before the incident.

Many incident investigation reports commonly cite ‘human error’ as the cause of incidents. However, Tripod Beta does not blame the person who caused the barrier to fail – their action was just the ‘active failure’ or the ‘immediate cause’, not the underlying cause. These people were set-up to fail at some point by the preconditions – the psychological or situational circumstances. These preconditions are often what we consider to be classic human factors issues, such as safety culture, competence, poor supervision, fatigue, workload, complicated tasks, the working environment, etc. Whilst we cannot say that these preconditions definitely caused the human failure, we can be reasonably sure that they increased the likelihood of it happening, and will increase the likelihood of it happening again to someone, somewhere else in the organisation.

Except for rare, unforeseeable natural disasters, preconditions are not random. In fact, they are precisely the human, environmental and operation factors that an organisation’s management system is meant to prevent or manage through the decisions that leaders make, by fostering a good working culture and having a robust process for managing risk. Therefore, the underlying or ‘root’ causes, ie why the incident happened, are actually the failures of the organisation to manage these preconditions.

Why is this important?

Interestingly, the actions taken to prevent an incident recurring should not focus on the individual(s) involved or even on the preconditions. In the short-term, they should focus on improving the barriers in place so that they cannot fail; but in the long-term, the underlying causes must be tackled. Barriers are many and are usually specific to an operation or incident. However, the underlying causes are few (they can be grouped into 11 categories) and are responsible for causing all incidents. If you can fix the underlying causes, you can potentially prevent many more incidents before they happen.

Resources available

Tripod Beta is a non-commercial methodology. It doesn’t require any special software, although commercial software is available. Tripod Beta is promoted by the Stichting Tripod Foundation, a group of volunteers who see barrier-based management of risk as being fundamental to safety performance.

Tripod Beta: Guidance on using Tripod Beta in the investigation and analysis of incidents, accidents and business losses, published by the EI, is available from www.tripodfoundation.com

The Foundation also lists accredited training courses on its website, and has an accreditation system to support and develop the competence of users of the Tripod Beta methodology.

e: tripod@energyinst.org


New Human factors foundation course, London, 24-28 November 2014

August 27, 2014

The Energy Institute (EI) is pleased to announce development of a new five-day course delivering a comprehensive introduction into human factors for non-specialists. The course provides a practical, engaging and interactive background to key topic areas, as well as to how human and organisational factors (HOF) can be applied within the workplace. Designed to bridge the gap between ‘awareness level’ and ‘practitioner level’ human factors knowledge and offerings, this course is designed to:

  • provide a comprehensive practical introduction to human factors
  • give non-specialists a basis from which to begin implementing HOF within their work

Who should take this course?

  • Those working within operating companies – including managers, operators and supervisors (anyone with a responsibility for people, safety and the environment)
  • Those receiving university training as a prelude to working within major accident hazard industries (eg. engineering degrees, business degrees, (such as MBA’s) as well as recent graduates

Learning outcomes

By the end of this course participants should understand:

  • the meaning of HOF and the scope of the subject
  • common approaches to the management of HOF, and appreciate the benefits of applying these approaches in a major accident hazard context
  • how HOF techniques can be integrated with other risk management activities

This course provides 35 hours CPD. Please click here for more information.

Price

EI member: £1,550.00 (+VAT) Non EI member: £1,800.00 (+VAT)

For more details on any of the training courses or to book please contact the training department on
t: +44 (0)20 7467 7135 or at e: wsadler@energyinst.org