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Human Factors Awareness

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by

Joe Cook

on 10 November 2015

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Transcript of Human Factors Awareness

Human Factors
Awareness

What is it?
"The scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance.
Using scientific understanding of how humans think and operate to optimise performance.
Or more simply...
1. "Human Factors is all about Human Error"
2. "It's just common sense really"
3. "It's all about behaviours"
4. "Human Error is the main cause of our accidents"
5. "Human Failure is unpredictable"
Common Fallacies
Why is Human Factors Important?
80%
HF Causes
20%
Non HF Causes
All Accidents
It's possibly higher than 80% if you include maintenance and design error.
(We'll come to that later...)
In reality...
Bhopal, India
20,000 lives lost, 120,000 still suffering symptoms.
Training cut to save money
Maintenance Reduced to save money
No learning from previous accidents.
Buncefield, England
£200 Million Cost
Poor Emergency Planning
Poor Maintenance Procedures
Insuffient containment measures
Herald of Free Enterprise
193 Lives Lost
Poor communication
Poor understanding of changes
Bad design
Top Topics
Other Top Topics
1.Human Failure
2.Procedures
3.Training and Competence
4.Staffing
5.Organisational Change
6.Safety Critical Communications
7.HF in Design
8.Fatigue
9.Culture
10.Maintenance, Inspection and Testing
How (and why) do we fail?
Human Failure
"An error is the failure of planned actions to achieve their desired goal, where this occurs without some unforeseeable or chance intervention."
Reason & Hobbs, 2003
Human Failure...
is not random, there are patterns and types of failure:
Unintentional
Intentional
Mental
Physical
Which matters because...
They have different causes and need to be managed differently.
The different types of Human Failure
Human Failure
Human Failure
Errors
Violations
Slips/Lapses
Mistakes
Intentional
Unintentional
Types of Failure
Slips and Lapses
Mental Working
The Different Levels
Where you mean to do something - but do something else!
Slips and lapses occur in skilled based behaviour, to well trained operators, in familiar environments
There are good levels of recovery because the normal pattern is broken
They occur because of familiarity, in tasks with many steps, in procedures which don’t flow naturally and when tasks are similar to other tasks which are frequently performed.
Slips and Lapses
How can we prevent them?
Design consistently
Use checklists or reminders
Check critical work
Remove Distractions and interruptions
Slips and Lapses cannot be prevented with more training!
(Because the operator is already highly skilled)
Mistakes
A mistake is an error of intention. Where you do what you meant to do, but what you meant to do was wrong.
Mistakes are decision making failures that occur in knowledge and rule based activities.
Mistakes
How can we prevent them?
Training
Guidance
Support
Practice of unusual Situation (e.g. fire drills)
Violations
Violations are different to erros because they are intentional failures
For example: Deliberately deviating from procedures.
Violations are usually well meaning and violations are a normal behaviour
Violations
Why do they occur?
Inappropriate priorities
Impractical procedure
Group pressures
Unlikely to get caught
Easy and convenient
Violations
Why do they occur?
When the perceived benefits outweigh the perceived consequences
Violations
How can we prevent them?
Improve risk perception
Increase likelihood of getting caught
Eliminate reasons to cut corners
Address procedures
Remove benefits
Involvement
Force compliance through design
(PIF)
Types of PIFs
Job
Organisation
Individual
Task
Workload
Environment
Displays
Controls
Culture
Leadership
Resources
Personality
Skills
Competence
Risk Perception
Why are PIFs important?
Knowing what the Performance Influencing Factors are for a given task allows us to improve the reliability of the people conducting the task.
Procedures
Training and Competence
Staffing
Organisational Change
Safety Critical Communications
HF in Design
Fatigue
Culture
Maintenance, Inspection and Testing
Procedures
Training and Competence
Staffing
Organisational Change
Safety Critical Coms.
HF in Design
Fatigue
Culture
Maintenance
How do we use our knowledge of human performance to create usable procedures?

Are our procedures maintained and controlled effectively?

Do we have procedures in all the required places?

Do we have the right level of procedural support for the situation?
How do we ensure we have a adequately trained workforce?

What does our succession planning look like?

Are all people in safety critical roles fully competent?
Do we understand our staffing level requirements?

Do we know the workload levels of our employees?

What are our supervision guidelines?

Are we an “intelligent customer”?
How do we manage organisational change?

Staffing levels after restructuring

Changes to contractor use

Changing roles and responsibilities
How do we control our safety critical communications?

Shift Handover standard/best practice adoption

Permit to work system
How do we integrate Human Factors knowledge from the start?

Control room design

Office Design

Alarm Management

Lighting, thermal comfort etc.
How do we monitor and manage fatigue?

How do we monitor overtime?

Are our shift patterns optimised?

How do we monitor contractor fatigue?
How good is our safety culture?

Are we a learning organisation?

How do we nurture a “Just Culture”?
How do we control maintenance error?

Do we design for maintenance?

Are we an “Intelligent customer” in regards to our contractors?
What influences us?
"Performance Influencing Factor"
Anything that influences a persons performance is called a
Complex systems would be safe but for the erratic behaviour of a few inherently unreliable people .
Human errors cause accidents
Humans are the dominant contributor to accidents
Failures are unexpected
Human Failure is not a conclusion to an investigation

Human Failure is a symptom of trouble deeper inside a system

Systems are not basically safe

Sources of error are structural, not personal

Has a range of types that determine necessary prevention strategies
Is made more or less likely by predictable performance influencing factors
Can be assessed with tried and tested techniques
Can be managed
Should be understood and addressed just as rigorously as ‘traditional’ technical and engineering safety
What to Remember
Human Failure
Old
New
Two Views of Human Failure
Two Views of Human Failure
The Top 5
Selected for Tata
1.Training and Competence
2.HF in Design
3.Safety Critical Comms
4.Procedures
5.Fatigue and Overtime
Domestics
High
Low
Knowledge-Based
No routines or rules available for handling situation
Rule-Based
If the symptom is X then cause is Y
If the cause is Y then do Z
Skill Based
Automated routines with little conscious attention
Consciousness
Full transcript