Presentation to the North Wales Occupational Health and Safety Group. Introduction to human factors

1. Tel: 01492 879813 Mob: 07984 284642
andy.brazier@gmail.com
www.andybrazier.co.uk
1
Human Factors
North West Wales Occupational Health
and Safety Group
28 March 2007

2. 2
A bit about me
Chemical engineer
10+ years working as a risk and safety
consultant
Specialising in human factors
Most work in major hazard industries
Self-employed for 2 years
Live in Llandudno
Registered member of the Ergonomics Society
Nebosh General Certificate.

3. 3
My aim for today
Introduce human factors’ and its role in safety
Tell you what we have learnt about human
factors in major hazard industries
Give some ideas of how this applies to lower
hazard activities.

4. 4
Physical demands - musculoskeletal disorders
Psychological demands - stress
Social conditions - job satisfaction
Human error - cause of accidents.
Human Factors
“Environmental, organisational and job factors,
and human and individual characteristics which
influence behaviour at work in a way which can
affect health and safety”
HSG48 Reducing error and
influencing behaviour

5. 5
Audience participation
Has anyone recently made an error?
Has anyone recently violated a rule or procedure
You knew the rule or procedure
But decided to do it differently.
Human factors is impotent when your asessing
tge risks in your organization

6. 6
Major accidents involving human factors
Piper Alpha Herald of Free Enterprise Chernobyl
Clapham Junction Esso - Longford Fixborough

7. 7
Errors in lower hazard industries
Inland revenue – record deleted
Australian immigration – deported wrong person
Nasa Polar Lander to Mars – crashed
Sunday Mirror – photos of wrong person
DWP – 40,000 PC out of action for 5 days
PC World – fned for selling old computers as new
IVF clinic – mixed race twins for white couple
Barclay’s Bank – 62,000 people’s wages late
$30 billion loss for errors in patent
UK industry – errors cost £9.3 billion per year
NHS - 30,000 deaths per year

8. 8
Piper Alpha
Very big event
Series of quite small errors
Initial explosion = gas release
equivalent to 10kg

9. 9
Chernobyl
Operators not told about poor reactor
design
Given instructions - assumed must be safe
Fatality of Mark & Luke Wells –
working as contractors for British
Waterways
Not told about previous accident
Given a job that had not been assessed

10. 10
Esso Longford (Australia)
Operators given training - but did
not understand what it meant
Cecil Kumar lost his hand
in a hydraulic press
He had been trained but the
light curtain around the
machine was not set up
properly

11. 11
Flixborough
Plant modification designed
by someone without
necessary competence
Q Carpark in Glasgow
Large concrete slab fell 4 floors
Project manager ignored advice
because was not competent in
structures

12. 12
Hence interest in human factors
Up to 80% of accident causes can be attributed
to human factors
All accidents involve a number of human failures
Human factors is concerned with
Accepting that errors and violations are not random
‘acts of God’
They are predictable and preventable
Different circumstances create different types of
errors.

13. 13
Human Factors
What are people being
asked to do
(the task and its
characteristics)?
Who is doing it (the
individual and their
competence)?
Where are they working
(the organisation and its
attributes)?

14. 14
Simple errors
Competent and experienced people
Minor lack of precision or attention to detail
Training won’t help – or telling people to “be
more careful”
Procedures won’t be read
Need to design systems to that they are
Arranged in a logical way
Labelled clearly
Can be used without thinking.

15. 15

16. 16
More complex errors
Making the wrong decisions or choices
People don’t understand how the system works
Presented with confusing or misleading
information
Training can help
Procedures can help in some circumstances
Letting people concentrate
Minimise fatigue and distractions.

17. 17
Made in China

18. 18
Violations
Deliberate deviations from rules & procedures
Most are motivated by trying to get the job done
Like errors, they are caused
Difference between policies and practices
Impractical recommended practices
Inappropriate priorities
Lack of understanding hazards and risks
Lack of feedback
Group or peer pressure
Frustration
Feeling that it doesn’t matter.

19. 19
Taking short cuts

20. 20
What should you do?
Have a clear view of:
Errors and violations that can cause accidents
Risk control measures that rely on human actions
Consequences of human failure
Consider human factors when:
Carrying out risk assessments
Investigating incidents
Buying new equipment
Developing systems
Make sure working arrangements help people
work reliability.

21. 21
HSE’s Top Ten Human Factors
Organisational change
Staffing levels and workload
Training and competence
Alarm Handling
Fatigue from shiftwork & overtime
Integrating human factors into risk assessment and investigation
Communication/interfaces
Organisational culture
Human factors in design
Maintenance error

22. 22
Risk assessments
Confusing equipment controls
Illogical or inconsistent layout
Poor labelling
Illegible, missing or hand written
Complex tasks
Possible short-cuts
People working when fatigued or stressed
Distractions and poor working conditions
Reliance on communication.

23. 23
Incident investigation
Human error is NOT a root cause
You need to understand why errors or violations
occur
Telling people to be more careful is not a
solution
Neither is writing more procedures
Or repeating more of the same training
If you can’t find the cause of the error or violation
you are saying it will happen again
Be very wary of taking disiplinary action.

24. 24
Buying new equipment
Try to make sure controls are consistent with
current equipment or normal conventions
Identify specific training needs
Don’t rely on the manufacturers instructions
Include ergonomics in your purchasing
specifications.

25. 25
Stress
People pay less attention
They do not communicate so well
As well as being bad for health, stressed people
make more errors.

26. 26
Communication
.
There were 20 sick sheep, one died, how many
were left?
Error is an integral part of communication.

27. 27
What are your procedures like?
A – Clear, concise and comprehensive
B – Clear, concise, some gaps
C- Wordy and complex

28. 28
Procedures - 80% rule
Page 1
Page 2
Page 3
Page 4
Page 5
0
10
20
30
40
50
60
70
80
90
100
% Whole read procedures

29. 29
Better procedures
Procedures can assist in risk control
Different types – depending on risk of activity
Mandatory – few where step-by-step instructions are
necessary
Job aids – summarise key information
Guidelines – primarily for training
Only write the procedures that are really needed
Aim them at experienced people
Not someone off the street.

30. 30
Training
Only a small part of people becoming competent
The following affect how people work
Knowledge
Skills
Attitude
Habits
Most learning is done ‘on the job’
Often very unstructured.

31. 31
Something to beware of
Any of these sound familiar?
Forgetting to take your change
Forgetting to take your receipt
Leaving headlights on when getting out of the car
Leaving the gas on when finished cooking
Leaving the original in the photocopier
Forgetting the attachment on an email
All examples of where there is an extra step
after the main task is complete.

32. 32
Where does ergonomics fit in?
Ergonomics
Human capabilities
Hardware design
Work stations
User interfaces
Working environment
Manual handling
Personal safety, health
and well being
Human factors
Whole system
Organisation
Culture
Tasks
Errors
Procedures
Training and competence
Accidents

33. 33
And what is Behavioural Safety?
Tends to be more concerned with
Physical activities
Personal safety accidents
Failures of people at the sharp end
The premise is that people are free to choose
the actions they make
Human factors is based on the principle that
people are ‘set up’ to fail
Management and organisational root causes.

34. 34
Where does human factors fit with
‘Traditional’ Health and Safety
Management responsibility
Safety culture.

35. 35
Management of
Health & Safety at Work
Regulations (MHSWR, 1999)
“Every employer shall make and give effect to
such arrangements as are appropriate, having
regard to the nature of his activities and the size
of his undertaking, for the effective planning,
organisation, control, monitoring and review of
the preventative and protective measures”
(Regulation 4).

36. 36
Robens Report, 1972
“Promotion of health and safety at work is an
essential function of good management … Good
intentions at the board level are useless if
managers further down the chain and closer to
what happens on the shop floor remain
preoccupied exclusively with production
problems”

37. 37
Industrial Accident Prevention
“Underlying accident causes are faults of
management and supervision plus the unwise
methods and procedures that management and
supervision fail to correct…”
Heinrich (1931)

38. 38