Event organised by the IMechE and Nuclear Institute or recent graduates working in the power generation industry. Human failures and performance problems.

1. Tel: (+44) 01492 879813 Mob: (+44) 07984 284642
andy@abrisk.co.uk
www.abrisk.co.uk
1
Human Performance Problems
Andy Brazier

2. 2
Overview
A bit about me
The ways people fail
Learning from accidents.

3. 3
A bit about me
Chemical engineer
16 years working as human factors consultant
7 years self-employed
Registered member of the Institute of
Ergonomics and Human Factors (IEHF)
Associate member of the Institution of Chemical
Engineers (IChemE).

4. 4
People are never 100% reliable
Our failures are predictable
They are not always preventable
Understanding human failure allows us to
manage the risks by:
Reducing consequences
Improving mitigation
Reducing likelihood.

5. 5
How many errors?
Human factors is impotent when your asessing
tge risks in your organization

6. 6
People are fallible
People are good at
Detecting small signals & perceiving patterns
Improvising and using procedures flexibly
Recalling historical information when needed
Exercising judgement
They are not so good at
Paying attention for a long time
Being precise in physical tasks
Analysing lots of data
Doing things exactly the same each time.

7. 7
Automatic
Conscious
Skill-Based
Automated routines with
little conscious attention
Rule-Based
IF symptom X THEN cause is Y
IF the cause is Y THEN do Z
Knowledge-Based
No routines or rules available
for handling situation
Understanding Human Behaviour

8. 8

9. Design is a compromise
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10. 10
Which button for
which ring?

11. 11
Taking short cuts

12. Major accidents
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Fixborough
Deepwater Horizon
Piper Alpha
Buncefield

13. Costa Concordia
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14. 14
Ship
Capsizes -
32 People
die
Captain
gives order
for unsafe
course
No one
intervenes
Safety
devices
failed
Not
everyone
is able to
escape
Passengers
did not know
procedure
Crew delays
declaring
emergency
Captain did
not co-
ordinate
evacuation
Why?
Why? Why?
Ship hits
rocks
Why? Why?

15. 15
Captain
gives order
for unsafe
course
No one
intervenes
Safety
devices
failed
Why?
Ship hits
rocks
Culture of
orders followed
without
question
Captain only person
to ever take
decisions - no one
else realised his
error
Everyone working
towards same goal
- no one realised
the error
Why?
System had
failed and no
one realised
People over-reliant
on technology - did
not know what to do
when it failed
People assumed
technology would not
allow them to do
something unsafe
Device prone to
spurious warnings -
people ignored
them.

16. Group Exercise
Watch the video
Develop a causal tree to explain
What happened
Why it happened
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