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2012 Young Generation Network - Human performance problems

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

Publié dans : Ingénierie
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2012 Young Generation Network - Human performance problems

  1. 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. 2 Overview A bit about me The ways people fail Learning from accidents.
  3. 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. 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. 5 How many errors? Human factors is impotent when your asessing tge risks in your organization
  6. 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. 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. 8
  9. 9. Design is a compromise 9
  10. 10. 10 Which button for which ring?
  11. 11. 11 Taking short cuts
  12. 12. Major accidents 12 Fixborough Deepwater Horizon Piper Alpha Buncefield
  13. 13. Costa Concordia 13
  14. 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. 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. 16. Group Exercise Watch the video Develop a causal tree to explain What happened Why it happened 16
  17. 17. 17

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