1. Safety, Health & Environment
Consulting, Training & Testing
HUMAN FACTOR
ANALYSIS
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Contact +91 981 0081 140
1

2. Safety, Health & Environment
Consulting, Training & Testing
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Bhopal Gas Tragedy
Flixborough Explosion
Sevaso Gas Release
Minamata Mercury Release
IPCL, Nagothane Explosion
Several others
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Contact +91 981 0081 140
2

3. Safety, Health & Environment
Consulting, Training & Testing
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Out of the total 91 accidents (property
loss/fatality/loss of 800MH/led to plant SD ),
66% were fire accidents
47% accidents happened during operational
jobs
Causes of accidents:
71% human error
11% Failure of plant
18% Presence of ignition source
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Contact +91 981 0081 140
3

4. Safety, Health & Environment
Consulting, Training & Testing
HUMAN FACTOR
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Contact +91 981 0081 140
4

5. Safety, Health & Environment
Consulting, Training & Testing
ACCIDENT
Man
Environment
TASK
Machine
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Contact +91 981 0081 140
5

6. Safety, Health & Environment
Consulting, Training & Testing
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An injury occurs only due to an accident
An accident occurs only as a result of unsafe
action or an unsafe condition
Unsafe actions/conditions exists only
because of fault of persons
Faults of persons are inherited or acquired
through environment
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Contact +91 981 0081 140
6

7. Safety, Health & Environment
Consulting, Training & Testing

Anatomical or physiological characteristics
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Improper psychological conditions
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Lack of knowledge/skill
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Improper physical or mechanical
environment
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Contact +91 981 0081 140
7

8. Safety, Health & Environment
Consulting, Training & Testing
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Behavior Model
Human Factors Model
Peterson Accident-Incident Causation Model
Epidemiological Model
Decision Model
Systems Model
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Contact +91 981 0081 140
8

9. Safety, Health & Environment
Consulting, Training & Testing
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Safety performance of an employee is
dependent on his level of motivation and
his ability to perform
Ability is a function of selection and training
Motivation depends on;
Climate
Style of organization
Personality
Peer group
State of mind
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Contact +91 981 0081 140
9

10. Safety, Health & Environment
Consulting, Training & Testing

Human error is caused by;
Overload: Mismatch of human capacity and the
load to which he is subjected
Incorrect response: By the person in a situation
which is due to basic incompatibility
Improper activity: Performed because he did not
know or deliberately took a risk
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Contact +91 981 0081 140
10

11. Safety, Health & Environment
Consulting, Training & Testing

•
•
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Goals and objectives of the human
Long term goals
Short term goals
Conflicting goals
Contradictory and Different behavior
Combination of goals and behavior is known
as personality
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Contact +91 981 0081 140
11

12. Safety, Health & Environment
Consulting, Training & Testing
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3 basic types of factors;
Genetic factor
Environmental or Learned Factors
Situational Factor
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Contact +91 981 0081 140
12

13. Safety, Health & Environment
Consulting, Training & Testing
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Height
Built
Color
Body
Personality
Intelligence
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Contact +91 981 0081 140
13

14. Safety, Health & Environment
Consulting, Training & Testing

Extra uterine influence
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Family and early upbringing
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Education
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Working environment and social group
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Culture
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Contact +91 981 0081 140
14

15. Safety, Health & Environment
Consulting, Training & Testing
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Changing physical and social environment
of individuals
Changing goals and objectives which an
individual is seeking

New work method

Change in allocation of job
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Contact +91 981 0081 140
15

16. Safety, Health & Environment
Consulting, Training & Testing

Saving time
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Saving effort
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Seeking comfort
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Getting attention
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Asserting independence
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Acceptance of group ethos
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Contact +91 981 0081 140
16

17. Safety, Health & Environment
Consulting, Training & Testing
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Attitude and Aptitude
Frustration and Conflict
Morale
Individual difference
Skill and Training
Motivation
Aspiration
Fatigue
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Contact +91 981 0081 140
17

18. Safety, Health & Environment
Consulting, Training & Testing
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A kind of mental set up
Change in attitude may radically change
opinions
Knowledge of attitudes helps find the real
cause of an accident
Attitudes are generally associated with likes
and dislikes
Methods of evaluation are interviews,
surveys, suggestion schemes and safety
committee
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Contact +91 981 0081 140
18

19. Safety, Health & Environment
Consulting, Training & Testing
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Means inclination or fitness
Ability related to the capacity to develop
proficiency on specific jobs
Aptitude tests during selection;
 Mental ability
 Mechanical ability
 Psychomotor ability
 Visual skills
 Specialized ability
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19

20. Safety, Health & Environment
Consulting, Training & Testing

Caused due to;

Characteristics;

Response
◦ Defeat or disappointment towards success
◦ Interference with the achievement of goal
◦ Aggression
◦ Regression
◦ Fixation
◦ Adaptive
◦ Maladaptive
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Contact +91 981 0081 140
20

21. Safety, Health & Environment
Consulting, Training & Testing

Physical and Mental

May arise due to;
Attitude
Jealousy
Bad behavior
Working conditions
Environment
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Contact +91 981 0081 140
21

22. Safety, Health & Environment
Consulting, Training & Testing
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Exploitative authoritative:
Fear/Threat/Punishment/Occasional rewards.
Information flows only downwards
Benevolent authoritative:Uses rewards and also
some punishment. Information flows only
downwards
Consultative: uses rewards, some punishment and
some involvement in decision making. Information
both up and down
Participative: uses entire group in setting goals.
Information flows both up and down
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Contact +91 981 0081 140
22

23. Safety, Health & Environment
Consulting, Training & Testing
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Operator input limitations
Operator decision limitations
Operator output limitations
Workplace environment limitations
Inadequate decision aids
No training needs analysis
Training needs oversights
Training needs not delivered
No refresher training
Incomplete refresher training
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Contact +91 981 0081 140
23

24. Safety, Health & Environment
Consulting, Training & Testing
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No retraining linked to change
Inadequate competence assurance
Procedures fail to cover normal operations
Procedures fail to cover abnormal operations
Procedures fail to cover maintenance
Implementation of procedures difficult/impractical
Organisation of procedures difficult/impractical
Ill-defined channels of communication
Excessive levels of communication
Authoritarian culture
Limited manning
Inadequate change-over procedures
Inadequate mix of experience
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Contact +91 981 0081 140
24

25. Safety, Health & Environment
Consulting, Training & Testing
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Ill-defined roles and responsibilities
Shift friction
Excessive hours (fatigue/stress)
Crew compatibility
Supervisory pressure
Peer pressure
No/poor safety leadership
Poor safety communications
Unresponsiveness to complaints
Blame culture
No safety audit procedures in place
Safety audit procedures poor
Safety audits not carried out
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Contact +91 981 0081 140
25

26. Safety, Health & Environment
Consulting, Training & Testing
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Actions not carried out
No transfer of knowledge across departments
Inconsistent monitoring of personnel
Poor feedback on performance
Limited accident investigation (fails to identify root
causes)
Lessons from past accidents not learnt
No/poor awareness of hazards
No update of risk assessment following change
Poor provision/use of PPE
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Contact +91 981 0081 140
26

27. HUMAN FACTOR ANALYSIS MODEL
Safety, Health & Environment
Consulting, Training & Testing
A
B
A
B
Inadequate Operator Information
Workplace Environmental Limitations
Inadequate Decision Information
Hazard Assessment not linked to design
1.3 Alarms
1Design
1.1 Man –Machine
Interface
1.2 Process/System Design
A
B
Alarm Handling Problem
Poor Provision/consideration of Alarms
A
B
C
A
B
C
A
B
A
No Training Needs Analysis
Training Needs Oversight
Training Needs not Delivered
No Refresher Training
Incomplete Refresher Training
No Retraining linked to change
No competence assurance
Inadequate Competence assurance
Training course inadequate/Inappropriate
B
On-job Training Inadequate/Inappropriate
C
No Formal Training Program
2.1 Training Needs
Analysis
Training/
Competence
2.2 Refresher / Retraining
2.3 Competence Assurance
2.4 Training Needs
Analysis
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Contact +91 981 008127140

28. Contd….
Safety, Health & Environment
Consulting, Training & Testing
A
Falls to cover Aspects of Normal Operation
B
Falls to cover Aspects of Abnormal Operation
C
Falls to cover Aspects of Maintenance
D
Insufficient Operator Procedure
A
Implementation Difficult/Impractical
B
Organization Difficult/Impractical
C
Procedures Not updated following changes
A
Ill-defined Channels of Communication
B
Excessive Hierarchy
C
Authoritarian/Submissive Culture
A
Incomplete Refresher Training
B
Inadequate Change-over Information
A
Key Information retained by Senior Personnel
B
Poor Clarity in Transfer of Information
3.1 Comprehensiveness
3Procedures
3.2 Practicality
4.1 Interpersonal
4.Communic
ation
4.2 Practicality
4.3 Information Availability
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Contact +91 981 008128140

29. Contd….
Safety, Health & Environment
Consulting, Training & Testing
A
B
No Training Needs Analysis
Training Needs Oversight
Endemic Pressure
B
Transient Pressure
C
Supervisor Pressure eg. Bonus
D
Peer Pressure eg Bonus
A
No/Poor Safety Leadership
B
6.2 Safety Culture
Crew Compatibility
A
6.Attitudes
Excessive Hours-Fatigue/Stress
B
Poor Safety Communication
C
Unresponsive to Complaints
D
6.1 Performance Pressure
B
A
5.3 Record Keeping
Shift Friction/Over Competitiveness
C
5.2 Shift work/Roasters
Ill-defined roles/Responsibilities
A
5.Organization
Inadequate Manning-mix-Experience
C
5.1 Manning–Roles/
Responsibilities
Inadequate Manning
Blame Culture
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Contact +91 981 0081 140
29

30. Contd….
Safety, Health & Environment
Consulting, Training & Testing
No Audit in Place
Audit in Place – Poor
Audit in Place – Not carried out
No/Sporadic Inspection
Actions not carried out
7.2 Inspection
No Transfer of Knowledge
Inconsistent Monitoring of Personnel
7.3 Supervision
Fails to feedback Performance
Fails to Identify Root Causes
8.1 Accident Investigation
Lessons from past not learnt
No/Poor Awareness of Hazards
No update linked to change
8.2 Hazard Awareness
Poor provision or use of PPE, Safeguards
etc.
D No Assessment/ Analysis of Risk
A Inadequate Control of Hazards
B Inadequate Procedures
9.1 Emergency Management
C No off-site Liaison
D No/Inappropriate Training
E Poor On-Site/Off-site Plans
A No Regular Practice/Drills
9.2 Fitness for Response
B Implementation Impractical981 0081 140
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Contact +91
7.1 Audit
7
Monitoring
8 Risk
Assessment
9 Emergency
Response
A
B
C
A
B
C
A
B
A
B
A
B
C
30

31. Safety, Health & Environment
Consulting, Training & Testing
Plant upset conditions (caused by an electrical storm) were poorly
handled, leading to 20 tonnes of hydrocarbon liquid being
continuously pumped into a process vessel with a closed outlet.
Once full, the liquid escaped through the pressure relief system to
the flare line, which was not designed to cope with such quantities.
As a result 20 tonnes of hydrocarbon was released and
subsequently ignited leading to a major fire and a number of
secondary fires.The investigation identified that the operators were
not sufficiently aware of how the plant operated to be able to take
control. Training had not addressed dealing with any similar
scenarios. The poor information relating to plant conditions provided
in the control room exaggerated the problem.
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Contact +91 981 0081 140
31

32. Safety, Health & Environment
Consulting, Training & Testing
1.1A DESIGN
Inadequate Operator Decision Information
Operators in the control room were unaware that valve B, which should have
allowed fluid from debutaniser into naphtha splitter, remained closed after the
initial upset trip.
1.2A DESIGN
Inadequate decision information
The system was operating on a single control loop leaving the operator
unaware that the outflow was not greater than the input from the deethanizer.
1.3A DESIGN
Alarm Handling Problems
During the incident, alarms were being presented to operators at the rate of one
every two to three seconds
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Contact +91 981 0081 140 32

33. Safety, Health & Environment
Consulting, Training & Testing
1.3B DESIGN
Poor Provision/Consideration of Alarms
The high level alarm for the flare drum was activated. There is no evidence
that it was seen.A number of other critical alarms (not directly related to the
incident) also appear to have been missed among the many equal status
alarms. Warnings of the developing problems were lost in the plethora of
instrument alarms triggered in the control room, many of which were
unnecessary and registering with increasing frequency, so operators were
unable to appreciate what was actually happening.
2.2C TRAINING COMPETENCE
No retraining linked to change
A key feature of the pump-out modification was reliance on appropriate
operator manual action to deal with high drum liquid levels. However, in
practice, personnel did not have instructions or experience of reconfiguring
the system
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33

34. Safety, Health & Environment
Consulting, Training & Testing
3.1B PROCEDURES
Failure to cover aspects of abnormal operations
Or
TRAINING COMPETENCE
Inadequate Competence Assurance
The flare knock-out drum’s contents were increased still further by the operators next
action which was to try to remove the flooding from the dry end of the interstage drum
by draining the liquid directly to the flare line by an impromptu modification which
employed steam hoses.’
3.2C PROCEDURES
Procedure not updated following change
An earlier modification to the pump out system severely reduced its automatic liquid
handling capacity. It overflowed, causing liquid to enter an outlet designed for gas
only.It was possible to restore the original pump-out capability, by manually opening a
valve, but this procedure had fallen into disuse from lack of practice and written
procedures.
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Contact +91 981 0081 140 34

35. Safety, Health & Environment
Consulting, Training & Testing
4.3B COMMUNICATION
Breakdown of Team Structure
Or
ORGANISATION
Ill-defined roles and responsibilities. Where more than one operator is working, an
increased emphasis on communication is required to ensure that each is working
with the team. As people at senior level helped out, they took on operating roles
rather than taking an overview of the whole process.Some managers and
supervisors were involved in ‘hands-on’ operational matters instead of performing a
strategic and diagnostic role.
8.1B RISK ASSESSMENT
Lessons from past not learnt
All the key elements of the incident, and the lessons drawn from it, have been seen
and publicized before, in major accidents around the world.
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35

36. Safety, Health & Environment
Consulting, Training & Testing
8.2 B RISK ASSESSMENT
No Update Linked to Change
There was no recorded safety assessment concerning this
modification.
9.1D EMERGENCY RESPONSE
No or inappropriate training
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Contact +91 981 0081 140
36

37. Safety, Health & Environment
Consulting, Training & Testing
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Identify major hazard installations
Carry out hazard assessment
Report to authorities the result of hazard
assessment
Set up emergency plans
Take measures to improve plant safety
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Contact +91 981 0081 140
37

38. Safety, Health & Environment
Consulting, Training & Testing
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Component failure
Deviation from normal operating conditions
Human and organizational errors
Outside accidental interferences
Natural forces
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Contact +91 981 0081 140
38

39. Safety, Health & Environment
Consulting, Training & Testing

Major Accident means an occurrence
including any type of emission, fire or
explosion involving one or more hazardous
chemicals and resulting from uncontrolled
developments in the course of industrial
activity or natural events likely to cause
substantial loss of life and adverse effects on
environment
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Contact +91 981 0081 140
39

40. Safety, Health & Environment
Consulting, Training & Testing

Legal Requirement : Rule 10, Schedule 8 of
MSIHC rules
 The occupier shall;
 Prepare safety report and send 90 days before
the activity starts
 Carry out safety audit by independent expert
 Send copy of auditors report within 30 days of
the audit
 Fresh audit every year and updation of report
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Contact +91 981 0081 140
40

41. Safety, Health & Environment
Consulting, Training & Testing
Safety report should contain;
A)
Description of installation and process
B)
Description of process
C)
Description of hazardous substances
D)
PHA
E)
Description of safety relevant units
F)
Hazard Assessment
G)
Organization
H)
Assessment of consequences
I)
Information on mitigation of major
accidents
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Contact +91 981 0081 140
41

42. Safety, Health & Environment
Consulting, Training & Testing
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Major changes in plant/process
New information about hazardous processes
Improvements in safety engineering
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Contact +91 981 0081 140
42

43. Safety, Health & Environment
Consulting, Training & Testing
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Check adherence to safety standard
Carry out specific inspection
Learn about the hazards
Siting of industries
Establish contingency plans
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Contact +91 981 0081 140
43

44. Safety, Health & Environment
Consulting, Training & Testing
1.
2.
3.
Hazid : Types and quantities of hazardous material, location and storage,
nature of hazard, What can go wrong ?
Risk : How often ? Probability of damage ?
Vulnerability : Extent of vulnerable zone, dispersion model, support systems
Control can
be reestablished
Action during the
May determine whether
first few seconds/ minutes
Damage/Injury
avoided
Accident can develop
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Contact +91 981 0081 140
44

45. Safety, Health & Environment
Consulting, Training & Testing



Legal requirement – Rule 13, Schedule 11 of
MSIHC Rules
Preparation of plan by occupier
Conduct mock drill every 6 months for;
•
Objectives
 Familiarity
 Confidence
 Accuracy
 Availability
 Statutory requirement
 To localize the emergency and eliminate it
 To minimize the effects of accidents on people and
property
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Contact +91 981 0081 140
45

46. Safety, Health & Environment
Consulting, Training & Testing


Name and address of person giving information
Key persons with assigned responsibility and duties
Outside organization assisting details
Details of liaison
Information on PHA
•
Site details
•
Likely dangers to plants



 Type of accident
 System elements/events that can lead to major accidents
 Hazards
 Safety relevant components
 Location of dangerous substances
 Emergency control centre
 Seat of key personnel
 Description of hazardous chemicals at site (MSDS)
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Contact +91 981 0081 140
46

47. Safety, Health & Environment
Consulting, Training & Testing


Likely dangers to plant
Effect of ;
•
Details of ;
•
Details of communication facilities
Details of fire fighting
Details of first aid and hospital services
•
•
 Stress and strain during normal operations
 Fire/explosion and secondary hazards
 Alarm and hazard control plans
 Reliable measuring instruments
 Precautions in designing of foundations
 General engineering practice
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47

48. Safety, Health & Environment
Consulting, Training & Testing


Overall Co-ordinator

Senior person
To decide level of emergency
Call key personnel
Exercise direct operational control
•
Action group leader/site incident controller








Assess scale
Initiate emergency procedure
Direct rescue and fire fighting teams
To search for casualties
Evacuate
Communicate with ECC
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Contact +91 981 0081 140
48

49. Safety, Health & Environment
Consulting, Training & Testing
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Team A : Plant/ Dept. Head, Supervisor, Worker – To control
emergency
Team B : Mechanical/Maintenance – To assist Team A
Team C: Safety, Firefighting, Security
Team D : Medical
Team E : None of the above – Reserve team
Administration Manager : Arrange for transportation
Personnel Manager : Food, Head Count, Liaison with external
agencies
Telephone Operator : Keep lines free
Assembly points : Depends on size of factory and wind
direction
ECC :
 Select so that no effect of emergency Eg. Security, Gate, Control
room
 Should be equipped with PPE, tel.nos. , details of emergency plans
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Contact +91 981 0081 140
49

50. Safety, Health & Environment
Consulting, Training & Testing



Legal requirements – Rule 14, Schedule 12 as per
MSIHC rules
Mock drill once every year
Formation;
Central crisis group
State crisis group
District crisis group
Local crisis group
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Contact +91 981 0081 140
50

51. Safety, Health & Environment
Consulting, Training & Testing
The off – site emergency plan should include;
 Types of accident
 Organization involved, including key personnel and liaison
arrangements between them
 Site information
 Technical information about substances
 Facilities and transport routes
 Contact for further advice e.g. meteorology, food, transport,
first aid, hospital
 Communication links
 Fire fighting equipment
 Emergency response procedures
 Public notification
 Evacuation arrangements
 Dealing with press
 Longer term “ Clean up “
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Contact +91 981 0081 140
51

52. Safety, Health & Environment
Consulting, Training & Testing
Local crisis group
 Prepare local emergency plan for industrial pocket
 Ensure dovetailing of local plan with district plan
 Train personnel in accident management
 Educate public
 Mock drill every 6 months at site and give report to District
crisis group
District crisis group
 Preparation of district off – site emergency plan
 Review on – site plans of all MAH units
 Continuously monitor every chemical accident
 Forward report of accidents to State crisis group
 Mock drill every year and report to SCG
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Contact +91 981 0081 140
52

53. Safety, Health & Environment
Consulting, Training & Testing
CCG
SCG
DCG
LCG
Chairperson Member
Secretary
Secretary
Jt. Sec MoEF
MoEF
Chief
Labour
Secretary
Secretary
District
Inspectorate
Collector
of Factories
Magistrate Inspectorate
of factories
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Contact +91 981 0081 140
53

54. Safety, Health & Environment
Consulting, Training & Testing
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Contact +91 981 0081 140
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