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Investigating and analysing human and organisational factors aspects of incidents and accidents Presented by Bill Gall

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Investigating and analysing human and organisational factors aspects of incidents and accidents Presented by Bill Gall New Guidance published May 2008 – PowerPoint PPT presentation

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Title: Investigating and analysing human and organisational factors aspects of incidents and accidents Presented by Bill Gall


1
Investigating and analysing human and
organisational factors aspects of incidents and
accidentsPresented by Bill Gall
  • New Guidance published May 2008

2
  • The Guidance was developed by the Energy
    Institutes Human and Organisational Factors
    Working Group

See website for details of the HOFWGs
work www.energyinst.org.uk/humanfactors
3
  • Introduction

This presentation explains why new guidance is
needed and introduces the document with some
selected extracts including general and specific
examples of problem areas
4
  • Background
  • The petroleum and allied industries investigate
    and analyse both incidents (near misses)
    and accidents whether with major hazards or
    occupational potential, but
  • Human and organisational factors aspects are
    rarely addressed sufficiently
  • That is, investigations/analyses often fail
    to establish root causes and thus fail to
    identify effective actions in response

5
  • Investigation - Analysis

Investigation gathering information,
reconstructing events, for example, using a
time-line, to make sense of the
incident Analysis thorough and systematic
review of the information to identify root causes
6
  • Investigation - Analysis
  • The guidance focuses on analysis but also
    advises on the investigation process/data
    gathering
  • Faults in the conduct of an investigation can
    make subsequent analysis difficult or its
    results invalid

7
  • HOF aspects are rarely addressed sufficiently
  • Evidence to justify the above statement
  • Reviewing incident investigation reports for this
    study and two other studies - one in the
    petroleum industry the other in the nuclear
    industry - it was not possible to establish
  • The type of human failure involved
  • The basis for the analysts conclusions

8
  • Further Evidence
  • Several incident analyses indicated
  • Immediate Cause Human Error
  • Root Cause Human Error

9
  • A Problem with Checklists
  • A checklist provided by a major hazard industry
    to assist investigators in their task proposed
    the following root causes
  • Lack of competence
  • Inadequate procedures
  • Inadequate tools or equipment
  • These are not root causes the investigator can
    and should continue to ask questions

10
  • Questions
  • Lack of competence Why? What organisational
    processes have failed?
  • Selection procedures?
  • Methods for identifying training needs?
  • Training delivery or assessment?
  • Inadequate procedures explain inadequate?
  • Are they difficult to find when they are
    needed?
  • Unclear or poorly worded/illustrated?
  • Out of date? Again, what failed here/what do
    we need to fix?

11
  • Case Study a spillage incident

A road tanker driver refuelling his vehicle left
it unattended with the trigger locked. Ten
litres of diesel spilled onto the forecourt of
the refuelling bay, requiring clean-up and
causing delay to other drivers
Why?
12
  • Example analysis of incident

Why?
The driver did not comply with company procedures
for refuelling. He had left his vehicle
unattended to speak to a colleague. He also
stated that he had done this before without
incident.
Why? What was so urgent?
Why? What was the payoff for violating?
13
  • Example further analysis
  • The investigation did not seem to explore the
    underlying causes of the drivers violation.
  • Did he need something from his colleague?
  • Did he feel under time pressure and could not
    stop after refuelling to talk to his
    colleague?
  • Was he simply bored?
  • The analysis also failed to explore the issue of
    safety culture the role of his colleague and
    other observers why did no-one else intervene?

14
  • Proposed solution

From the incident report Driver was made aware
of what can happen when not taking full care when
carrying out any operation within the terminal
Be more careful?
15
  • Better solutions?
  • Discipline the driver and warn others about
    this hazardous practice
  • Explore the sites safety culture
  • Consider removing the locking trigger on
    filler nozzles or add an automatic cut-off
  • BUT removing the locking trigger could
    encourage drivers to improvise. An automatic
    cut-off could create false sense of safety

16
  • Learn from Incident and Accidents

An incident or accident has to be seen as a
learning opportunity and one not to be wasted by
unless the true HOF root causes are
established The more thorough the level of
analysis, the better the response in terms of
focused improvements
This is what you see
This is what you dont see until you start to
dig
17
  • Improving investigation and analysis

Which investigation/analysis methods are the most
useful in identifying HOF root causes? The
guidance does not tell you The guidance provides
criteria for you to choose And before that, gives
some information you will need to get the best
from the methods
18
  • Basic Understanding of HOF Issues
  • The Guidance Describes
  • Human failure types
  • Slips, Lapses, Mistakes, Violations
  • Safety Management
  • Safety Culture

19
  • A Useful Failure Model

Direction of Events
Direction of Analysis
20
  • The Need for a Just Culture

The need for a fair system of sanctions and
rewards Too punitive reporting/cooperation will
be reduced Too lenient complacency, low
motivation conform to rules
21
  • Lifecycle of an Investigation
  • The Guidance provides advice and cautions for
    each lifecycle stage and advises on how best to
    address HOF issues. The stages are
  • Report
  • Investigate/analyse
  • Make recommendations
  • Assign, track and close out actions
  • Share information

22
  • Brief Checklists/Aides Memoire
  • Key Factors Affecting Human Failure
  • Workplace design and layout of workspace
    and equipment, work environment
  • Task poorly designed, workload
  • Personnel competence, fitness, motivation
  • Organisation supervision/leadership, change
    management

23
  • Selecting an Appropriate Method
  • Cautions
  • Be realistic about the teams expertise in HF
    may require training
  • Checklists can help as an initial prompt but
    - as shown already - can mislead the user

24
  • Criteria for Selection of a Method
  • Training requirements
  • Paper or software-based method
  • Retrospective analysis of incident reports
  • Used in petroleum industry
  • Generates graphical content e.g. timeline
  • A complete method for incident analysis
  • Provides solutions
  • Includes checklists or flowcharts

25
  • Matrix Criteria Against Methods

Method Training Required Paper-Based or Software Paper-Based or Software Retrospective Analysis Of Incident Reports Used in Petroleum Industry Generates Graphical Content (e.g. timeline) Complete Method for Incident Analysis Provides Solutions Includes Checklists or Flow Diagrams
Paper Software
Fishbone ? ? ?
lysis ? ?
System ? ? ?
igat ? ? ? ? ? ?
W TIES ? ? ? ?
26
  • Methods
  • 28 methods described briefly in the Guidance
  • Included because they
  • Were cited by interviewees as methods they
    had successfully used
  • Feature prominently in incident investigation
    literature or
  • Clearly offer a sound approach to identifying
    HOF aspects

27
  • Further Methods
  • 6 additional methods are described but not in
    detail because they
  • Do not appear to be mainstream methods
  • But they are cited in the literature and
  • Have potential for application in the petroleum
    and allied industries (and others)

28
  • Incident/Accident Investigation/Analysis Methods

ARCA APOLLO Root Cause Analysis Black Bow
Ties DORI Defining Operational Readiness To
Investigate ECFA Events and Causal Analysis
(Charting) and ECFA - Events and Conditional
Factors Analysis Fishbone diagram HERA Human
Error Repository and Analysis System HERA-JANUS
Human Error Reduction in ATM (Air Traffic
Management) HFACS The Human Factors Analysis
and Classification System HFAT Human Factors
Analysis Tools HFIT Human Factors Investigation
Tool HSYS Human System Interactions and allied
industries (and others)
29
  • Incident/Accident Investigation/Analysis Methods

ICAM Incident Cause Analysis Method MEDA
Maintenance Error Decision Aid MORT Management
Oversight and Risk Tree PEAT Procedural Event
Analysis Tool PRISMA Prevention and Recovery
Information System for Monitoring and
Analysis SCAT Systematic Cause Analysis
Technique SOL Safety through Organisational
Learning SOURCE Seeking Out the Underlying
Root Causes of Events STEP Sequentially Timed
Events Plotting Storybuilder TapRooT (Kelvin)
Top-Set
30
  • Incident/Accident Investigation/Analysis Methods

TRACEr Technique for Retrospective and
Predictive Analysis of Cognitive Errors Tripod
Beta WBA Why-Because Analysis 5 Whys Why
Tree Additional Methods CALM Combined Accident
anaLysis Method ISIM Integrated Safety
Investigation Method PROACT SACA Systematic
Accident Cause Analysis STAMP Systems Theoretic
Accident Modelling and Process TOR Technique of
Operations Review
31
  • References and Bibliography

The Guidance describes sources of information
used including useful websites
32
  • Obtaining a Copy

Free download (PDF) available from www.energyinst
.org.uk/humanfactors/incidentandaccident Printed
copy from EI Publications online section of the
Energy Institute website (10) ISBN 978 0 85293
521 7
33
  • Acknowledgements

The Energy Institute gratefully acknowledges the
valuable contributions that the following
individuals and companies made to this
project Dr Kathryn Mearns Aberdeen
University Prof Rhona Flin Aberdeen
University Lee Vanden Heuvel ABS
Consulting Denise McCafferty American Bureau of
Shipping Andrew Livingston Atkins Global John
McCollom BAe Systems Prof Graham Braithwaite
Cranfield University Les Smith DNV Dominique van
Damme Eurocontrol Dr Barry Kirwan
Eurocontrol Rachael Gordon Eurocontrol
34
  • Acknowledgements continued

Peter Ackroyd Greenstreet Berman John Chappelow
Human Factors Investigations Dr Claire Blackett
Human Reliability Euan Dyer Kelvin Top-Set Ronny
Lardner Keil Centre Richard Scaife Keil
Centre Prof Trevor Kletz Loughborough
University Stuart Withington Marine Accident
Investigation Branch Rainer Miller Mensch-Technik
Organisation Louise Farrell National Grid Chris
Mostyn National Grid Dr Steve Shorrock NATS
35
  • Acknowledgements continued

Rudolf Frei Noordwijk Risk Foundation Prof Ann
Mills RSSB Declan Kielty Pfizer Gerry Gibb
Safetywise Solutions Mark Paradies System
Improvements Inc Tjerk van der Schaaf Technical
University Eindhoven Gerard van der Graaf Tripod
Foundation Dr Linda Bellamy White Queen BV Step
Change in Safety Organisation The Energy
Institute would also like to acknowledge the HSE
for their financial contribution to the
development and dissemination of this
publication.
36
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