Energy Institute ME

branch
Human and organisational factors:
Preventing the causes of incidents before
they happen?
13 October 2014
Stuart King, Technical Products Manager
sking@energyinst.org

www.energyinst.org

About me

MSc Social Anthropology

Working for the EI since October 2009
Manage a portfolio of human factors and process
safety related activities:
Human and Organisational Factors Committee
Hearts and Minds programme
Stichting Tripod Foundation
Process Safety Management Framework
Production of resources, e.g. guidelines, tools, research,
focusing on various aspects of improving health and
safety, by tackling the human element of risk.

www.energyinst.org

Energy Institute

The Energy Institute (EI) is the chartered

professional membership body for the global energy
industry
Serves society with independence, disseminating
knowledge, skills and good practice towards a safe,
secure and sustainable energy system.
Licensed by:
the Engineering Council to award Chartered,
Incorporated and Engineering Technician status,
the Science Council to award Chartered Scientist
status, and
the Society for the Environment to award
Chartered Environmentalist status.
Technical work programme funded by EI Technical
Partner Companies
www.energyinst.org

Membership

19,000 individual EI members

350 company members
Technical work programme funded by EI Technical
Partner Companies:
BG Group
BP Exploration
BP Oil UK Ltd
Centrica
Chevron
ConocoPhillips
Dana Petroleum
DONG Energy
EDF Energy
ENI
E.ON UK
ExxonMobil International
International Power
Kuwait Petroleum Aviation
Maersk Oil North Sea

www.energyinst.org

Todays topic:
Human and organisational factors:
Preventing the causes of incidents before
they happen?

www.energyinst.org

Research: 1980-2000 (and beyond)

Tripod
Beta

Tripod
Delta

Hearts and
Minds

Bow Tie

Shell and OGP Life Saving

Rules

www.energyinst.org

Original research question: Can you

predict the causes of accidents before they
occur?

Jop
Groeneweg

Patrick
Hudson

Jim Reason

Answer: Yes!
www.energyinst.org

Why incidents happen (1)

Swiss cheese model
- Organisations manage risk using barriers

- Barriers use of equipment, design of plant (redundancy,

overflows, etc.), following rules, procedures, standards
usually barriers are people doing a job
- Barriers are functions

www.energyinst.org

Why incidents happen (2)

Incidents happen when barriers fail.

www.energyinst.org

Why do barriers fail? The Tripod

causation path

Underlying
causes

Preconditions

Creates

That influences the

person

SMS
Leadership
Culture

To take
action or
inaction

Error /
violation
promoting
conditions

An
organisation

Immediate
causes

Performance
influencing factors
(PIFs)
- Competence
- Fatigue
- Environment
- Supervision
- Task
- Etc.

That causes
barriers to
fail

That
result in

Accidents,
incidents and
business upsets

Human action or
inaction
slips, lapses,
mistakes,
violations

Knowledge.energyinst.org
www.energyinst.org

Why do barriers fail? The Tripod

causation path

Underlying
causes

Preconditions

Creates

That influences the

person

SMS
Leadership
Culture

To take
action or
inaction

Error /
violation
promoting
conditions

An
organisation

Immediate
causes

Performance
influencing factors
(PIFs)
- Competence
- Fatigue
- Environment
- Supervision
- Task
- Etc.

That causes
barriers to
fail

That
result in

Accidents,
incidents and
business upsets

Human action or
inaction
slips, lapses,
mistakes,
violations

Knowledge.energyinst.org
www.energyinst.org

What is human and organisational factors (HOF)?

environmental, organisational
and job factors, and human and
individual characteristics which
influence behaviour at work. 1
Piper Alpha (1988)
Texas City (2005)

www.energyinst.org

Types of human failure the immediate

cause

Unintended
actions

Intended actions

Violations

Mistake

Lapse

Slip

Errors
www.energyinst.org

Human factors the PIFs (two similar

models)
Task
complexity.
Facilities.
Environmen
t

Job

Individual

Organisation

Personality,
psychology,
height,
weight,
competency
, fatigue

Culture,
leadership,
supervisors,
rules and
procedures
www.energyinst.org

Human factors Top 10 issues

1.
2.
3.
4.
5.

Organisational change (and transition management)

Staffing arrangements and workload
Training and competence (and supervision)
Fatigue (from shiftwork and overtime)
Human factors in design:
(a) General
(b) Alarm handling
(c) Control rooms
(d) Ergonomics design of interfaces
(e) Ergonomics health ergonomics
6. Procedures (especially safety critical procedures)
7. Organisational culture (and development)
8. Communications and interfaces
9. Integration of human factors into risk assessment and
investigations (including Safety Management Systems)
10.Managing human failure (including maintenance error)

www.energyinst.org

The organisation the underlying cause

Individuals
Management systems
Design of facilities and
equipment

Burden of risk
management

Best
possible?

ALARP?

Current?

Adapted from OGP, Human

factors engineering in projects

www.energyinst.org

Todays topic:
Human and organisational factors: Preventing
the causes of incidents before they happen?

Tools to help us

www.energyinst.org

Investigation

www.energyinst.org

Tripod Beta user guide

Tripod Beta:
Guidance on using Tripod Beta in
the investigation and analysis of
incidents, accidents and
business losses

The current manual on

Tripod Beta
Step-by-step process, along
with detailed guidance
Also good introduction to
human factors causes of
incidents

Purchasable, or included in some

Tripod Beta training courses.
www.tripodfoundation.com

www.energyinst.org

Investigation (e.g. Tripod Beta)

Underlying
cause

Immediate
cause

Preconditio
n

Agent

Event Event
Agent

Failed
barrier

Event

Object

Failed
barrier

Failed
barrier

Object
Event

www.energyinst.org

Guidance on investigating and analysing

human and organisational factors aspects
of incidents and accidents
Guidance on investigating and analysing human and organisational
factors aspects of incidents and accidents (May 2008) ISBN 978 0
85293 521 7
Developed by Kingsley Management Services
Launched at EPSC Learning from accidents and Ergonomics Society
Human factors in oil, etc conferences (November 2008)
Tackles deficiency that human error as investigation end point.
Promotes better investigation of human and organisational factors
aspects
Reviews attributes of tools

www.energyinst.org.uk/humanfactors/incidentandaccident

www.energyinst.org

Risk assessment

www.energyinst.org

Bow Tie
- Promote barrierbased thinking

Tripod Delta
- Questionnaire survey
- Tries to uncover performance
influencing factors
- Determines the underlying
causes before they cause an
accident
www.energyinst.org

Safety critical task

analysis
Guidance on human factors safety critical task analysis ,
2011.

Defines a methodology and

introduces the most common
techniques for conducting human
factors safety critical task analysis.
Topics include:

Introduction to SCTA

SCTA good practice dos and

don'ts

Case studies, examples of good

and bad SCTA

SCTA methodologies.
Launched at IChemE Hazards XXII
(April 2011)

www.energyinst.org

Quantified human reliability analysis

(QHRA)
Guidance on QHRA
Methodologies,
e.g. Heart, Cream,
Spar-H
Pitfalls
Uses and abuses
of HEPs
Competencies
required
Checklists
Illustrative
examples
www.energyinst.org

Human factors management

www.energyinst.org

Awareness

Human factors briefing notesHuman factors awareness:

web-based training course
www.eihoflearning.org
www.energyinst.org

Basic

Human and organisational

factors professional
development: complete
training resource

https://
www.energyinst.org/technical/human-and
-organisational-factors/complete-train
ing-resource

www.energyinst.org

Established

https://www.energyinst.org/humanfactors

www.energyinst.org

Hearts and Minds Safety culture

improvement toolkit
Shell E&P Winning hearts and minds toolkit

Understanding your culture

Managing rule breaking
Risk assessment matrix
Making change last
Improving supervision
Achieving situation awareness
Seeing yourself as others see you
Working safely
Driving for excellence

Published by Energy Institute since 2004

www.energyinst.org

Fatigue
Managing fatigue using a fatigue risk
management plan (FRMP)
Advocates the management of
fatigue using a management system,
in the same way other risks are
managed.
Ultimately it is about ensuring the
workforce can sleep, and carrying out
high risk activities during periods of
alertness (or building in safe guards
so that fatigue cannot cause major
incidents.

www.energyinst.org

Hearts and Minds: Learning from

incidents

LFI-engage followup study to 20092012 PhD

Funded by Hearts and
Minds research fund
Glasgow Caledonian
University, will run
The
untilproject
June2013.
aims to
address two main
problems that limit
the impact of LFI
initiatives:
Frontline employees tend to engage with learning from incident
initiatives in limited ways
Frontline managers and supervisors are not fully equipped to
engage staff in learning in ways that maximise reflection and
sense making.

www.energyinst.org

Cognitive
Social
Personal

Crew resource management

(non-technical skills)
Contracted to Aberdeen University.
Develop guidance for managers on
implementing crew resource management
(non-technical skills) training, as pertains to
major incidents.
Focus on:

What is CRM

Its benefits

How to identify CRM skills needed in the organisation

How to implement CRM

Relevance to safety culture and management systems

Situation
Awareness
Decision
Making
Leadership
Team Work

Synergies with OGP project to develop a Well

Operations Crew Resource Management
training syllabus, due end 2012.
Highly relevant to major incidents e.g.
Macondo, Montara.

Communicatio
n
Fatigue
Stress
Know the
situation. Know
the solution

www.energyinst.org

Measurement

www.energyinst.org

Human factors performance

indicators
Research report: Human factors performance indicators for
the energy and allied process industries, 2010.
Joint industry project:
EI
HSE
Lloyds Register
Methodology for
developing HF
performance
indicators for each
HSE top 10 human
factors issues.
Example performance
indicators suggested
NB: OGP IPIECA: Performance Indicators for Fatigue Risk Management Systems
by or being used in
www.energyinst.org

Summary

Incidents are caused by barrier failures.

Barriers almost always fail due to human action.
Humans do not behave in a vacuum. Performance
influencing factors make human failure more or less likely.
Managing these performance influencing factors is the
purpose of the organisations leadership, management
system and culture. The underlying causes of incidents are
failures to manage PIFs.
Performance influencing factors are basically what we call
Human and organisational factors.
Preventing incidents before they happen = managing PIFs.
Underlying causes can be identified through:
good accident investigation. Underlying causes are the
cause of all incidents.
Risk assessment, e.g. Tripod Delta.
EI has many freely available resources on managing human
and organisational factors.

www.energyinst.org

Thank you

www.energyinst.org