Keil 安全中心文件

1Human Factors in Incident Investigation –p practical tools & techniques qand organisational g vRonny Lardner AFIChemE F Founder d & Registered R i t d Psychologist P h l i t The Keil Centre Ltdronny@keilcentre com au ronny@.au© The Keil CentreAgenda• Common shortcomings in oil & • • • • • • •gas industry incident investigations Development & application of Human Factors Analysis Tools The importance of interview skills R l ti Relationship hi to t improving i i safety, and other aspects of performance? An oil & gas industry case study Alignment with “just and fair culture” Questions & discussion Further reading & resources2© The Keil CentreWhat do we mean by ‘human factors’ in hazardous industries?and organisational g v UK HSE “top-ten” human factors issues  Managing human failure  Procedures  Training T i i and d competence  Staffing, including supervision  Organisational change  Safety Safety-critical critical communication  Human factors in design  Fatigue & shiftwork  Organisational (safety) culture  Maintenance, inspection and testing3© The Keil Centre 2013GOAL: Managing human reliability & f il failureInfluences on human reliability & performance Organisational (safety) cultureUsable procedures Training and competence Staffing levels, including supervision Organisational change Safety-critical communication Human factors in design Fatigue & shiftwork Maintenance, inspection and testing4© The Keil Centre 2013Background• Major j oil and g gas company p y • Good quality technicalanalysis, l i poor on b behaviour h i / cultural aspects5• Tended to focus on blame, andassume all unsafe acts are intentional• Desire to improve p© The Keil CentreHuman Factors Analysis ToolsGather EvidenceTraditional analysis6Assemble TimelineIdentify Critical Factors & Causes; Write recommendationsCF 1 CF 2 CF 3Specify behaviour(s) to be understoodHuman factors analysisIntentionalABC AnalysisBehaviour intentional or unintentional?UnintentionalHuman Error Analysis© The Keil Centre 2013Human Factors Analysis ToolsGather EvidenceTraditional analysis7Assemble TimelineIdentify Critical Factors & Causes; Write recommendationsCF 1 CF 2 CF 3Specify behaviour(s) to be understoodHuman factors analysisIntentionalABC AnalysisBehaviour intentional or unintentional?UnintentionalHuman Error Analysis© The Keil Centre 20138Human error analysis Oil and gas industry case study© The Keil CentreHFAT analysis of five isolation incidents• Three Th human h errors, two tviolations of the control of work / isolation procedures. • One O incident i id t i involved l d a very experienced electrical technician – a classic maintenance i t error • The investigations identified a number of performanceshaping h i f factors, t which hi h increased the likelihood of errors • Control of work system was analysed to establish if it was “error-tolerant”© The Keil Centre9Human Factors Analysis ToolsGather EvidenceTraditional analysis10Assemble TimelineIdentify Critical Factors & Causes; Write recommendationsCF 1 CF 2 CF 3Specify behaviour(s) to be understoodHuman factors analysisIntentionalABC AnalysisBehaviour intentional or unintentional?UnintentionalHuman Error Analysis© The Keil CentreHow people process information11Perceive Memory of Perceive Memory of training 12DecisionPerceive Perceive information from outside worldtraining, procedures, recent events,etcMake decision PerceptionMemoryMake decision based on perceptionsd 3Actionand information from memoryTake action based on decisionTake action based 412Performance Shaping FactorsOrganisationalvType of Factor ExampleYour ExampleWorkload rushing to The taskWorkload –rushing to finish a job Communications Poor handwriting Procedures & documentation Ambiguous wordingEnvironmentHigh background noiseTraining & experience New startg p Human-MachineInteraction Alarm floodPersonal Recent bereavement Social &team Personality clash Social & teamPersonality clashf-a proactive technique for critical tasks -Task Probability of failureTask of similar nature to??in 1000Task of similar nature to process isolation, with some independent checking of output ?? in 1000Above,??in 1000without independent checking of output?? in 1000?? in 1000Above plus time shortage forAbove, plus time shortage for error detection and correctionTask Probability of failureTask of similar nature to3in 1000Task of similar nature to process isolation, with some independent checking of output 3 in 1000Above,9in 1000without independent checking of output9 in 100081 in 1000Above plus time shortage forMinimum platform error rate =22in 1000Above, plus time shortage for error detection and correctionMinimum platform error rate = 22 in 1000*older people are less reliable on perceptual tasks Performance-shaping(e.g. reading P&ID diagrams or small print on labels).factorsRecommendations15•Reducing isolation error rateg•Early detection of isolation errors•Educate personnel on human error, and performance-shaping factorsf t•Share learning with other platforms, and other organizations using same control of work softwareg•Reducing isolation violations•Result: 66% reduction in errors, and remaining errors are of lower potential consequence16Safety culture and human factorsStrong safet c lt re Cannot eliminate •Key pointsD i Strong safety culture : Cannot eliminate error; ATC = 98% error; 2% intentionalMany process industries need more management focus, tools & techniques for identif ing and red cing Decreasing number of unsafe actsAdeveloping safety identifying and reducing error, and performance-shaping factors safety culture : 55% violations;Human error includes management errorMore traditional behavioural Maturingsafety cultureCapability improvement 45% errorMore traditional behavioural safety wont helpStrong Link to Just & Fair Culture p o e e t needed here?CultureUnintentional (Error)Intentional (Violation)Weak safety culture :Weak safety culture : Error obscured by focuson more obviousTop-ten tips•Choose a well-researched human factors analysis tool •Carefully select those who you train to use this tooly y•Include interviewing skills in the training•Brief senior managers and workforce on potential benefits •Define type(s) of incidents where human factors analysis is mandatory, and where it is optional•Include a human factors skillset in the investigation teamI l d h f t kill t i th i ti ti t •Ensure a clear distinction is made between intentional and unintentional behavioursunintentional behaviours•Ensure the investigation and analysis uncovers what influenced unsafe behaviour, or made error more likely •Give your analysts coaching and feedback to keep skills fresh•Publicise successFurther reading 1•General reading about human performance and failureE d f h i f tError and performance-shaping factors–Safety at the Sharp End: A guide to non-technical skills, by Rhona Flin and colleagues.Published by Ashgate(2008). $29.00 on AmazonIntentional behaviour / violations–Bringing out the Best in People, by Aubrey Daniels. Published by McGraw-Hill (2000).$17.00 on Amazon. Short book on ABC analysis, not specifically about safety.–The Psychology of Safety Handbook, by Scott Geller. Published by CRC Press (2000).$147.00 on Amazon. Longer book specifically about safety.•Energy Institute guidance on investigating and analysing human and organisational factors aspects of incidents and accidentshttp://tinyurl com/brswynv/brswynvFurther reading 2•Human Failure Typeshttp://tinyurl com/d5ou9y7/d5ou9y7•InterviewingInvestigative Interviewing: Psychology and Practice, by Rebecca Milne and Ray Bull.Published by Wiley (1999). $56.00 on Amazon. This is an interesting read for those whoP bli h d b Wil(1999)$5600A Thi i i t ti d f th hwant to know some theory and practice on this subject.Investigative Interviewing Explained, by Brian Ord and colleagues. Published by LexisNexis/Butterworths(2008). $86.00 on Amazon.•Human Factors Analysis ToolsA paper published in Process Safety and Environmental Protection -the official journal ofthe European Federation of Chemical Engineering -which describes methods which have been successfully used to enhance incident investigations, and develop betterrecommendations to address violations, errors. /cy4cavj•Human Factors Analysis Tools case study –reducing isolation errors /c2aadaw•Just and Fair Culture Model/c65nuol。