Transcript Title subtitle

Investigating and analysing
human and organisational
factors aspects of incidents
and accidents
Presented by Bill Gall
New Guidance published May 2008
The Guidance was
developed by the
Energy Institute’s
Human and
Organisational Factors
Working Group
See website for details
of the HOFWG’s work:
www.energyinst.org.uk/humanfactors
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
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
Investigation - Analysis
Investigation – gathering information,
reconstructing events, for example, using a timeline, to make sense of the incident
Analysis – thorough and systematic review of the
information to identify root causes
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
“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
Further Evidence
Several incident analyses indicated:
• Immediate Cause – Human Error
• Root Cause – Human Error
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
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• Out of date?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?
Case Study – a spillage incident
A road tanker driver refuelling his vehicle left it
unattended with the trigger locked.
Why?
Ten litres of diesel spilled onto the forecourt of
the refuelling bay, requiring clean-up and
causing delay to other drivers
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 the
‘payoff’ for violating?
Why?
What was
so urgent?
Example – further analysis
The investigation did not seem to explore the
underlying causes of the driver’s 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?
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”?
Better solutions?
• Discipline the driver and warn others about this
hazardous practice
• Explore the site’s 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 cutoff could create false sense of safety
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
This is what
you see
The more thorough the level of analysis, the
better the response in terms of focused
improvements
This is what you don’t see –
until you start to dig
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
Basic Understanding of HOF Issues
The Guidance Describes:
• Human failure types
– Slips, Lapses, Mistakes, Violations
– Safety Management
– Safety Culture
A Useful Failure Model
Direction of Events
Direction of Analysis
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
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
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
Selecting an Appropriate Method
Cautions
• Be realistic about the team’s expertise in HF;
may require training
• Checklists – can help as an initial prompt but
- as shown already - can mislead the user
Criteria for Selection of a Method
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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
Matrix – Criteria Against Methods
Method
Training Required
Paper-Based or
Software
Paper
Fishbone
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lysis
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System
igat
W TIES
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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
Software
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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
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)
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)
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®
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
References and Bibliography
The Guidance describes sources of information
used including useful websites
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
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
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
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.