Presented 2018 via Skype to process safety professionals in Pakistan

Incident investigations often conclude that one of the causes was either that people did not follow a “good” procedure or that procedures were not fit for purpose. These findings are often based on an inflated opinion of what procedures can achieve. The reality is that procedures appear very low on the hierarchy of risk control and will only ever make a fairly modest contribution to safety. Avoiding hindsight bias when considering the role of procedures in incidents can mean that more effective recommendations can be made, leading to a set of procedures that provide effective support to competent people.

Published in Loss Prevention Bulletin December 2018.  Available as a free download at https://www.icheme.org/media/7205/lpb264_pg09.pdf

Poor communication at shift handover was identified as one of the causes of the Piper Alpha disaster. The operators decided to start the standby condensate pump but did not realise its relief valve was not in place. The inquiry into the disaster found no evidence to suggest that the people involved had done this intentionally and concluded that they made decisions that, in hindsight, were clearly wrong because they did not have a full and accurate understanding of equipment status and condition.
Unfortunately, in the 30 years since Piper Alpha there has been relatively little effort put into improving shift handover across industry. This is despite subsequent major accidents where problems with shift handover failures have been identified.
This paper summarises the issues of shift handover and the challenges with achieving improvement. It refers to work carried out at a client’s site to improve shift handover, which has had a very positive effect on shift workers and their managers.

Published in Loss Prevention Bulletin June 2018

Removal of an isolation was identified as one of the causes of the Piper Alpha disaster. The operators did this to start a pump without realising its relief valve had been removed for maintenance. The underlying cause was that the pump isolation was not cross referenced with the removal of the relief valve.
This paper summarises several issues with process isolations based on the events at Piper Alpha, namely use of shared isolations and management of change. Process isolation is a critical and complex subject, and this paper only touches on the subject. A key message is that people can often perceive an isolation as guaranteeing safety when the reality is that it is only a means of reducing rather than eliminating a risk.

Published in Loss Prevention Bulletin June 2018

Introduction to alarm management including guidance from EEMUA 191.

View the video on YouTube

Bowtie diagrams were developed in the 1970s as a way of illustrating how risks are managed.  Their use increased significantly after the Piper Alpha disaster and continues to this day.  Although originating in the process industry, other sectors are starting to use Bowtie diagrams.

However, the popularity of Bowtie diagrams is not without its problems.  There has been no definitive guide or standard on how to develop them, or even when they should be used.  People clearly like Bowtie diagrams, but often have inflated opinions of what they can actually achieve and there is a misguided assumption that they can be applied to any activity where there is risk.  Representation of human factors is one particular area where there appears to be a lot of variability and differences of opinion. 

I have written this paper to share my views of how Bowtie diagrams should be used and how human factors should be represented.  I hoped it would start some discussion.  If you have any comments, I would be very happy to receive them.

Bowtie diagrams and human factors (full paper in PDF format)

I hope you find these resources interesting and useful.  I have developed them over the years I have worked as a consultant and they cover some of the key issues I have encountered.

Papers & Publications

A collection of papers I have written over recent years covering topics including human factors, staffing assessments, task risk management, control rooms, shift handover, procedures, training and competence.

Video Animations

Links to some short video animations I have created showing how to perform task analysis, human error analysis and develop causal trees when analysing incidents.

Presentations

Links to presentations I have given in recent years covering topics including staffing assessments, control rooms, shift handover and accident avoidance.  Also, an introduction to ergonomics for senior school pupils and a two day human factors course presented to companies working in major hazard industries.

 

This 25 minute presentation looks at the alarms that are received in control rooms typically found in oil refineries, gas plants, chemical sites, power stations and similar.  These may be hard wired alarms to a fixed panel, but most nowadays will be computer based systems.

 

These alarms should warn operators about something that requires their prompt attention.  Typically an equipment malfunction or control failure.  However, there are lots of problems with alarms in many control rooms, especially with newer computer based systems.

Please note - the videos are hosted on YouTube. if you are looking at this from work your company may have blocked access.

 

 

 

If you don't see the videos above it probably means YouTube has been blocked on your server

Causal Tree Analysis provides a means of analysing the critical human errors and technical failures that have contributed to an incident or accident in order to determine the root causes.  It is a graphical technique that is simple to perform and very flexible, allowing you to map out exactly what you think happened rather than being constrained to accident causation model.  The diagrams developed provide useful summaries to include in incident and accident reports that give people a good overview of the key issues.

View the video on YouTube

Click here to download a copy of the Causal Tree

 

Interlocks provide a means of coordinating the function of different components so that task steps have to be performed in a specified sequence or certain conditions have to be met before a task can proceed. Valves used to create process isolations can be interlocked so that it is physically impossible to manoeuvre them in an incorrect sequence. This is often seen as a method of eliminating the potential for human error.


Advances in technology have allowed more extensive and complex interlocks to be used, which on the face of it, appears to provide the opportunity to make isolations safer than ever before. However, interlocks do not actually eliminate errors; and complexity can be a source of risk. In fact, when all factors are considered there may be an argument to say ‘less is more.’


Whilst there is some guidance available about when interlocks can or should be used; there is very little to say which or how many components should be interlocked. This leaves designers with a dilemma. Do they attempt to apply a ‘sensible’ approach, which may leave them open to criticism because their design is not totally ‘error proof?’ Or do they go to an interlock vendor and ask them to interlock everything,?


One of the problems is that the reason for using interlocks is not always clearly understood or defined. Are they provided to:
• Ensure a ‘spared’ item (e.g. relief valve, filter) remains available at all times and is not interrupted when changing over duty/standby?
• Ensure isolation valves are in the correct position before carrying out a task?
• Ensure the item has been fully isolated and prepared for the task by ensuring valves are manoeuvred in a defined sequence and secured in the correct position;
• All of the above?

Extensive and complex interlock systems are expensive to purchase, install and maintain. They are often only effective for performing one task, and so cause significant problems when other activities have to be performed or if a problem occurs (e.g. valve passes or pipework is blocked). Also, they can create a false sense of security that introduces human factors risks. This paper will discuss these issues using real life examples and suggest that less really can be more.

 

Presented at Hazards 2017

Whilst Human Factors Engineering (HFE) is starting to be adopted for projects in the oil and gas industry, there is a tendency to leave it until relatively late. This means that opportunities to influence and improve the design are being missed. The reasons for this include a lack of understanding of what HFE can contribute amongst project personnel; and a similar lack of project understanding by the people responsible for integrating human factors. This paper will make the case of doing more HFE earlier in projects, which will improve the way human factors are addressed and result in better design.

Presented at EHF 2017

Effective emergency procedures that support the people who have to detect, diagnose and respond to hazardous situations can reduce the likelihood that minor incidents will escalate.  Unfortunately, procedures often fail to support the people who have to deal with the early stages of an incident. This paper examines the reasons why emergency procedures may not provide adequate support, and sets out some guidelines to help in writing more effective ones.

Published in the Loss Prevention Bulletin April 2017

Presented to the Irish Ergonomics Society 2016

The double block and bleed method of valve isolation has become almost the default method of isolation in the process industry. However, there are limitations and misunderstandings in the methods of proving integrity.  This paper highlights several ways in which double block and bleed isolations can fail, resulting in hazards with major accident potential. Key learning points include:


• Implementing an isolation involves more than simply closing some valves;
• Multiple failures can and do occur — and because valves are often of the same type and in the same service, common cause failures are an issue;
• Valve integrity must be proven and this requires pressure. There will be times when no pressure is available from the process, or it is only available from the wrong direction;
• Reducing the risk to personnel carrying out maintenance will often be transferred to those implementing the isolation.

 

Published in the Loss Prevention Bulletin August 2016

Here are some of the presentations I have given over the years. They are all hosted on Slideshare.

 

2016 - Irish Ergonomics Society

{slideshare}[slideshare id=61712928&doc=2016irishergonomics-hfeinoilgas-160505153814]{/slideshare}

 

2015 - Trinity College Dublin TOSCA project

{slideshare}          [slideshare id=61712656&doc=2015trinitydublin-taskriskmanagement-hfinprocesssafety-160505153024] {/slideshare}

 

 2014 - IChemE Hazards conference

{slideshare}    [slideshare id=61712610&doc=2014hazards-linkingtaskanalysiswithotherprocesssafetyactivities-160505152925]       {/slideshare}

 

2012 - Young Generation Network

{slideshare}[slideshare id=61712749&doc=2012younggenerationnetwork-taskanalysis-160505153328]           {/slideshare}

 

2012 - Young Generation Network

{slideshare}     [slideshare id=61712748&doc=2012younggenerationnetwork-humanperformanceproblems-160505153326]      {/slideshare}

 

2012 - IEHF North West Branch

{slideshare}     [slideshare id=61712537&doc=2012iehfnorthwest-taskriskmanagement-160505152744]      {/slideshare}

 

2012 - IEHF Annual Conference

{slideshare}      [slideshare id=61712490&doc=2012iehf-taskriskmanagement-160505152606]     {/slideshare}

 

2011 - Society of Petroleum Engineers Europe

{slideshare} [slideshare id=61712889&doc=2011spe-electronicloggingtoimprovesafety-160505153704]{/slideshare}

 

2010 - Ysgol Aberconwy Secondary School GCSE Technology

{slideshare} [slideshare id=61712855&doc=2010ysgolaberconwysecondaryschool-ergonomicsforgcse-160505153614]{/slideshare}

 

2010 - IBC Control Rooms course

{slideshare}    [slideshare id=61712461&doc=2010ibc-managingrisksofcontrolroomoperations-160505152524]       {/slideshare}

 

2010 - Ergonomics Society Annual Conference (now CIEHF)

{slideshare}  [slideshare id=61712391&doc=2010ergonomicssociety-actionsinacoachfire-160505152412]         {/slideshare}

 

2008 - IChemE Hazards conference

{slideshare}      [slideshare id=61712341&doc=2008hazards-shifthandover-160505152247]     {/slideshare}

 

2008 - Ergonomics Society Annual Conference (now CIEHF)

{slideshare}       [slideshare id=61712291&doc=2008ergonomicssociety-staffingassessmentsandsupervision-160505152150]    {/slideshare}

 

2007 - North Wales Occupational Health and Safety Group

{slideshare}     [slideshare id=61712254&doc=2007northwalesohs-humanfactorsoverview-160505152049]      {/slideshare}

 

2007 - Ergonomics Society Annual Conference (now CIEHF)

{slideshare}   [slideshare id=61712210&doc=2007ergonomicssociety-whatworksinindustry-160505151935]        {/slideshare}

 

2006 - IChemE Manchester Branch

{slideshare}        [slideshare id=61712180&doc=2006ichememanchester-humanfactorsriskmanagement-160505151849]   {/slideshare}

 

 2006 - IChemE Hazards conference

{slideshare}       [slideshare id=61712140&doc=2006hazards-managingchangepresentation-160505151804]    {/slideshare}

 

2005 - IBC Control Rooms course

{slideshare}   [slideshare id=61712100&doc=2005ibc-managingrisksofcontrolroomoperations-160505151710]        {/slideshare}

2008 - European Process Safety Centre

{slideshare}    [slideshare id=61711368&doc=2008epsc-accidentavoidance-160505145708]       {/slideshare}

This paper is a development of one I presented at Hazards 24 [Ref 1].  I believe that human factors can make a great contribution to the way the risks of major accidents are managed.  However, whilst its use in industry is growing it is failing to reach its potential because it is not properly integrated into other safety studies.  Task analysis is arguably the human factors technique that has the greatest potential for overcoming this hurdle.

Integrating Human Factors into Safety Studies (download full paper in PDF format)

In 2001 a document Contract Research Report (CRR) 348/2001 was published by the Health and Safety Executive (HSE) that introduced a method of assessing staffing arrangements for process operations in the chemical and allied industries.  I’ve lost count, but over the last 10 years I have been involved in at least 30 staffing assessment projects for more than 15 different clients.  Also, even where the method is not formally used I often refer to elements of it as guidance for my other human factors and risk consultancy work.  Having spent 10 years using the method I decided it was a good time to stand back and reflect.  In general, although I can point to some flaws in the method, I have found it to be a very good framework for assessing human and organisational factors.  It prompts you to ask challenging questions and to be objective in your analysis.  Also, I have found that the observations and recommendations I have made as a result of using the method have been very well received by my clients.

Download my Christmas 2011 Paper - 10 Years of Staffing Assessments

I have used task analysis for many years and have always found it very useful for a wide range of human factors applications.  However, in the last year or so people have started to show more interest in the analyses and have been asking more probing questions about the method, presentation and application.  This has led me to develop a more comprehensive template for recording the findings of task analyses.

Download my Task Analysis Template issued Christmas 2013

Presented at the Ergonomics Society oil and gas conference, October 2008

School Presentation - Ergonomics.

 

Ysgol Aberconwy School approached the Institute of Ergonomics and Human Factors, asking for someone to give their GCSE technology classes a presentation.  As the only local member of the institute, I was asked if I would oblige.

I was happy to agree and gave the presentation twice, to two separate classes.  It seemed to go well.

Click here to download a copy of my presentation.

Hierarchical Task Analysis is an excellent method of capturing how tasks are performed in a systematic and structured fashion. It is a graphical technique that allows groups to work on the analysis together.  This is useful for identifying different practices and for developing a consensus on what constitutes best practice.

Hierarchical Task Analysis is particularly useful when developing procedures, training plans and competency systems.  Also, being hierarchical it is particularly suited to new projects as it can be developed in conjunction with the design.

This article titled Task Risk Management will give you a context in which HTA is particularly valuable. The following video clips should you how to carry out HTA in practice.

View Part 1 of the video on YouTube

View Part 2 of the video on YouTube

 

Human Error Analysis (also known as Task HAZOP) provides a systematic method of considering the possible errors and other human failures that may occur when performing a task.  A check-list of error types is used as a prompt to ensure all the most relevant failure types are considered.  This is similar to HAZOP, which is a widely used technique for assessing process safety.

Using a laptop and data projector, groups can participate in the HEA.  This helps demystify the topic of human error.  By involving the right people (typically those who have practical experience of doing the task), the method helps you to evaluate your current approach to managing human factors risks and to identify anything else that can be done to effectively reduce the risks.

View Part 1 of the video on YouTube

View Part 2 of the video on YouTube

Click here to download the Task Risk Management job aid including a Human Error Checklist

 

 

All organisations involve people in some way.  One issue that this brings is that all people make mistakes, forget things, get distracted, break rules and generally fail.  Human Factors helps us understand how people fail, the potential consequences of failure and how the associated risks can be reduced.

Why are human factors important?

Person at an industrial site Despite great advances in technology over recent years, people are still heavily involved throughout any organisation's lifecycle.  Even where a process has been largely automated, the equipment is still designed, maintained and monitored by people.

People have many abilities that cannot be replace by machines. They are particularly good at applying judgement, working flexibly and recalling information gained from many different experiences.  But they have natural weakness that mean error is always a possibility. Human Factors uses the knowledge of people to make sure their strengths are achieved whilst avoiding the weaknesses.

Download the full article

This paper proposes Task Risk Management as a means of integrating the principles of task analysis into a wider risk management process. The paper describes methods and approaches that I have used and found to be very effective and practical.

I have used the term Task Risk Management to show the benefits of taking a task based approach prioritised around process safety risks. I believe that done properly, the way human factors and process risks are understood and managed can be improved significantly.

Task Risk Management (full paper in PDF format)

Task Risk Management job aid

Recent accidents at Buncefield and Texas City have illustrated how poor shift handover can contribute to major accidents.  This is not a new discovery, but given the ever greater interest in human factors, it is one that is finally receiving attention.

Shift handover is a complex, high risk activity that is performed very frequently.  Normally we would try to ‘engineer out’ high risk frequent tasks, or at least automate them to minimise the likelihood of error.  However, this is not an option for shift handover.

Co-author Brian Pacitti of Infotechnics

Shift handover paper (PDF format)

All organisations involve people in some way.  One issue that this brings is that all people make mistakes, forget things, get distracted, break rules and generally fail.  Human Factors helps us understand how people fail, the potential consequences of failure and how the associated risks can be reduced.

Why are human factors important?

Person at an industrial site Despite great advances in technology over recent years, people are still heavily involved throughout any organisation's lifecycle.  Even where a process has been largely automated, the equipment is still designed, maintained and monitored by people.

People have many abilities that cannot be replace by machines. They are particularly good at applying judgement, working flexibly and recalling information gained from many different experiences.  But they have natural weakness that mean error is always a possibility. Human Factors uses the knowledge of people to make sure their strengths are achieved whilst avoiding the weaknesses.

The consequences of human failure

Tank fire Estimates vary, but the general consensus is that up 80% of accident causes involve a human failure.

Accidents involving human failures have included major industrial disasters that have caused significant loss of life.  But it is not only major accidents that are caused by human failure.  No business is immune from the financial costs of events such as:

  • Banking system failures
  • Critical business data being lost
  • Missed deadlines
  • Security systems being left vulnerable to attack
  • Medication errors.

How can human factors help?

People often think that human errors are random and so there is not much that can done to prevent them.  In fact all forms of human failure are predictable.  Whilst they cannot be eliminated, human factors allows the likelihood and/or consequences to be reduced.  This is achieved by understanding how people are able to cope with physical and psychological demands, and how they are effected by the social conditions at work.

Types of human failure

As well as telling us human failures are not random, Human Factors demonstrates that there are different types of human failure.  They occur in different circumstances, and understanding this gives our best opportunity to reduce them.

Flow chart categorising human failures as slips, lapses, mistakes and violations

One of the key messages is that it is not only lack of experience or competence that leads people to commit errors.  In fact slips and lapses are most likely when people are very well practiced at a task so that they are performing on 'auto pilot.'  The other key message is that violations are rarely willful acts, and instead are situations where people are trying to do what they think is best and do not expect any negative consequences to occur.

AB Risk can help

Human Factors is a relatively new discipline but it is rapidly establishing itself as a key element of risk management, particularly in major hazard industries.  Unfortunately it is sometimes seen as a rather theoretical subject both by the experts and industry.

AB Risk risk has works the sharp end of industry, evaluating the true risks of human failure and identifying practical methods of reducing risks.  Human Factors is dealt with using language that engineers and other non-experts understand.  AB Risk deal with people on the shop floor right through to the board room, making sure everyone understands the issues and is involved reducing risks.

 

 

The design of modern control rooms has benefited a great deal from ergonomics and resulted in working environment, furniture and human-machine interfaces that are more consistent with the needs of the people who work in them.  However, I feel that many people involved in the design of control rooms assume that using the latest technology and following the most up to date standards will result in a successful outcome.  They are reassured that what they have developed looks like a control should, but fail to understand that they are not simple objects that can be defined by their physical arrangements.  A control room is actually a component of a complex system where people and equipment come together to control that system.

Control room human factors paper (PDF format)

Companies have invested a great deal of time and effort into training over the years, and it is not the intention here to say that this has all been wasted.  However, unless training is closely linked to a competence system the chance are that the fundamental requirements of the business may not be met because the training provided may not be what is required and/or the cost of that training may be greater than the benefit achieved.

Moving from training to competence (PDF format)

 There are a lot of issues that relate to staffing levels and how individuals work as teams.  However, it can be difficult to discuss them as abstract ideas.

Using an analogy based on 'tug of war,' a number of staffing and teamwork scenarios are discussed. Can bigger teams always achieve more than smaller ones?  Does everyone have to be hands on?  How do technical and engineering solutions fit in?

Download a PDF version

One of the challenges facing companies, particularly those dealing with major hazards, is deciding whether they have enough people to operate safely? This is a difficult question to answer and is rarely purely about the number of people.  Put simply, having a small number of competent people who can work well together is usually better than having more, less competent people.

The staffing challenge

Modern control roomNew technology allows a lot of activities that were performed manually in be automated. This appears to suggest that less people are required to achieve the same rate work than would have been the case in the past.  Whilst this is undoubtedly true, one of the main problems is that the workload created during normal activities gives little indication of the workload created by unplanned and unwanted events and emergencies.  The challenge for companies is to maintain a sufficient workforce to cover those high demand events whilst being able to keep them gainfully employed for most of the time when the demands are much less.

 Link to full article

I think everyone is familiar with procedures, but do we really know what they are?  Dictionary definitions vary, but they typically suggest a procedure is:

  • A manner of proceeding; a way of performing or effecting something.
  • A series of steps taken to accomplish an end.
  • A set of established forms or methods for conducting the affairs of an organised body such as a business, club, or government.

Interestingly none of the definitions refer to written documents. However, in practice it is generally accepted that a procedure is written in a way that describes a task method.

What do procedures look like?

The term 'procedure' is used widely, but there are many other names for documents that describes methods of work, including:

  • Instruction or work instruction
  • Safe or standard operating procedure (often shortened to SOP)
  • Method statement
  • Job method
  • Safe system of work
  • Standing order.

Whilst some organisations may differentiate between these different types of document it is important to realise that there is no universally agreed standard, and the same issues apply to all.

Link to full article

One of the challenges facing companies, particularly those dealing with major hazards, is deciding whether they have enough people to operate safely? This is a difficult question to answer and is rarely purely about the number of people.  Put simply, having a small number of competent people who can work well together is usually better than having more, less competent people.

The staffing challenge

Modern control roomNew technology allows a lot of activities that were performed manually in be automated. This appears to suggest that less people are required to achieve the same rate work than would have been the case in the past.  Whilst this is undoubtedly true, one of the main problems is that the workload created during normal activities gives little indication of the workload created by unplanned and unwanted events and emergencies.  The challenge for companies is to maintain a sufficient workforce to cover those high demand events whilst being able to keep them gainfully employed for most of the time when the demands are much less.

Modern organisations

Partly driven by technology, but also by changes in society and management theory, there have been significant changes in the way companies are organised.  This has provided another opportunity to consider reducing staffing numbers.

Traditional hierarchical team structure More modern, self-managed team structure

 

 

 

 

 

 

 

Traditional teams tended to have more levels of hierarchy and there are large degree of demarcation. Modern teams often have flatter structures, requiring people to more work flexibly and be more 'self-managed.'

Modern organisations do provide an opportunity to reduce head count by delayering the  organisation.  Unfortunately companies often assume that this can be achieved easily, without risk.  Even if the new organisation has the ability to work safely introducing such a change can create significant risk.

 

 

Supervision

In many ways modern organisations have downplayed the importance of supervision.  This may be appropriate in low hazard industries but where the hazards are more significant, Supervisors have always had an important role in making sure safe practices are maintained and providing leadership in emergencies.

There is no reason why companies cannot implement more flexible working and self-managed teams, but that does not mean supervision is not important.  In fact supervision does need to happen, but if someone is not allocated it as a specific role (whether they be called a Supervisor, Team Leader, Coach) it does make supervision more difficult and potentially less effective.

 

Diagram showing how methods of supervision cross a spectrum with traditional hierarchies at one extreme through to self-managed teams at the other.

 

The diagram above shows a 'continuum of Supervision.' It shows that there is no right or wrong way of organising teams and that there is a spectrum of methods with traditional hierarchies at one end and self-managed teams (SMT) at the other.  The reality is that most organisations fall somewhere in between.

Demonstrating staffing is adequate

Where there is a risk, it is not good enough to assume your staffing arrangements are adequate.  Even if you have enough people, do they have the right competencies, are they able to work together effectively and do they have enough support from others?

Communications in an emergency One way of demonstrating the adequacy of staffing arrangements is to consider how people would cope in a high demand situation.  This is not necessarily the worst case scenario but instead the more minor event that can escalate if not dealt with effectively.  Questions you need to ask include:

  • Who will be involved?
  • Who can assist?
  • How will they communicate?
  • Will they know what to do?
  • What is a the likelihood that the event will be dealt with effectively, in a timely manner?

This ttype of exercise invariably highlights weaknesses within the organisation.  However, it is much better to do it before the event rather than finding them when something has gone wrong.

AB Risk can help

There are techniques available that can assist you in evaluating staffing arrangements.  They provide structured methods that assist in addressing some rather intangible factors in order to develop risk based conclusions.

AB Risk has been involved in many projects with clients where staffing arrangements have been considered, often as the result of organisational change.  Clients find that having an objective third party involved in such assessment brings great benefits, especially when using structured methods described above.  They also appreciate that the recommendations made by AB Risk are practical, effective and  risk based.

References and links

CRR 348/2001 Assessing the safety of staffing arrangements for process operations in the chemical and allied industries

Safe staffing arrangements - User guide to CRR 348/2001 methodology - produced by the Energy Institute

Different types of supervision and the impact on safety in the chemical and allied industries

HSE on organisational change

I think everyone is familiar with procedures, but do we really know what they are?  Dictionary definitions vary, but they typically suggest a procedure is:

  • A manner of proceeding; a way of performing or effecting something.
  • A series of steps taken to accomplish an end.
  • A set of established forms or methods for conducting the affairs of an organised body such as a business, club, or government.

Interestingly none of the definitions refer to written documents. However, in practice it is generally accepted that a procedure is written in a way that describes a task method.

What do procedures look like?

The term 'procedure' is used widely, but there are many other names for documents that describes methods of work, including:

  • Instruction or work instruction
  • Safe or standard operating procedure (often shortened to SOP)
  • Method statement
  • Job method
  • Safe system of work
  • Standing order.

Whilst some organisations may differentiate between these different types of document it is important to realise that there is no universally agreed standard, and the same issues apply to all.

How are procedures used?

Procedures are provided for many different types of activity, including:

  • Operations - To document normal and unusual operating tasks, e.g. start-up, shut-down, normal operation and response to unplanned events.
  • Maintenance - Often divided into the different disciplines, e.g. mechanical, electrical, utilities, computers and control systems.
  • Administrative - To explain how management systems are implemented, e.g. safety, environment, quality, finance and human resources.
  • Health and safety - Generic instructions that ensure regulations and standards are maintained whilst performing tasks, e.g. permit to work, confined space entry, hot work, electrical isolation, incident reporting and investigation.
  • Environmental - Generic instructions that ensure environmental regulations and standards are maintained whilst performing tasks, e.g. energy conservation, waste disposal, discharge monitoring, incident reporting and investigation.
  • Engineering - Methods used that ensure design and modification of equipment conforms to standards.

But this is where the problems start because, although procedures may be provided, how often are they really used in practice?  Unfortunately, a lot of organisations have put a great deal of time and effort into writing procedures that are rarely, if ever used.  What a waste!

The problem with procedures

It is quite easy to look at a procedure and see what may be wrong with it.  Some are to difficult to read or badly printed.  Others are too wordy and complicated.  Some are technically incorrect or impossible to follow in practice.  Others are not in the right place.  However, the overriding problem is that most proceduresGraph showing how the proportion of people who read each page of a document diminishes as the number of pages increases are not used.

Although not scientifically proven, the 80% rule shown by the graph alongside demonstrates the problem.  In any group of people, 20% will probably not read any documents they are given.  That leaves 80% who will read the first page.  However, only 80% will read the second, and8 0% of them the next.  This pattern shows that less than 50% of people will get to page 4.

The conclusion from this must be that:

  • Procedures must be kept as short as possible
  • The first page must show the most important information (i.e. should not be wasted on administrative details)
  • If a procedure is more than one page long people will need to be taken through the contents
  • Action is required to address the 20% who read nothing.

Developing better procedures

Most organisations have some considerable scope to improve their procedures.  However, when doing this it is important to look at the overall system as well as the individual procedures.  The aim should be to make sure the right procedure is in the right place at the time it is needed, and this is unlikely to be achieved by simply writing a procedure for everything, which causes a bureaucratic nightmare where procedures are not used because they are difficult to find, use and keep up to date.

For procedures to be improved it is necessary to accept that:

  • Some tasks are more critical than others, and so their procedures must be a higher priority;
  • People who perform a task frequently will not read the procedure for that task, no matter how critical it is;
  • Different tasks lend themsleves to different procedure formats.  The 'one size fits all' just does not work;
  • You cannot write a procedure for every task, and so should not try.

Ultimately the most important thing to do is to start viewing procedures from the end-users perspective.  If you want them to use your procedures what do they really need.  This may appear to make the job of writing procedures more complicated, but in fact it will often result in less procedures with less detail; and at least they are far more likely to be used.

Identifying which tasks need procedures

The main things to consider when determining whether a procedure is required is what are the consequences likely to be if a task is performed incorrectly and how helpful is a procedure likely to be in avoiding this?

A research from report from HSE (OTO099:092 ) documents a method for applying some objective assessment of tasks that can be used to determine where procedures should be provided.  It is easy to adapt to many different circumstances and has proven to be a really useful tool for focusing effort, whilst demonstrating an effective risk based approach.

The first thing to do is to develop a list of tasks performed within the domain you are interested.  You then score each task against a number of criteria.  The default criteria are:

  • How hazardous is the system involved?
  • Does the task introduce a source of ignition?
  • To what extent does the task result in a change to systems?
  • How does the method used for the task affect the likelihood that the hazard will be released?
  • Does the task involve overriding any safety feature?

These criteria can be adapted to suit.  A simple scoring system is used, typically giving a score of between 0 and 3 for each criteria.  These are added together to identify which tasks score most highly and hence are considered to be most critical.

What should procedures look like?

Having accepted that the 'one size fits all' approach does not work for procedures it is clear that different tasks will have different procedures.  Whilst each should be formatted according to the task requirements, there is a general pattern that emerges:

Procedures for the most critical tasks should be detailed and step-by-step.  However, a checklist is often better for these types of task than more traditional procedures.  Problems with failure to use these procedures should be avoided as critical tasks should not be performed very often.  If this is not the case it is likely that you will need examine the existing risk controls as there may be an unacceptable risk from human error.

The least critical tasks may not require any form of procedure.  If this is too radical a step to take, a simple one-page summary of the task will suffice.

Task that fall between the above will require some form of procedure, but it is unlikely to be needed every time the task is performed.  Instead, the procedure should be used to form the basis for training and a standard for validation.  Hence the end-user for the procedure is more likely to be a trainee than a fully competent person.

Some tasks, no matter what criticality, do not lend themselves to detailed procedures but may require some form of job aid.  Response to emergencies is a good example here because in the heat of the moment people will not be able to handle much text, but will need some prompts to make sure they do not forget important actions.  These job aids needs to be supplemented with good training and validation, refreshed regularly, to overcome the fact that people will not be able to use detailed procedures.

The benefits of better procedures

The benefits of the approach described above include

  • Better consistency in the way tasks are done, using agreed methods that are practical and efficient;
  • Minimising bureaucracy, making it easier to access procedures and keep them up to date
  • Improving understanding of the tasks, hazards and procedures through structured analyses of tasks and improved training
  • Supporting a culture improvement because everyone is clear what procedures are, why they are needed and when they are to be used.

AB Risk can help

There is considerable scope at most organisations to improve procedures.  This invariably requires a change of view of what procedures are there for, embracing an approach that focuses on the end-user needs.

Whilst AB Risk can write good procedures for you, this is rarely an effective use of time and resources.  Instead itis much better to use consultancy to develop the overall principles and systems.  In particular:

  • How to score task criticality;
  • Determine what types of task require what type of procedure;
  • Developing a suite of procedure formats for different types of task;
  • Establishing a procedure checking and authorising process;
  • Developing links between procedures and  training and competence systems;
  • Demonstrating how the approach taken towards procedures achieves good management of risks.

References and links

HSE on procedures

Information sheet on revitalising procedures

OTO 1999/092 Human factors assessment

 

 

Although people often want to eliminate risk, this is simply not possible.  Instead it is important we understand the risk we undertake, put sensible controls in place and then make a conscious decision about whether we are happy to accept the risks that remain.  This is what we call risk management.

Human Factors Course.

During 2010 Andy presented a two day human factors course for a client at a number of their sites. It was largely generic, and so the material can be used widely. I've made copies of the slides available here. If you would like me to present this course at your company, please get in touch.

Presented in London, IBC control rooms course, December 2008

2008 (also 2006 and 2005)

Presentation and workshop at course 'Control Rooms: Operation and design '

IBC, London

In order to manage risks it is necessary to understand them.  This requires the hazards to be known so that the potential consequences and their likelihood can eb evaluated: allowing the necessary controls to be implemented.

This paper explores the risks associate with control room operations and how they need to be managed.  It considers the role of the operator, taking into account the reality of what actually happens in the control room.  It identified how these activities can cause harm, both to the health and safety of the operator; and due to the failure to control major hazards and process risks.  It describes a number of techniques that can provide some structure and assistance in carrying out these assessments.  Also, it suggests a number of areas where specific attention is required to control the risks of control room operations.

The associated workshop provides course attendees the opportunity to gain hands-on experience of applying the Health and Safety  Executive's 'Staffing assessment methodology' (CRR348/2001 ).  Participants are asked to consider the impact of changing staffing arrangements and how the risks can be managed.

2008

Special Report for Indicator Tips & Advice - Health & Safety

Available to purchase here

Presented at IChemE's Hazards XX conference, 2008

2007

Special Report for Indicator Tips & Advice - Health & Safety

Available to purchase here

The aim of health and safety is to prevent staff being harmed by business activities.  Whilst the health element can be concerned with normal working activities, the safety element is primarily aimed at preventing events that cause harm in the shorter term.  We usually call these events accidents.


The best way of achieve safety is to prevent accidents.  To do this we need to understand their causes and what can be done to avoid them.  Also, by understanding how harm is caused by events, we can prevent incidents (with no consequence) becoming accidents (causing harm).

Companies can learn a lot by investigating and analysing their own accidents.  This can be a time consuming and complex activity, but with many rewards.  However, companies have so few really significant accidents that the actual amount of information they have at any time that can help them avoid accidents is fairly limited.

However, there is a wealth of readily available information regarding the causes accidents.  It’s contained in reports of major accidents.  These are the events that typically result in multiple fatalities and major injuries, harm to the environment and/or significant disruption to business.  The question is, how useful is the learning from these events for more “normal” business?

2005

Presented at seminar titled 'Workload, organisational change and stress'

Energy Institute, London

2004

Guidance Document -available here

Energy Institute

Co-authors P Waite and A Gait

The user guide relates to Contract Research Report CRR348/2001 from the Health and Safety Executive Assessing the safety of staffing arrangements for process operations in the chemical and allied industries

The Energy Institute launched in April 2004 guidance setting out a best practice approach to the CRR348/2001 methodology that captures learnings from its use. In addition, the user guide sets out supplementary guidance on how best to apply the CRR348/2001 methodology to automated plant and/or equipment.

2004

Health and Safety Executive Research Report RR292

Co-authors A Gait and P Waite

2004

Presented at conference 'Control Rooms: Operation and Design'

IBC, London

 

2008

Loss Prevention Bulletin issue 204

Also, IChemE Hazards XX Conference, Manchester(April 2008)

Co-author B Pacitti of Infotechnics

 Recent accidents at Buncefield and Texas City have illustrated how poor shift handover can contribute to major accidents.  This is not a new discovery, but given the ever greater interest in human factors, it is one that is finally getting some attention.

Shift handover is a complex, high risk activity that is performed very frequently.  Normally we would try to ‘engineer out’ high risk frequent tasks, or at least automate them to minimise the likelihood of error.  However, this is not an option for shift handover.

There are two complimentary approaches that can be used to improve shift handover.  The first is to improve the handover process by supporting the people involved with better systems, tools and competencies.  The second is to change perceptions by maximising the value of the information collected as part of the handover process and increasing its use.  This creates additional stakeholders in the process and subsequently ensures a more effective feedback cycle regarding the quality of handover.

This paper will examine the human factors involved in shift handover.  Also, it will illustrate that information about minor incidents, human errors and reliability issues is often collected; and will demonstrate how this can be collected and disseminated effectively and efficiently.

2003

Health and Safety Executive Research Report RR174

Co-authors R Lancaster, R Ward, P Talbot

2003

Health and Safety Executive Research Report RR092

Co-author P Waite

Concerns the 'softer' issues of COMAH such as the impact of writing a safety report and the views and perceptions of duty holders. A group of new entrants to COMAH were identified as the ideal 'target' group, with two counterfactual groups chosen. Questionnaires were sent to 303 establishments, the response rate was 50%, with 66% for the target group. 43 interviews were also carried out. 90% of establishments had made some changes to their arrangements for major accident hazards as a result of COMAH. 55% commented that without COMAH these changes would not have happened, or would have taken much longer. Suggests that although writing a safety report helps to systematically identify where changes are needed and target changes it can conversely lead to delays in implementing changes to the way safety is managed. The financial impact of COMAH on industry has been significant, , and the judgement as to whether this represents value for money is finely balanced.

2004 - Energy Institute

The Energy Institute (formerly the Institute of Petroleum) had identified that the staffing assessment methodology (CRR 348/2001) developed by Entec for the Health and Safety Executive was a very valuable tool, but that some companies were not using it because they perceived it to be too difficult to learn and use. Also, the Institute had received feedback from its members saying that they did not feel the methodology was suitable for automated plant. Working closely with the Institute's human factors working party, Andy developed a 'User Guide' that explained the practical aspects of conducting an assessment using the methodology. As well as explanations about the underlying principles and terminology used, the guide provided practical advice and forms that could be used to collect information during assessment workshops. Also, it explained how companies should use the methodology in managing organisational change, including the assessment of risks associated with existing staffing arrangements and the impact of proposed changes. An extension to the methodology was developed to provide users with a method of assessing the impact to the operator of implementing technological change. The report and associated material is freely available from the Energy Institute's website.

2002

Health and Safety Executive Contract Research Report CRR 2002/432

Co-authors J Henderson, K Wright

Following the 1999 'competition of ideas' process, Human Reliability Associates (HRA) was commissioned by the Health and Safety Executive (HSE) to carry out a study of human factors aspects of remote operation in process plants. HRA developed a proposal that consisted of two phases of work. The first phase, described in this report, was a survey of current practices in industry. The second, which has not yet been commissioned, was to involve the application of the survey results to develop a tool to assist companies introducing remote operation and to audit existing operations.

Download from HSE

1996

PhD Thesis

Edinburgh University

Abstract

The desire for continuous improvement in safety performance has lead the process industry to a situation where the main contribution to accident causation is the actions of people rather than equipment failure. Models of human behaviour and accident causation, and risk assessment techniques aim to improve safety by reducing human error rates. These models require appropriate data and this thesis examines sources of information that could be used to provide accurate data for use in human factors studies.

Accident reporting systems are widely used by the process industry to record events resulting in loss. A survey of the systems used by companies has been carried out. This found that some of the information recorded in accident reports was relevant to human factors studies although it was generally limited to details of the behaviour of people “at the sharp end.” Little consideration had been given to the actions of people working away from the plant or of the factors that affect human performance.

Near miss reporting systems are now used by most companies in the process industry to increase the number of incidents from which they can learn about their safety performance. Most systems lack maturity and at present the provision of data for use in human factors studies is poor. This thesis describes studies carried out to determine the potential of near miss reporting systems to provide appropriate data. It was found that people find it difficult to determine what events and consequences might have happened because there is a lack of evidence. Simple risk assessment based on what people do, the hazards involved and overall unit objectives has been used to provide the required evidence. This has resulted in more effective human factors assessment. Near miss reporting has great potential to provide data for use in human factors studies but it should be considered as a living risk assessment exercise rather than an extension to accident reporting.

Investigation allows an in-depth analysis of incidents to be carried out. A review of the techniques developed to aid investigations has shown that most guide investigators to uncover and record root causes. A study of actual incident investigation reports has shown that human factors problems are considered in reasonable detail although formal techniques are rarely used. Only major accident inquiries, however, are able or willing to identify management and cultural failures so that changes can be made that will lead to wide-ranging improvement to overall safety performance.

Companies operating continuous process require people to work shifts. Log books and handover reports are used to pass on important information about past and future activities. A survey of log books and handover reports was carried out. The contents included; information about routine and non-routine tasks, descriptions of problems experienced, and records of human errors and unreported incidents. These could provide much data useful for use in human factors studies and may actually provide a mechanism for improved incident reporting.

Systems currently used in the process industry to report and record events have been examined. Although companies in the process industry rarely use these sources of information in assessing human factors these existing systems have all been shown to have the potential to provide the site specific data that is required but often missing in the assessment.