2011 - Gas

The client had experienced an incident. Although the consequences had been relatively minor it was recognised that a number of failures had occurred, including errors by the control room operator, that could indicate deep set human factors problems. Because of his knowledge of the site, Andy was asked to assist in the analysis of the incident. He was able to point towards systemic weaknesses that had contributed to the errors. Also, he was able to show that warning signs had been visible for some time prior to the incident, but people had not appreciated their significance. The client is using the findings from the incident, including Andy's report, to develop plans to improve the management of human factors across the business.