• 2006 - Steel manufacture

    The client had experienced an incident that caused significant plant upset and had the potential to be a COMAH (major hazard) accident. Andy was asked to investigate how the incident had been responded to by the plants affected and the wider site, and to evaluate whether the emergency management systems were adequate for the nature of hazards present.

    Talking to key people involved and reviewing logs from the incident, Andy developed a comprehensive timeline of the incident; and assessed the communications and decision making processes that had been employed. From this he identified a number of apparent shortcomings. He then compared the existing emergency management system and procedures with documented good practices from HSE and others and was able to identify the root causes of weaknesses in the system, particularly regarding command and control. He recommended that the existing system could be restructured and simplified, and that this would significantly improve the way it works in practice.

  • 2007 - Gas, offshore

    Following a major incident on an offshore platform the client identified a number of human errors that had occurred during evacuation, escape and rescue.

    Andy was asked to carry out a human factors analysis of the systems in place, taking into account the events that occurred during this incident. He visited the platform in order to observe arrangements and talk to key personnel. He then completed a task and error analysis. From this Andy made a number of recommendations for improving procedures, training and equipment arrangements.

  • 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.