• Analysis of a process following a number of hazardous incidents

    2010 - Steel

    The client was experiencing a number of recurring hazardous incidents, and the high level team set up to investigate were struggling to determine the precise cause or come up with practical means of reducing the risk.  Working with a cross section of personnel from several departments involved in the activity including contractors, Andy facilitated a workshop where the whole process was mapped out.  This identified approximately 20 stages, 45 variables and a further 30 factors that may influence human behaviour and performance.  From this Andy was able to show that the problem was more complex than had been realised and that the solutions that had been tried to reduce the risk were unlikely to be effective or reliable.  As a result, the client fundamentally changed their view of the situations and their method of dealing with it.

  • COMAH risk assessment processes

    2006 - Steel manufacture

    The client had experienced an incident that should have been predicted and prevented as a result of risk assessment carried out for COMAH. Andy was asked to investigate how the risk assessment process had failed. From talking to key personnel and reviewing related documents, Andy was able to develop a root cause 'why tree.' From this he recognised that the incident had been predicted but the mindset of people at the site meant they focused on only part of the problem and hence did not develop a full solution. This was further affected because assessments had been carried out at a generic level, and specific areas with higher risks had not been identified . Also, changes had occurred in the way areas of the site were being used and because the management of change processes had not worked as intended, there had been no prompt to revisit the original risk assessments. Andy was able to make recommendations about how to improve the underlying processes and specific applications of risk assessment and management of change. The objective being to not just prevent the same incident occurring, but to have a wide ranging impact on how risks are managed.

  • Evaluation of site emergency response arrangements

    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.

  • Human factors introductory course

    2006 - Steel manufacture

    An employee of the client had attended a previous course. On this basis Andy was asked to deliver a similar course in house to bring the site up to speed with the requirements of human factors and how it applies to COMAH. Feedback from the course was very favourable and has resulted in further work.

  • Improving a large site's emergency plan

    2007 - Steel manufacture

    Following an incident at the client's site, Andy recommended that emergency plans and procedures needed to be simpler and easier to follow. He worked with site personnel to modify the current documents to cover foreseeable emergencies, including COMAH major incidents.  The updated system was based on the POPMAR principles. There was an agreed policy statement with an organisation and set of site and plant emergency plans for implementation.  Also, arrangements for performance measurement, audit and review were considered.

  • Task analysis of a maintenance task performed on a low pressure gas system where it is not practicable to prove isolation integrity

    2010 - Steel

    The plant studied in this project uses low pressure gas.  The high proportion of impurities in the gas meant that pipework required regular dismantling and cleaning.  However, because the gas was of such low pressure it was difficult to prove isolation and as a result the plant had experienced a number of gas releases and fires over the years.  Andy was asked to carry out a task and error analysis of the task in order to identify if there were any further actions that could be carried in preparing the plant for maintenance that would reduce the risk.  Working with the contractors who performed the task, along with the client's maintenance team Andy was able to identify three potential options that would reduce the risk of gas release.  All were considered practical and plans were immediately put in place to run trials of the new methods.  This was a particularly project because the client's technical experts had reviewed the situation a number of times in the past and had been unable to come up with any suggestions for improvement.