• A gap analysis of the approach taken to addressing human factors in a COMAH report

    2011 - Gas (LPG)

    Due to the quantities of Liquefied Petroleum Gases (LPG) stored at the client's sites, and hence potential for major accidents, they were required by Control of Major Accident Hazard (COMAH) regulations to develop a safety report. Whilst they had carried out some human factors assessments the assessor from the Health and Safety Executive (HSE) was not satisfied that they had addressed all the relevant issues in sufficient detail. Andy was asked by the client to carry out a gap analysis of what had been done vs. latest standards and guidance. He found that they had made a very good initial attempt, and had been effective at identifying critical tasks and some of the errors that could occur. However, their decision to base their analyses on existing procedures meant that some of the realities of the job had been overlooked. Also, their approach to identifying potential human errors was not particularly systematic. The result of these weaknesses was that opportunities to improve human factors had been missed and so it was not possible for the client to demonstrate that they were managing the risks effectively. Andy advised where the client's methods and approached required improvement.

  • 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.

  • Control room task analysis

    2008 - Chemical manufacture

    The client's site was undergoing significant plant modifications. Additional equipment was being installed with its own control system. This was to be operated by the existing personnel. The requirement was that throughput would increase with the number of plant disturbances being decreased. Andy was asked to identify opportunities to reduce the current workload by improving the operator interface of the existing control system. He did this using task analysis, with a team of plant operators providing  job knowledge. The client was very impressed with how quickly Andy was able to understand plant operations and with how effective task analysis was at identify practical improvements.

  • Critical task analysis

    2011 - Power/gas

    The client had identified that they needed to improve their management of process safety risks. A key element of this was human factors, with Critical Task Analysis being a defined as a deliverable for all facilities. Andy was tasked with assisting eight sites around the UK with identifying critical operations and maintenance tasks, carrying out task and human error analyses; and recommending improvements to the way human factors risks were being managed.  All personnel involved were impressed with the practicality of the methods Andy used and Andy's ability to identify areas for improvement.

  • Critical task identification

    2008 - Gas Terminal

    During a previous piece of work Andy commented that the client lacked a robust system for procedures, training and competence. As a result he was invited to return to site to develop a detailed plan of how to proceed.

    Andy proposed that a full list of operational tasks ranked according to criticality would be the best way to start and proceeded to develop this with site personnel. Using a modest number of assessment criteria, Andy was able to create a spreadsheet that automated the criticality ranking and also suggested the optimum solution for managing risks through use of detailed procedures, job aids, on the job training, more formal method of training and competency assessment.

    As a result the client had a very good idea of exactly what they needed to do to develop an effective system, and was able to demonstrate an approach based on process risk and human factors principles.

  • Critical task identification and analysis

    2010 - Gas storage

    The client operated two similar facilities, although one was several decades old and the other brand new. Given the high hazard of the operation it had been recognised that a task and human error analysis needed to be carried.  A two stage approach was used. The first activity was to identify the task performed on each facility and to use a simple scoring system to assign criticality.  This showed that a similar number of tasks were performed on each, but a higher proportion were considered to be critical on the older facility because of the higher degree of manual operation involved.  The second stage involved carrying out a task and criticality analysis for the most critical tasks.  This showed that on the older facility risks were higher than they should be because items put in place to assist some manual monitoring and operation were not as reliable as they needed to be.  For the new facility the analysis showed that the design process had failed to address human factors and that were a number of features of the plant that did not achieve current good practice.  For both facilities it was found that there was no standard set for procedures and other written instructions.

  • Human factors for a control room at a new facility

    2007 - Liquefied natural gas (LNG)

    The client was building a new facility, which was to include a new control room. Andy was asked to comment on the engineering contractor's design. He identified a number of deficiencies and was able to advise on how current good practices could be incorporated. He was subsequently asked to provide more detailed advice on the operator interfaces in the control room.

    Andy conducted a task analysis workshop with the future operators of the plant. From this he was able to specify requirements for overview and detailed graphics; including task and scenario based displays where appropriate. As well as using the analyses carried out by Andy in the design of their user interfaces, the operators continued to carry out additional task analyses using the same method as they found it a very valuable exercise in reviewing the plant design and considering how they were to operate the plant in the future.

  • Human factors for a new facility

    2006 - Gas terminal

    Andy was seconded to the pre-operations team during the final design and construction phases of a new gas terminal. Andy's role was to facilitate task analysis and risk assessment, and to use the results to specify plant and interface design, procedural and competence requirements. This was a significant contribution to the preparation of the COMAH safety report and development of safe systems of work. Andy has provided ongoing support to the project, and this has demonstrated that human factors best practices can be incorporated into a project with minimal extra time and cost over 'traditional' approaches.

  • Improving operating procedures at an onshore gas terminal

    2009 - Gas terminal

    Andy was engaged by the client to provide a range of human factors support.  A significant part of this was the development of improved operating procedures.  This involved developing a comprehensive task list, ranked using a systematic method of assigning criticality.  Detailed procedures, developed using task analysis were produced for the 10% of tasks considered to be most critical.  The procedures were considered to be far superior to the previous procedures because they were shorter, clearer and more accurate.

  • Initiating a human factors program at COMAH site

    2008 - Waste incinerator

    The client had been asked by their inspector about their plans to address human factors within their COMAH report. Andy was asked to present two one day courses to staff from a number of sites as a general introduction. Also, he facilitated a number of workshops where critical tasks were subject to task analysis and human HAZOP. The result was some much improved procedures and a much better understanding of the human factors risks. The client adopted the techniques as a key part of developing procedures and managing change. They found that the training Andy had provided had quickly allowed them to address human factors with minimal support.

  • Operator training in start-up and shutdown of a new unit

    2004 - Chemical manufacture

    This project took place at an established manufacturing site that was adding an additional process unit to improve quantities of high value products being produced. A workshop was organised for operating staff to learn about the new unit. This included a day to learn start-up and shutdown procedures. Andy suggested that, rather than a class- room lecture, a more interactive approach was possible. Using a graphical task analysis technique (hierarchical task analysis), Andy facilitated the group in developing their own start-up and shutdown procedures. The participants found that, although they knew very little about how to operate the new unit they were able, using their operating experience, process descriptions and drawings, to work out how tasks would be performed. This meant they achieved a much higher level of understanding of the new plant and how it was to be operated.

  • Supporting the analysis of an incident that involved errors by a control room operator

    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.

  • 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.

  • Task analysis of well operations

    2010 - Gas storage

    As part of a critical task analysis exercise, two operations were subject to task and error analysis.  They were the replacement of Sub-Surface Safety Valves (SSSV) and changing a wing valve.  Both are quite different from the normal operating and maintenance tasks performed on process plants.  The analyses highlighted the importance of good planning, engaging competent contractors and ensuring appropriate procedures are in place.  Equally the analyses demonstrating that tasks that on the face of it are particularly hazardous can be performed in a safe and effective manner.