Process Isolations
This was on last year’s list, but it continues to be a hobby horse of mine.  During the year I have had the opportunity to review in-house isolation standards for two companies.  This work has further reinforced my view that there are many instances where following the guidance from HSE (HSG 253) is not achievable, and may sometimes increase risk when all factors are considered.  My paper is an attempt to illustrate the real-life issues that operators and technicians have to deal with.  Click here for the paper.

I am concerned that the use of interlocks is increasing dramatically with no real thought as to the benefit and potential risks.  The problem is that there is no clear guidance to say what functions should be interlocked or how many interlocks should be used.  And vendors are able and willing to sell ever more sophisticated and complicated interlocking solutions.

I believe that over use of interlocks encourages, or even forces, people to stop thinking about what they are doing, and they become focussed on identifying what they need to do to get the next key.  I believe at some point this risk must outweigh the benefits of having interlocks in the first place.
I have tried to encourage clients on a number of occasions to reduce the number of interlocks in their design, but with little (or no) success.  I think people feel that they cannot be criticised if they include the interlocks, and may be queried if they do not adopt the most ‘complete’ solution.  I have submitted a paper on this subject to the Hazards 27 Conference, which takes place in May 2017 titled “Interlocking isolation valves – less is more.”

Human Factors in Projects
Another repeat from last year.  Human Factors in Projects (often known as Human Factors Engineering – HFE) is starting to become normal, which is definitely positive.  I have helped two companies with generating in-house procedures for implementing HFE.  In both cases the aim was to make implementation as simple as possible, whilst ensuring suitable focus was given to the most important issues.

One of the key messages is that HFE should be on the agenda as soon as possible for any project.  I have had the opportunity to assist one client with two projects this year that were at a very early stage.  In both cases the consensus of all participants was very positive.

I have submitted a paper titled “Human Factors Engineering at the early phases of a project” to the Ergonomics and Human Factors 2017 conference, which take place in April. 

Also, you may find this presentation on HFE interesting.

Incident Investigations
I have taken part in two investigations this year.  Both highlighted human factors issues that I know crop up widely.

In one, scope creep on a maintenance task, combined with an over reliance on informal communications led to misunderstandings about plant status.  The operating team, who were considered to be very competent and able, made some assumptions based on past experience, which turned out to be incorrect.  The operating team were fully engaged in the investigation, and admitted that they were very disappointed with themselves for the errors they made, and wanted to understand why this had happened.

In the other, the plant was operating on the edge of its capability and multiple items of equipment were unavailable.  When a problem occurred the operators perceived that their options to respond were very limited, and they reacted in a way that they thought was correct, but in hindsight simply exacerbated the problem.  One thing that this investigation highlighted was how effective operators can be at ‘working around’ problems to keep the plant running.  The unfortunate outcome of this is that the problems no longer appear to be so significant and so do not get resolved.  However, as this incident demonstrated, this leaves the plant very vulnerable to events as there are not the safety margins available to cope.

I hope you find some of this interesting.  To finish, I would like to remind you about a free publication from the Loss Prevention Bulletin summarising major accidents that have had their anniversary this year.  It is available at