dr. linda bellamy, white queen safety strategies the netherlands

white queen

S a f e t y S t r a t e g i e s

3rd International Conference on Working on Safety

12-15th September, 2006

Development Of A Functional Model Of How Human Factors,

Safety Management Systems And Wider Organisational Issues

Fit Together

Dr. Linda Bellamy, White Queen Safety Strategies

The NetherlandsTim Geyer, ERM Risk

London, UKJohn Wilkinson, Health and Safety

ExecutiveBootle, UK

white queen


3rd International Conference on Working on Safety12-15th September, 2006

2

HFRCS

ORG

SMSProject overview

regulates and inspects the chemical industry

assesses safety reports

Safety Case

HSE recognises

Human Factors

Human factors

Safety Management

System

A Safety Management

System

are important in

Control

Risk Control

Organisationalfactors

provides guidance

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3

HFRCS

ORG

SMSBut how do they fit together for Major Accident Prevention (MAP)?

Organisation

Human Factors

Safety Managemen

t

System

Risk Control

UNDER CONTROL

LOSS OF CONTROL

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4

HFRCS

ORG

SMSConcept: Indicating the degree of hazard associated with a chemical

• National Fire Protection Agency’s hazard diamond

• Simple

• Informative

• Underlying taxonomy

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HFRCS

ORG

SMSMAP WARNING Triangle “Archetype”

• Same idea as Hazard Diamond but using Major Accident Prevention (MAP)

• All elements interface the same key risk control system elements

• Want model that makes more explicit hidden HF aspects in long standing inspection approaches

• ..together with organisation and SMS

HumanFactors

KeyRisk Control

System(MAP)

Organisation

Safety Management System (SMS)

The perspectiveThe perspective

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HFRCS

ORG

SMSMAP elements

• There could be many MAP elements to choose from and fit together (like Lego bricks)

• Need to make a collection of these potential MAP bricks

• And work out meaningful combinations

Risk perception

DesignLeadership

Measuring performance

Competence /expertiseHuman

Factors

Modifications

KeyRisk Control

System

Planning & implementing

SMS

Complexity

Organisation

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7

HFRCS

ORG

SMSLego Analogy

• Many bricks

• Limited meaningful combinations

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HFRCS

ORG

SMSMeaningful combo sub elements = Theme

Theme

Safety Management

System

Risk Control

OrganisationHuman Factors

Theme

Them

e

Theme

Safety Management

System

Risk Control

OrganisationHuman Factors

Theme

Them

e

What makes a vehicle

What makes (Loss of) Control (LOC themes)

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9

HFRCS

ORG

SMSSteps

• 1. Defined our “bricks”, a taxonomy of Major Accident Prevention (MAP) elements, from the literature, research etc.

• 2. Found meaningful combinations (themes) by seeing which ones (re-)occurred together in major accidents

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HFRCS

ORG

SMSTaxonomy

• Our taxonomy comprised 850 factors

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11

HFRCS

ORG

SMSe.g. Human Factors• Task demands (physical,

mental)

• Human capacities (physical, physiological, mental)

• Behavioural outcomes (symptoms of mismatch, speed, accuracy..)

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12

HFRCS

ORG

SMSAccidents analysedAccidents analysedAlloid Colloids (UK 1992)Alloid Colloids (UK 1992)

• Fire following misclassification of chemicalsFire following misclassification of chemicals

Associated Octel (UK 1992)Associated Octel (UK 1992)• Fire due to poor awareness of risks in complex poorly maintained plantFire due to poor awareness of risks in complex poorly maintained plant

Cindu (NL 1992)Cindu (NL 1992)• Explosion due to runaway reaction in a batch processing plant. Explosion due to runaway reaction in a batch processing plant.

Flixborough (UK 1974)Flixborough (UK 1974)• Explosion due to release from a temporary bypass assembly Explosion due to release from a temporary bypass assembly

Grangemouth (UK 1987)Grangemouth (UK 1987)• Fire due to passing valve (poor design) and inadequate isolation proceduresFire due to passing valve (poor design) and inadequate isolation procedures

Hickson & Welch (UK 1992)Hickson & Welch (UK 1992)• Jet fire following runaway reaction during non routine vessel cleaning Jet fire following runaway reaction during non routine vessel cleaning

Longford (AUS 1998)Longford (AUS 1998)• Explosion and fire due to incorrect valve operation.Explosion and fire due to incorrect valve operation.

Texaco (UK 1994)Texaco (UK 1994)• Explosion and fire due to failure to recover deviationsExplosion and fire due to failure to recover deviations

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13

HFRCS

ORG

SMSModel development – Accident contributors

• Half the taxonomy factors (around 400) occurred at least once across the 8 accidents

• A limited set appeared in all 8 accidents

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14

HFRCS

ORG

SMSRESULTS – Main Accident contributors (1)RESULTS – Main Accident contributors (1)

• Risk control failures in:…Risk control failures in:…• OperationsOperations

- ..Detection of departures from normal..Detection of departures from normal- ..Inspection, test and maintenance of plant, equipment, ..Inspection, test and maintenance of plant, equipment,

facilitiesfacilities

• DesignDesign- ..Safety and environmental implications are identified..Safety and environmental implications are identified- ..Necessary S & E control measures defined, documented, ..Necessary S & E control measures defined, documented,

implementedimplemented

• ModificationsModifications- As design (but less cases)As design (but less cases)

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HFRCS

ORG

SMSRESULTS – Main Accident contributorsRESULTS – Main Accident contributors(2)(2)

• Safety Management System failures in:Safety Management System failures in:

• ..Planning & Implementing: *Identifying ..Planning & Implementing: *Identifying hazards and assessing the riskshazards and assessing the risks

• ..Measuring: *Ongoing assessment of ..Measuring: *Ongoing assessment of compliancecompliance

• ..Organising: Providing competences ..Organising: Providing competences (specifically for MAP tasks) (specifically for MAP tasks)

• ..Organising: Communicating information ..Organising: Communicating information important to the controlimportant to the control of MA hazards

• ..Audit and review..Audit and review

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16

HFRCS

ORG

SMSRESULTS – Main Accident contributorsRESULTS – Main Accident contributors (3)(3)

• Organisation failuresOrganisation failures• Organisational learning, memory and knowledge Organisational learning, memory and knowledge

failures dominatefailures dominate

• Personnel in job positions with key authorities and Personnel in job positions with key authorities and roles in MAP - Job allocation /provision of training roles in MAP - Job allocation /provision of training failuresfailures

• Norms and pressures Norms and pressures

• Chemical/process complexityChemical/process complexity- Actions on a single substance (drying, cooling, Actions on a single substance (drying, cooling,

heating, distillation and separation)heating, distillation and separation)

• Control complexityControl complexity

• Control InteractionsControl Interactions

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17

HFRCS

ORG

SMSModel development – accident Model development – accident contributors (4)contributors (4)

• Human Factors failuresHuman Factors failures

• Demands :Demands :- Workload**Workload**- man-machine interfaceman-machine interface- detecting deviations and process disturbancesdetecting deviations and process disturbances- Identification and recognition (what am I dealing with here, Identification and recognition (what am I dealing with here,

what does this situation require from me)what does this situation require from me)

• Capacities :Capacities :- failures in understanding, interpretation & situational failures in understanding, interpretation & situational

awareness**awareness**- learning & knowledge failures**learning & knowledge failures**- incorrect decisions or choicesincorrect decisions or choices- selective attention, signal / pattern recognition failureselective attention, signal / pattern recognition failure- competence / expertise / skillscompetence / expertise / skills

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18

HFRCS

ORG

SMSSymptoms of demand-capacity mismatch

• Individual symptoms of strain

• Reduced situational awareness

• Self reported feelings of strain

• Conflicts between safety and business processes

• Unsafe group (collective) practices

• Human error: deviations and omissions in doing task

• * Mistakes [8 accidents]

• Action physically impossible

• Rule violations

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19

HFRCS

ORG

SMSThemes

• “Warning" triangle –warning themes concerning hazardous combinations of the main components found in accidents

• The warning triangle sits within a larger triangle (light blue) that shows the ‘theme’ under which the elements are linked

• The theme is the name chosen to best describe what fails

• The theme constrains the possible taxonomy elements that can appear in each of the parts of the warning triangle

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HFRCS

ORG

SMSUnderstanding Major Accident Prevention

Understanding of MAP

Hazard identification

& risk assessment

MAP measures

Selection & training, roles & responsibilities

Cognition & understanding

Understanding of M

AP

Und

erst

andi

ng o

f MA

P



& risk assessment

MAP measures



Understanding of M

AP

Und

erst

andi

ng o

f MA

P

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HFRCS

ORG

SMSCompetence for tasks

Competence for tasks

Competence delivery system

CompetenceSelection & training for competence

Tasks relating to MAP

measures

Com

petence for tasksC

ompe

tenc

e fo

r ta

sks





measures

Com

petence for tasksC

ompe

tenc

e fo

r ta

sks

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22

HFRCS

ORG

SMSPriorities, attention & conflict resolution

Priorities, attention & conflict resolution

Employee involvement &

communication

Job & equipment design for MAP

tasks

CommunicationDemand-

capacity match

Priorities, attention &

conflict resolutionP

rior

ities

, att

entio

n &

con

flict

res

olut

ion


Employee involvement &

communication


tasks


capacity match


conflict resolutionP

rior

ities

, att

entio

n &

con

flict

res

olut

ion

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23

HFRCS

ORG

SMSAssurance

Assurance

Compliance with objectives

Goals & procedures

for MAP

Organisational knowledge &

learning

Behaviouraloutcomes

Assurance

Ass

uran

ce

Assurance


Goals & procedures

for MAP


learning

Behaviouraloutcomes

Assurance

Ass

uran

ce

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HFRCS

ORG

SMSPyraMAPS

• The four primary chemical major accident prevention warning triangles can be joined to make a pyramid

• The pyramid of chemical Major Accident Prevention (the PyraMAP).

• The pyramid is a 3-D representation of the four main triangles identified and is a multidimensional archetype

• It also represents the fact that the 4 triangles are linked by issues which cut across the 4 areas

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25

HFRCS

ORG

SMSPyraMAPs





measures

Com

petence for tasks

Com

pete

nce

for

task

s

Assurance


Goals & procedures

for MAP


learning

Behaviouraloutcomes

Assurance

Ass

uran

ce



& risk assessment

MAP measures



Understanding of M

AP

Und

erst

andi

ng o

f MA

P


Employee involvement & communication


tasks


capacity match


conflict resolutionPri

oriti

es, a

tten

tion

& c

onfli

ct r

esol

utio

n




tasks


capacity match



oriti

es, a

tten

tion

& c

onfli

ct r

esol

utio

n





measures

Com

petence for tasks

Com

pete

nce

for

task

s

Assurance


Goals & procedures

for MAP


learning

Behaviouraloutcomes

Assurance

Ass

uran

ce



& risk assessment

MAP measures



Understanding of M

AP

Und

erst

andi

ng o

f MA

P




tasks


capacity match



oriti

es, a

tten

tion

& c

onfli

ct r

esol

utio

n




tasks


capacity match



oriti

es, a

tten

tion

& c

onfli

ct r

esol

utio

n





measures

Com

petence for tasks

Com

pete

nce

for

task

s

Assurance


Goals & procedures

for MAP


learning

Behaviouraloutcomes

Assurance

Ass

uran

ce



& risk assessment

MAP measures



Understanding of M

AP

Und

erst

andi

ng o

f MA

P




tasks


capacity match



oriti

es, a

tten

tion

& c

onfli

ct r

esol

utio

n




tasks


capacity match



oriti

es, a

tten

tion

& c

onfli

ct r

esol

utio

n





measures

Com

petence for tasks

Com

pete

nce

for

task

s

Assurance


Goals & procedures

for MAP


learning

Behaviouraloutcomes

Assurance

Ass

uran

ce



& risk assessment

MAP measures



Understanding of M

AP

Und

erst

andi

ng o

f MA

P




tasks


capacity match



oriti

es, a

tten

tion

& c

onfli

ct r

esol

utio

n




tasks


capacity match



oriti

es, a

tten

tion

& c

onfli

ct r

esol

utio

n

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HFRCS

ORG

SMSWORKING MODEL

• Run issue (s) through the PyraMAP

• A kind of HAZOP/scenario generator tool

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27

HFRCS

ORG

SMS

Example: non-routine maintenance for Triangle 1



& risk assessment

MAP measures



Understanding of M

AP

Und

erst

andi

ng o

f MA

PUnderstanding of MAP


& risk assessment

MAP measures



Understanding of M

AP

Und

erst

andi

ng o

f MA

P

2) Are there criteria & resources for including

[non-routine maintenance] and possible

consequences in a RA?

1) What risk control measures have been identified from the risk assessment to prevent a major accident resulting from [non-routine maintenance]?

4) Do people in jobs that could be related to MAP measures understand the risks of [non-routine maintenance] and the possible consequences?

3) Is selection and training used to deliver understanding of measures and effects of loss of control for MAP where [non-routine maintenance] could play a role?

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HFRCS

ORG

SMSThe working model applied generally

Warning Triangle archetype + a sector

specific taxonomy for defining constraints

3) Define constraints: limit the building components to be used in the archetype=themed combinations

1) Specify inputs: issues of interest or concern/theme

4) Outputs: Issues translated into model terms

2) Resources: users' knowledge (provides building components – can update & share)

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HFRCS

ORG

SMSThe working model

• Stakeholders have many professionals who are knowledgeable in specialist areas

• The archetypes provide a basis for bringing this knowledge together

• Flexible for the user

• Specialist teams can generate themed instances (like the ones here for MAP)

• Stakeholders can then transform issues into archetypes based on this expertise

• The warning triangle archetype ensures that Human Factors can be integrated into major hazard activities in a meaningful way

dr. linda bellamy, white queen safety strategies the netherlands

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