Ron  Whalen  

It  would  be  reasonable  to  expect  that  as  the  world  becomes  increasingly  

technologically  sophisticated  the  risk  of  major  disasters  would  reduce…..  

 but  statistics  suggest  otherwise.    

Out  of  the  30  worst  industrial  accidents  to  occur  in  the  past  100  years    

(in  terms  of  number  of  people  killed  or  millions  of  dollars  of  damage),    

15  have  happened  in  the  last  20  years.  

Progression  of  technology  means  a  progression  of  machines  where  they  are    ! Smaller  ! Faster  ! More  accurate  Than  what  humans  can  be  

Enter  the  shi/  worker…..  

The  Shi/  Worker  

! Long  hours  with  a  partner,  that  you  don’t  choose  and  may  either  like  or  dislike  working  with,  yet  it  is  expected  that  you  work  well  together  as  a  team  and  ensure  a  safe  environment.    

The  Shi/  Worker  ! Control  Rooms  now  consist  of  people  with  different  religions,  accents,  cultures  and  habits  

! Different  work  experiences  and  qualifications,  often  poached  from  other  companies    

! Automation  risks  deskilling  Operators  

! Field  crews  trust  and  rely  on  Operators  to  have  arranged  a  safe  work  location  for  them.  

The  Shi/  Worker  ! Lots  of  distractions  these  days  in  rooms  

! Routinely  repetitive  and  boring  tasks  for  a  lot  of  the  time  but  expected  to  perform  magnificently  in  extraordinary  critical  incidents  –  and  be  able  to  tell  the  difference  between  the  two  

! Training  (getting  what  they  need)  

! Discipline  to  ALWAYS  follow  procedures  can  be  a  problem  

Situa7onal  Awareness  

! The  accuracy  of  a  person’s  current  knowledge  and  understanding  of  actual  conditions  compared  to  expected  conditions  at  a  given  time.    

Situa7onal  Awareness  

! What  are  the  things  that  can  affect  the  amount  of  situational  awareness  an  Operator  can  have?  

Expert  v  Novice  –  Prof  Wiggins    

Fa7gue  &  Rosters  –  Mark  Holmes  

Changing  need  of  Quals  

But  what  we  learn  is  being  outdated  

For  students  star7ng  a  4yr  technical  degree  

Half  of  what  they  learn  in  their  first  year  of  study  

Will  be  outdated  in  their  third  year  of  study  

Room  Design  –  Russell  Ockendon  

 Slide  18  

Summary  

Human  Performance  

We  learn  from  incidents  

Human  factors  

! study  of  all  aspects  of  the  way  humans  relate  to  the  world  around  them,    

! with  the  aim  of  improving  operational  performance,  safety,  or  adoption  through  improvement  in  the  experience  of  the  end  user.    

Some7mes  it  is  the  Human  

Cogni&on    

! What  are  you  thinking  about?    ! Working  memory  versus  Long  Term  Memory    

! Experts  versus  Novices    

Mental  Model  

! One’s  understanding  of  a  system,  how  it  operates,  its  characteristics,  performance  parameters,  couplings  within  itself  and  other  systems  and  how  one  interacts  with  it.    

Mental  Model  

! It  is  a  representation  of  the  surrounding  world,  the  relationships  between  its  various  parts  and  a  person's  intuitive  perception  about  his  or  her  own  acts  and  their  consequences.    

Mental  Model  

! Our  mental  models  help  to  shape  our  behaviour  and  define  our  approach  to  solving  problems  (a  personal  algorithm)  and  carrying  out  tasks,  especially  within  a  system.    

Mental  Model  

! Mental  models  are  like  opinions,  they  can  be  partially  or  completely  right  or  wrong,  complete  or  incomplete  and  most  often  are  unique  for  each  individual.    

Decision  Making  

! Information  overload    ! Experts  vs  Novices    ! Biases    

Informa7on  Overload  

Bias  

! Assumptions  –  A  condition  taken  for  granted  or  accepted  as  true  without  verification  of  the  facts.    

Bias  

! Habit  –  An  unconscious  pattern  of  behaviour  acquired  through  frequent  repetition.    

Bias  

! Confirmation  bias  –  The  reluctance  to  abandon  a  current  solution  

! To  change  one's  mind—in  light  of  conflicting  information  due  to  the  investment  of  time  and  effort  in  the  current  solution.    

! This  bias  orients  the  mind  to  “see”  evidence  that  supports  the  original  supposition  and  to  ignore  or  rationalize  away  conflicting  data.    

Bias  

! Similarity  bias  –  The  tendency  to  recall  solutions  from  situations  that  appear  similar  to  those  that  have  proved  useful  from  past  experience.    

Audio  visual  examples  

! New  York  Blackout  2003  

! Three  Mile  Island  1979  

! AF  447  2009  

! QF  32  2010  

Slow  things  down  ! All  human  performance  tools  deliberately  slow  things  down  to  ultimately  speed  things  up  by  avoiding  delays  that  accompany  events  triggered  by  active  errors.    

! When  used  conscientiously,  these  tools  give  the  individual  more  time  to  think  about  the  task  at  hand;  about  what  is  happening,  what  will  happen,  and  what  to  do  if  things  do  not  go  as  expected.    

! Have  a  conversation    

! Be  disciplined  and  follow  the  process  

Where  to  from  here…..?  ! Simulation  Training  ! Review  what  training  you  do  to  see  if  it  is  achieving  what  you  really  need  

! Look,  Listen  and  Talk  –  your  Operators  are  demonstrating  to  you  every  day  their  strengths  and  weaknesses  

! Maturity  and  attitude  to  report  near  misses  etc  for  future  improvement  and  training  

Classifica7on  of  errors  

! Human  Error  Classifications    ! Skill  Based    ! Rule  Based    ! Knowledge  Based    

! Often  we  will  operate  in  all  three  levels,  going  back  and  forth  in  a  single  event.    

Back  to  Six  Human  Considera7ons  

! Attention    ! Sensation    ! Perception    ! Cognition    ! Decision  making    ! Action    

Considera7ons  Broken  Down  

There's  a  need  for  accep7ng  responsibility  -­‐          for  a  person's  life  and  making  choices  that  are  not  just  ones  for  immediate  short-­‐term  comfort.    

You  need  to  make  an  investment,  and  the  investment  is  in  health  and  educa7on.    

Buzz  Aldrin