Behaviour-based safety (BBS) is the “application of science of behaviour change to real world problems”. BBS “focuses on what people do, analyzes why they do it, and then applies

HUMAN FACTOR ANALYSIS

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Safety, Health & Environment

Consulting, Training & Testing

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Bhopal Gas Tragedy

Flixborough Explosion

Sevaso Gas Release

Minamata Mercury Release

IPCL, Nagothane Explosion

Several others

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Out of the total 91 accidents (property loss/fatality/loss of 800MH/led to plant SD ), 66% were fire accidents

47% accidents happened during operational jobs

Causes of accidents:

71% human error

11% Failure of plant

18% Presence of ignition source

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HUMAN FACTOR

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5

Man Environment

Machine

TASK

ACCIDENT




An injury occurs only due to an accident

An accident occurs only as a result of unsafe action or an unsafe condition

Unsafe actions/conditions exists only because of fault of persons

Faults of persons are inherited or acquired through environment

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Anatomical or physiological characteristics

Improper psychological conditions

Lack of knowledge/skill

Improper physical or mechanical environment

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Behavior Model

Human Factors Model

Peterson Accident-Incident Causation Model

Epidemiological Model

Decision Model

Systems Model

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Safety performance of an employee is dependent on his level of motivation and his ability to perform

Ability is a function of selection and training Motivation depends on; Climate Style of organization Personality Peer group State of mind

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Human error is caused by; Overload: Mismatch of human capacity and the

load to which he is subjected

Incorrect response: By the person in a situation which is due to basic incompatibility

Improper activity: Performed because he did not

know or deliberately took a risk

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Goals and objectives of the human Long term goals

Short term goals

• Conflicting goals

• Contradictory and Different behavior

• Combination of goals and behavior is known as personality

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3 basic types of factors;

Genetic factor

Environmental or Learned Factors

Situational Factor

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Height

Built

Color

Body

Personality

Intelligence

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Extra uterine influence

Family and early upbringing

Education

Working environment and social group Culture

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Changing physical and social environment of individuals

Changing goals and objectives which an individual is seeking

New work method Change in allocation of job

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Saving time

Saving effort

Seeking comfort

Getting attention

Asserting independence

Acceptance of group ethos

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Attitude and Aptitude

Frustration and Conflict

Morale

Individual difference

Skill and Training

Motivation

Aspiration

Fatigue

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A kind of mental set up Change in attitude may radically change

opinions Knowledge of attitudes helps find the real

cause of an accident Attitudes are generally associated with likes

and dislikes Methods of evaluation are interviews,

surveys, suggestion schemes and safety committee

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Means inclination or fitness

Ability related to the capacity to develop proficiency on specific jobs

Aptitude tests during selection; Mental ability

Mechanical ability

Psychomotor ability

Visual skills

Specialized ability

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Caused due to; ◦ Defeat or disappointment towards success ◦ Interference with the achievement of goal

Characteristics; ◦ Aggression ◦ Regression ◦ Fixation

Response ◦ Adaptive ◦ Maladaptive

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Physical and Mental May arise due to; Attitude Jealousy Bad behavior Working conditions Environment

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Exploitative authoritative: Fear/Threat/Punishment/Occasional rewards. Information flows only downwards

Benevolent authoritative:Uses rewards and also some punishment. Information flows only downwards

Consultative: uses rewards, some punishment and some involvement in decision making. Information both up and down

Participative: uses entire group in setting goals. Information flows both up and down

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Operator input limitations

Operator decision limitations

Operator output limitations

Workplace environment limitations

Inadequate decision aids

No training needs analysis

Training needs oversights

Training needs not delivered

No refresher training

Incomplete refresher training

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No retraining linked to change

Inadequate competence assurance

Procedures fail to cover normal operations

Procedures fail to cover abnormal operations

Procedures fail to cover maintenance

Implementation of procedures difficult/impractical

Organisation of procedures difficult/impractical

Ill-defined channels of communication

Excessive levels of communication

Authoritarian culture

Limited manning

Inadequate change-over procedures

Inadequate mix of experience

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Ill-defined roles and responsibilities

Shift friction

Excessive hours (fatigue/stress)

Crew compatibility

Supervisory pressure

Peer pressure

No/poor safety leadership

Poor safety communications

Unresponsiveness to complaints

Blame culture

No safety audit procedures in place

Safety audit procedures poor

Safety audits not carried out

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Actions not carried out

No transfer of knowledge across departments Inconsistent monitoring of personnel

Poor feedback on performance

Limited accident investigation (fails to identify root causes)

Lessons from past accidents not learnt

No/poor awareness of hazards No update of risk assessment following change

Poor provision/use of PPE

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No Formal Training Program C

On-job Training Inadequate/Inappropriate B

Training course inadequate/Inappropriate A

Inadequate Competence assurance B

No competence assurance A

No Retraining linked to change C

Incomplete Refresher Training B

No Refresher Training A

Training Needs not Delivered C

Training Needs Oversight B

No Training Needs Analysis A

Poor Provision/consideration of Alarms B

Alarm Handling Problem A

Hazard Assessment not linked to design B

Inadequate Decision Information A

Workplace Environmental Limitations B

Inadequate Operator Information A 1.1 Man –Machine

Interface 1.2 Process/System Design

1.3 Alarms

2.1 Training Needs

Analysis

2.2 Refresher / Retraining

2.3 Competence Assurance

2.4 Training Needs

Analysis

1Design

Training/

Competence

HUMAN FACTOR ANALYSIS MODEL



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Poor Clarity in Transfer of Information B

Key Information retained by Senior Personnel A

Inadequate Change-over Information B

Incomplete Refresher Training A

Authoritarian/Submissive Culture C

Excessive Hierarchy B

Ill-defined Channels of Communication A

Procedures Not updated following changes C

Organization Difficult/Impractical B

Implementation Difficult/Impractical A

Insufficient Operator Procedure D

Falls to cover Aspects of Maintenance C

Falls to cover Aspects of Abnormal Operation B

Falls to cover Aspects of Normal Operation A

3.1 Comprehensiveness

3.2 Practicality

4.1 Interpersonal

4.2 Practicality

4.3 Information Availability

3Procedures

4.Communic

ation

Contd….




Blame Culture D

Unresponsive to Complaints C

Poor Safety Communication B

No/Poor Safety Leadership A

Peer Pressure eg Bonus D

Supervisor Pressure eg. Bonus C

Transient Pressure B

Endemic Pressure A

Training Needs Oversight B

No Training Needs Analysis A

Crew Compatibility C

Excessive Hours-Fatigue/Stress B

Shift Friction/Over Competitiveness A

Ill-defined roles/Responsibilities C

Inadequate Manning-mix-Experience B

Inadequate Manning A 5.1 Manning–Roles/

Responsibilities

5.2 Shift work/Roasters

5.3 Record Keeping

6.1 Performance Pressure

6.2 Safety Culture

5.Organization

6.Attitudes

Contd….




Implementation Impractical B

No Regular Practice/Drills A

Poor On-Site/Off-site Plans E

No/Inappropriate Training D

No off-site Liaison C

Inadequate Procedures B

Inadequate Control of Hazards A

No Assessment/ Analysis of Risk D

Poor provision or use of PPE, Safeguards

etc.

C

No update linked to change B

No/Poor Awareness of Hazards A

Lessons from past not learnt B

Fails to Identify Root Causes A

Fails to feedback Performance B

Inconsistent Monitoring of Personnel A

No Transfer of Knowledge C

Actions not carried out B

No/Sporadic Inspection A

Audit in Place – Not carried out C

Audit in Place – Poor B

No Audit in Place A 7.1 Audit

7.2 Inspection

7.3 Supervision

8.1 Accident Investigation

8.2 Hazard Awareness

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Monitoring

8 Risk

Assessment

9.1 Emergency Management

9.2 Fitness for Response

9 Emergency

Response

Contd….




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Plant upset conditions (caused by an electrical storm) were poorly handled, leading to 20 tonnes of hydrocarbon liquid being continuously pumped into a process vessel with a closed outlet. Once full, the liquid escaped through the pressure relief system to the flare line, which was not designed to cope with such quantities. As a result 20 tonnes of hydrocarbon was released and subsequently ignited leading to a major fire and a number of secondary fires.The investigation identified that the operators were not sufficiently aware of how the plant operated to be able to take control. Training had not addressed dealing with any similar scenarios. The poor information relating to plant conditions provided in the control room exaggerated the problem.




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1.1A DESIGN

Inadequate Operator Decision Information

Operators in the control room were unaware that valve B, which should have

allowed fluid from debutaniser into naphtha splitter, remained closed after the initial upset trip.

1.2A DESIGN

Inadequate decision information

The system was operating on a single control loop leaving the operator unaware that the outflow was not greater than the input from the deethanizer.

1.3A DESIGN

Alarm Handling Problems

During the incident, alarms were being presented to operators at the rate of one every two to three seconds




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1.3B DESIGN

Poor Provision/Consideration of Alarms

The high level alarm for the flare drum was activated. There is no evidence

that it was seen.A number of other critical alarms (not directly related to the

incident) also appear to have been missed among the many equal status alarms. Warnings of the developing problems were lost in the plethora of

instrument alarms triggered in the control room, many of which were

unnecessary and registering with increasing frequency, so operators were unable to appreciate what was actually happening.

2.2C TRAINING COMPETENCE

No retraining linked to change

A key feature of the pump-out modification was reliance on appropriate

operator manual action to deal with high drum liquid levels. However, in

practice, personnel did not have instructions or experience of reconfiguring the system




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3.1B PROCEDURES

Failure to cover aspects of abnormal operations

Or

TRAINING COMPETENCE

Inadequate Competence Assurance

The flare knock-out drum’s contents were increased still further by the operators next action which was to try to remove the flooding from the dry end of the interstage drum

by draining the liquid directly to the flare line by an impromptu modification which employed steam hoses.’

3.2C PROCEDURES

Procedure not updated following change

An earlier modification to the pump out system severely reduced its automatic liquid

handling capacity. It overflowed, causing liquid to enter an outlet designed for gas

only.It was possible to restore the original pump-out capability, by manually opening a

valve, but this procedure had fallen into disuse from lack of practice and written procedures.




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4.3B COMMUNICATION

Breakdown of Team Structure

Or

ORGANISATION

Ill-defined roles and responsibilities. Where more than one operator is working, an increased emphasis on communication is required to ensure that each is working

with the team. As people at senior level helped out, they took on operating roles

rather than taking an overview of the whole process.Some managers and

supervisors were involved in ‘hands-on’ operational matters instead of performing a strategic and diagnostic role.

8.1B RISK ASSESSMENT

Lessons from past not learnt

All the key elements of the incident, and the lessons drawn from it, have been seen

and publicized before, in major accidents around the world.




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8.2 B RISK ASSESSMENT

No Update Linked to Change

There was no recorded safety assessment concerning this

modification.

9.1D EMERGENCY RESPONSE

No or inappropriate training




Identify major hazard installations

Carry out hazard assessment

Report to authorities the result of hazard assessment

Set up emergency plans

Take measures to improve plant safety

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Component failure

Deviation from normal operating conditions

Human and organizational errors

Outside accidental interferences

Natural forces

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Major Accident means an occurrence including any type of emission, fire or explosion involving one or more hazardous chemicals and resulting from uncontrolled developments in the course of industrial activity or natural events likely to cause substantial loss of life and adverse effects on environment

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Legal Requirement : Rule 10, Schedule 8 of MSIHC rules

The occupier shall;

Prepare safety report and send 90 days before the activity starts

Carry out safety audit by independent expert Send copy of auditors report within 30 days of

the audit

Fresh audit every year and updation of report

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Safety report should contain; A) Description of installation and process B) Description of process C) Description of hazardous substances D) PHA E) Description of safety relevant units F) Hazard Assessment G) Organization H) Assessment of consequences I) Information on mitigation of major

accidents

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Major changes in plant/process

New information about hazardous processes

Improvements in safety engineering

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Check adherence to safety standard

Carry out specific inspection

Learn about the hazards

Siting of industries

Establish contingency plans

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1. Hazid : Types and quantities of hazardous material, location and storage, nature of hazard, What can go wrong ?

2. Risk : How often ? Probability of damage ? 3. Vulnerability : Extent of vulnerable zone, dispersion model, support systems Control can be reestablished Action during the May determine whether first few seconds/ minutes Damage/Injury avoided Accident can develop

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Legal requirement – Rule 13, Schedule 11 of MSIHC Rules

Preparation of plan by occupier Conduct mock drill every 6 months for; Familiarity Confidence Accuracy Availability Statutory requirement • Objectives To localize the emergency and eliminate it To minimize the effects of accidents on people and

property

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Name and address of person giving information Key persons with assigned responsibility and duties Outside organization assisting details Details of liaison Information on PHA Type of accident System elements/events that can lead to major accidents Hazards Safety relevant components • Site details Location of dangerous substances Emergency control centre Seat of key personnel Description of hazardous chemicals at site (MSDS) • Likely dangers to plants

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Likely dangers to plant Effect of ;

Stress and strain during normal operations Fire/explosion and secondary hazards

• Details of ; Alarm and hazard control plans Reliable measuring instruments Precautions in designing of foundations General engineering practice

• Details of communication facilities • Details of fire fighting • Details of first aid and hospital services

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Overall Co-ordinator Senior person To decide level of emergency Call key personnel Exercise direct operational control

• Action group leader/site incident controller Assess scale Initiate emergency procedure Direct rescue and fire fighting teams To search for casualties Evacuate Communicate with ECC

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Team A : Plant/ Dept. Head, Supervisor, Worker – To control emergency

Team B : Mechanical/Maintenance – To assist Team A Team C: Safety, Firefighting, Security Team D : Medical Team E : None of the above – Reserve team Administration Manager : Arrange for transportation Personnel Manager : Food, Head Count, Liaison with external

agencies Telephone Operator : Keep lines free Assembly points : Depends on size of factory and wind

direction ECC : Select so that no effect of emergency Eg. Security, Gate, Control

room Should be equipped with PPE, tel.nos. , details of emergency plans

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Legal requirements – Rule 14, Schedule 12 as per MSIHC rules

Mock drill once every year Formation; Central crisis group State crisis group District crisis group Local crisis group

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The off – site emergency plan should include; Types of accident Organization involved, including key personnel and liaison

arrangements between them Site information Technical information about substances Facilities and transport routes Contact for further advice e.g. meteorology, food, transport,

first aid, hospital Communication links Fire fighting equipment Emergency response procedures Public notification Evacuation arrangements Dealing with press Longer term “ Clean up “

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Local crisis group Prepare local emergency plan for industrial pocket Ensure dovetailing of local plan with district plan Train personnel in accident management Educate public Mock drill every 6 months at site and give report to District

crisis group

District crisis group Preparation of district off – site emergency plan Review on – site plans of all MAH units Continuously monitor every chemical accident Forward report of accidents to State crisis group Mock drill every year and report to SCG

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Chairperson Member Secretary

CCG Secretary MoEF

Jt. Sec MoEF

SCG Chief Secretary

Labour Secretary

DCG District Collector

Inspectorate of Factories

LCG Magistrate Inspectorate of factories




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Behaviour-based safety (BBS) is the “application of science of behaviour change to real world problems”. BBS “focuses on what people do, analyzes why they do it, and then applies

Health & Medicine

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training testing goals

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