Human Factor in Offshore Safety

2ND INTERNATIONAL WORKSHOP ON HUMAN FACTORS IN OFFSHORE OPERATIONS

Demystifying Human FactorsPractical solutions to reduce incidents and improve safety, quality and reliability

APRIL 8-10, 2002

INTERCONTINENTAL HOTEL, HOUSTON, TEXAS USA

Edited By: Christy Franklyn Rodger D. Holdsworth James Reason Charles Smith John Wreathall

MMSMinerals Management Service

For additional copies of proceedings, contact:

RRS Engineering2525 South Shore Harbor, Suite # 206 League City, TX - USA 281.334.4220 (phone) 281.334.5809 (fax) http://www.rrseng.com

2nd International Workshop on Human Factors in Offshore Operations - Overview

TABLE OF CONTENTS

PAGE1.0 2.0 3.0 4.0 5.0 LIST OF ORGANIZING COMMITTEE................................................................................................3 LIST OF SPONSORS ...................................................................................................................4 EXECUTIVE SUMMARY ...............................................................................................................5 SCOPE ....................................................................................................................................6 WORKSHOP OVERVIEW ..............................................................................................................7 5.1 5.2 5.3 5.4 6.0 Supporting Remarks .................................................................................................8 Keynote Addresses...................................................................................................8 Theme Presentations................................................................................................8 Working Group Papers ...........................................................................................10

ACKNOWLEDGMENT .................................................................................................................12

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1.0

LIST OF ORGANIZING COMMITTEE

Mr. Rodger Holdsworth Professor James Reason Dr. John Wreathall Ms. Christy Franklyn Mr. Charles Smith Mr. Jeffrey Thomas Ms. Denise McCafferty Mr. Gerry Miller Mr. Frank Amato Mr. Richard Meyer Mr. Bob Gilbert Mr. Bob Miles Mr. Paul Mount Mr. Patrick OConnor Mr. Henry Romero Mr. Jim Spigener Ms. Amy White Dr. Thomas B. Malone Dr. Johan Hendrikse

RRS Engineering University of Manchester John Wreathall & Co. RRS Engineering

Workshop Coordinator Workshop Facilitator Workshop Facilitator Workshop Admin./Logistics

U.S. Minerals Management Services ExxonMobil American Bureau of Shipping G.E. Miller & Assoc. Paragon Engineering Shell Exploration & Production Co. University of Texas Health and Safety Executive (UK) California State Lands Commission BP America Inc., Upstream Technology Group Halliburton Behavioral Science Technology U.S. Minerals Management Services Carlow International Incorporated Paragon Engineering Services

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2.0

LIST OF SPONSORSABB Lummus Global Inc. American Bureau of Shipping ANP BP America Inc. California State Lands Commission ChevronTexaco ExxonMobil USA Go Gulf Magazine Health and Safety Executive (UK) Norwegian Petroleum Directorate (NPD) Offshore Technology Research Center (OTRC) Paragon Engineering Services Petrobras Risk, Reliability and Safety Engineering (RRS) Statoil University of Texas United States Department of Energy United States Coast Guard United States Minerals Management Service

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3.0

EXECUTIVE SUMMARY

Five years have passed since the 1996 International Workshop on Human Factors in Offshore Operations. Over this period, we learned that the level of knowledge of human factors has increased dramatically. We also made significant advances in applying human factors disciplines more effectively within an organization. In order to invest the necessary resources, technical specialists, engineers and corporate leaders need to be confident that the human factors tools they choose to implement will meet the desired goals. To this end, the 2002 International Workshop on Human Factors in Offshore Operations (HFW2002) brought together six key work groups to help those who wish to develop more effective human factors measures to reduce risk, improve safety and production performance. Each group was successful in developing a set of guidelines, tools and references that are invaluable to those active in the design of new facilities, maintaining the integrity of existing facilities, managing the workforce, conducting incident investigations, developing, implementing and controlling health, safety and environmental (HSE) management systems and managing behavioral processes. The applications and tools discussed by each working group during the course of the workshop documented practical approaches for applying human factors techniques in many areas. These reflect state-of-the-art practices within industry. The supportive remarks, keynote addresses and theme papers presented by government leaders, representatives from regulatory and certification agencies, and management of several international oil companies clearly demonstrated the importance of applying human factors. All six (6) working groups enjoyed a balanced number of representatives from industry, government and institutions who pro-actively discussed applications related to each topic of discussion. Exchange of information and points of discussion were based upon state of the art white papers written by working group leaders and co-chairs in attendance and submitted to each participant at the opening of the workshop. From the beginning of deliberations, each white paper was enhanced by the participants to capture the true essence of each topic and clearly established a roadmap for the practical application of human factors in the life cycle of an offshore facility. The purpose of HFW2002 was to provide practical applications and economical solutions to effectively establish and implement human factors as accepted practice vs. an add-on to existing practice. The workshop was successful in providing tools, references and guidelines to more effectively integrate human factors into six key areas targeted by the workshop to improve safety performance and reduce risk: Incident Investigation Design of New Systems Design of Existing Systems Operations / Work Force Management System Practices and Policies Behavior Processes

It is up to Industry to develop its own specification(s) of acceptable performance with input from peers,

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regulatory agencies, certification bodies, institutes and specialists to reduce risk and improve safety performance. This workshop brought together representatives of all of these organizations from different corners of the world to work together toward this common goal. The application of integrating human factors can be overwhelming without going through a long learning curve and being exposed to expensive time consuming lessons. With the aid of information developed by the HFW2002 Chairs, Co-Chairs and many participants, organizations have started to acquire the fundamental knowledge needed to integrate human factors in the lifecycle of offshore operations. What is now needed is for these organizations to start, or those that have already started, to continue, to apply the knowledge from the Workshop in their day-to-day design and operations. There is no single war to be won to improve human factors and safety; it is a never ending battle, seeking to continuously improve the safety performance. At the conclusion of the workshop one key point was clear: ignoring human factors will result in an increase not a decrease in incidents, lower safety performance and increased costs. Human factors are paramount to all aspects of offshore operations and essential in reducing human performancerelated risks.

4.0

SCOPE

The scope of HFW2002 included the following:

Establish awareness of what human factors is Identify existing tools for human factors that can be used or developed to prevent incidents Integrate principles for human factors into offshore design by assessing guidance and identifying gaps and barriers Define the status of the science and technology of human factors in the management of safety, behavior and environmental hazards for offshore operations and facilities Provide an international forum, attracting participants from all aspects of human factor disciplines (e.g. corporate leadership, offshore facilities designers, human factors, behavioral science and safety engineers, practitioners, certification body representatives and regulatory leaders) Produce a record describing the current practice, science and technology of human factors engineering & ergonomics, process safety and behavioral science and the opportunities and tools for using human factor disciplines in the management of safety, behavior and environmental hazards for offshore operations and facilitiesFurther promote the use of human factor disciplines to personnel and contractors responsible for managing, performing and verifying work activities in offshore facilities design, construction, operation, decommissioning, and maintenance

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5.0

WORKSHOP OVERVIEW

The format of HFW2002, like the 1996 Workshop, was a carefully balanced, two and a half (2-1/2) day workshop with presentations on the state of the art of human factors and interactive working group sessions. A total of three (3) Supporting Remark presentations, two (2) Keynote Address presentations and nine (9) Theme Paper presentations were delivered. The manuscripts of these presentations are included in this volume. With respect to the working group sessions, there were six groups established which covered the following areas related to human factors in offshore operations: 1. 2. 3. 4. 5. 6. Incident Investigation Working Group - Improving Incident Investigation through Inclusion of Human factors New Facilities Design Working Group - Effectively Including Human Factors in the Design of New Facilities Existing Facilities Design Working Group - Application of Human Factors in Reducing Human Error in Existing Offshore Facilities Work Force Working Group - Solving Human Factor Issues as Applied to the Work Force Management Systems Working Group - Effective Integration of Human Factors into HSE Management Systems Behavior Based Process Working Group - Effective Application of Behavioral Based Processes in Offshore Operations

Each working group started with the presentation of the groups white paper which identified the needs required to practically apply human factors related to each work group topic. Barriers to the progress of integrating human factors into operations as-well-as guidelines and references were also discussed. The position white papers were given to each participant prior to the working sessions. During the working group period, the participants were encouraged to visit more than one session to maximize their contributions to the practical application of different aspects of human factors. In addition, supporting papers were submitted to some working groups focusing on specific topics of concern. The atmosphere of the workshop was extremely positive and upbeat. All participants felt that the level of understanding of human factors technology has undergone significant progress since the 1996 workshop. Each participant received a clearer understanding of the tools available to formally integrate human factors throughout the lifecycle of an offshore facility. Participants also learned that more fundamental human factors programs are needed to resolve issues unique to offshore operations and to understand and control human factors related failures. It is up to industry to develop its own specification(s) of acceptable performance with input from peers, regulatory agencies, certification bodies, institutes and specialists to reduce risk and improve safety performance. This workshop brought together representatives of all of these organizations from different corners of the world to work together toward this common goal. The application of integrating human factors can be overwhelming without going through a long learning curve and being exposed to expensive time consuming lessons. With the aid of information developed by the workshop Chairs, Co-Chairs and many participants, organizations have started to acquire the fundamental knowledge needed to

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integrate human factors in the lifecycle of offshore operations. What is now needed is for these organizations to start, or those that have already started, to continue, to apply the knowledge from the Workshop in their day-to-day design and operations. There is no single war to be won to improve human factors and safety; it is a never ending battle, seeking to continuously improve the safety performance. At the conclusion of the workshop one key point was clear: ignoring human factors will result in an increase not a decrease in incidents, lower safety performance and increased costs. Human factors are paramount to all aspects of offshore operations and essential in reducing human performance-related risks. 5.1 Supporting Remarks

Supporting remarks were given by: Dr. Chris C. Oynes Regional Director, Gulf of Mexico Region, U. S. Minerals Management Service (MMS)

Mr. Ken Arnold Chief Operating Officer, Paragon Companies Mr. Tom Theriot 5.2 Keynote Addresses ExxonMobil Production Company, Manager, Safety, Health and Environment

The following keynote addresses were given: An overview of what was accomplished in the 1996 workshop and the status today Mr. Mahdi Hasan, Vice President, Shell Exploration and Production Integration of Human Factors into Classification / Certification Mr. James Card, Senior Vice President, American Bureau of Shipping 5.3 Theme Presentations

The following theme presentations were given: Overview of the P-36 Incident Mr. Carlos Tadeu Da Costa Frage, E&P Structural & Naval Technology Manager Petrobras Exploration & Production Mr. Jose Barusco Filho, E&P Structural & Naval Technology Manager Petrobras Exploration & Production Return on investment in Use of Human Factors in Offshore Systems Mr. Harrie J. T. Rensink, R.e., Eur Erg., Group Advisor Human Factors Engineering

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Shell International Health Services Analysis of Human Factors Related Accidents and Near Misses Prof. James Reason, University of Manchester An Integrated Approach to Behavioral Based Safety Mr. Jim Spigener, Vice President, BST New Method for Integrating Human Factors into the Design of Offshore Command and Control Systems Mr. Adam Balfour, Managing Director, Human Factor Solutions Capitalizing on Behavior Based Safety to Address Human Resource Development Needs Mr. Ron Newton, President, Peak Incorporated Incidents and Near Misses Rear Admiral John Lang, Chief Inspector of Marine Accidents, Marine Accident Investigation Branch U. K., Dept. for Transport, Local Government and the Regions Working Offshore: Its Effects and their Management Mr. Mark Shrimpton, Community Resource Services Limited, Socio-Economic Consultants Accident Investigation Trends A Safety Management Perspective Mr. Frank Pausina, Senior Accident Investigation Coordinator, MMS

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5.4

Working Group Papers

There were six working groups, topics, chairs and co-chairs are identified below: 1 Incident Investigation Working Group - Improving Incident Investigation through Inclusion of Human factors Group Leader Anita Rothblum U. S. Coast Guard, USA Co-Chairs: Captain David Wheal and Stuart Withington, UK Marine Accident Investigation Branch, USA William Boehm, Stolt-Nielsen Transportation Group, USA Marc Chaderjian, California State Lands Commission, USA Scott A. Shappell, FAA Civil Aeromedical Institute, USA Douglas A. Wiegmann, University of Illinois at Urbana-Champaign, USA

2

New Facilities Design Working Group - Effectively Including Human Factors in the Design of New Facilities Group Leader: Johan Hendrikse Paragon Engineering, USA Co-Chairs: Rick Meyer, Shell, USA Gerry Miller, G.E. Miller & Associates, USA Ben Poblete, Lloyds Register, USA Kevin McSweeney, American Bureau of Shipping, USA George Conner, ChevronTexaco, USA Paul Atkinson, ExxonMobil, USA Pat OConnor, BP America Inc., USA Hilde Heber, Norwegian Petroleum Directorate, Norway Eileen B. Hoff, Paragon Engineering, USA

3

Existing Facilities Design Working Group - Application of Human Factors in Reducing Human Error in Existing Offshore Facilities Group Leader: Jeffrey Thomas, ExxonMobil, USA Co-Chairs: Clifford C. Baker, American Bureau of Shipping, USA Thomas Malone, Carlow International Incorporated, USA John T. Malone, Carlow Associates, USA Ivan C.L. Rezende, Petrobras, Brazil Christina L. Hard, BP America Inc., USA Sally Carvana, BOMEL Limited, UK Mark Witten, ChevronTexaco, USA

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4

Work Force Working Group - Solving Human Factor Issues as Applied to the Work Force Group Leader: Bob Miles Health and Safety Executive, UK Co-Chairs: Dennis Atwood, ExxonMobil, USA Amy White, Minerals Management Service, USA

5

Management Systems Working Group - Effective Integration of Human Factors into HSE Management Systems Group Leader: Denise McCafferty American Bureau of Shipping, USA Co-Chairs: Rodger Holdsworth, RRS Engineering, USA Kevin P. McSweeney and Clifford C. Baker, American Bureau of Shipping, USA

6

Behavior Based Process Working Group - Effective Application of Behavioral Based Processes in Offshore Operations Group Leader: Jim Spigener Behavioral Science Technology, USA Frank Amato, Paragon Engineering Services, USA Co-Chairs: Gillis Gaupreaux, Shell, USA Brian N. Craig, PhD, CPE, Lamar University, USA

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6.0

ACKNOWLEDGMENT

The organizing committee would like to extend their most sincere gratitude to the Department of Interior - Minerals Management Service (MMS) and the American Bureau of Shipping for their contributions beyond sponsoring this event. The support of their staff and facilities was greatly appreciated. The major government, institutional and industrial sponsors are also acknowledged for contributions which made this event possible. The industrial participants with booth exhibitions are greatly appreciated for their effort in bringing their information to the workshop. During the Workshop, University of Texas and Texas A & M University graduate students were asked to assist in facilitating the work of each working group and four RRS Engineering staff, Ms. Christy Franklyn, Ms. Donna Hamilton, Ms. Jennifer Summers and Ms. Cathy Malek were asked to handle the logistics and administration of the workshop. Their efforts are gratefully acknowledged. Finally, the organizing Committee congratulates each of the participants for their active participation in the working group sessions with questions, comments, and suggestions. As to the request for holding the next Human Factors workshop within the next three years, it will be made known to the concerned parties.

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HFW2002 - Speakers

Page 1 of

Speaker Presentations

Rodger Holdsworth Director, Management Systems Risk, Reliability and Safety Engineering Dr. Chris Oynes Regional Director, Gulf of Mexico Region, U.S. Minerals Management Service Ken Arnold Chief Operating Officer Paragon Companies Tom Theriot ExxonMobil Production Company Manager, Safety, Health and Environment James Card Senior Vice President American Bureau of Shipping Carlos TadeuDa Costa Frage E&P Structural & Naval Technology South/Southeast Division, PETROBRAS Pedro Jose Barusco Filho E&P Structural & Naval Technology Manager, Exploration & Production, PETROBRAS Welcome/Introductions

Opening Remarks

Opening Remarks

Opening Remarks

"Integration of Human Factors into Classification/Certification" "Overview of the P-36 Incident" (PLEASE NOTE: FOR BEST VIEWING, "MAXIMIZE" THE MOVIE PLAYER ON YOUR COMPUTER SCREEN.) Faster Computers Please Use: Movie 640x480 - P36_movie.avi, 275 MB) Slower Computers Please Use: Movie 320x240 - P36_movie.avi, 105 MB)

file://D:\Miscellaneous\speakers.htm

5/22/2003

2002

International Workshop on Human Factors in Offshore Operations

Workshop Overview

hfw2002.com

SPONSORSABB Lummus Global American Bureau of Shipping (ABS) ANP BP America California State Lands Commission ChevronTexaco ExxonMobil Go Gulf Publishing Health & Safety Executive (HSE) Minerals Management Services (MMS) Norwegian Petroleum Directorate (NPD) Offshore Technology Research Center (OTRC) Paragon Engineering Services Petrobras Risk, Reliability and Safety Engineering Statoil US Coast Guard US Department of Energy (DOE) Page 1

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1996 Workshop Purposehfw2002.com

SPONSORSABB Lummus Global American Bureau of Shipping (ABS) ANP BP America California State Lands Commission ChevronTexaco ExxonMobil Go Gulf Publishing Health & Safety Executive (HSE) Minerals Management Services (MMS) Norwegian Petroleum Directorate (NPD) Offshore Technology Research Center (OTRC) Paragon Engineering Services Petrobras Risk, Reliability and Safety Engineering Statoil US Coast Guard US Department of Energy (DOE)

Define the status of human factors spanning the life cycle of an offshore facility including design, fabrication and installation, field operations, management systems, standards and regulation and science and application.

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What We Learnedhfw2002.com


The 1996 workshop brought together three human and organizational factor disciplines:

Engineering & ergonomics Process safety Behavioral science as applied to the life cycle of offshore operations

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What We Learned (Cont)

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To apply human and organizational factor disciplines within an organization, engineers and corporate leaders need a high level of confidence that the approach(es) they choose will meet the anticipated objectives

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What We Learned (Cont)hfw2002.com


Practical application of time-proven science and technology, as related to each human and organizational factor discipline, supported by industry and regulatory consensus is needed for industry to embrace human factors as accepted practice as opposed to an add-on to existing safety programs

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HFW2002 Workshop PurposeTo work together to demystify human factors by documenting practical solutions to reduce incidents and improve safety, quality and reliability in the lifecycle of offshore facilities


2002


Workshop Objectiveshfw2002.com


Establish human factors awareness Identify human factors tools that can be used or developed to prevent incidents Integrate human factors principles into offshore design by assessing available guidance and identifying gaps and barriers

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Workshop Objectives(Cont)hfw2002.com


Further promote the use of human and organizational factor disciplines to personnel and contractors responsible for managing, performing and verifying work activities in offshore facilities design, construction, operation, decommissioning, and maintenance

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Most Common Questions and AnswersWho is responsible for facilitating each work group?


Workgroup Chairs together with Co-Chairs and Scribes will facilitate the discussion on each working group paper topic.

2002


Most Common Questions and Answers (Cont)hfw2002.com


How can I provide input or contribute my knowledge and experience to the workgroup?

By submitting input and comments related to the working group paper at the workgroup session of choice or within 60 days following the workshop.

2002




Can I move from one workgroup to another workgroup?

Yes, participants can move from one workgroup to another. However, it is requested that the flow of the discussion not be disrupted. Submit comments and input related to previous discussion during reviews or during breaks.

2002




When can I expect to receive the workshop proceedings?

Within 120 days following the workshop.

2002


Questions?

hfw2002.com


2nd International Workshop on Human Factors in Offshore Operations

Opening Remarks

by

Chris C. Oynes Regional Director, Gulf of Mexico Region Minerals Management Service April 8, 2002

Industry Changes Since 1996

A lot has happened since the first workshop in 1996

We have continued moving into deeper and deeper waters in search of resources. The industry continues to develop new technology at a record pace. There has been a great number of mergers in industry, resulting in fewer, but much larger companies. Small, independent operators play a major role in the Gulf of Mexico, especially on the shelf. Opportune to meet and discuss Human Factors

Human Factors

Its not the panacea for todays problems. Taf Powell UK HSE

MMS Responsibilities Responsibilities

Administration of 91.76 billion acres on the OCS 9Over 7,500 leases 94,000 + production facilities OCS production 925% of U.S. natural gas 927% of U.S. crude oil Revenue collection for U.S. OCS 9Since 1953, almost $133 billion 9Nearly $10 billion in 2001

Many Agencies Involved U.S. Coast Guard Office of Pipeline Safety Air and water quality Oil-spill response, port regulation, vessel inspection Pipeline inspections, standards

Environmental Protection Agency National Marine Fisheries Service Fish and Wildlife Service Coastal programs Marine mammals/endangered species Marine mammals/endangered species

Department of Commerce

Safety & Environmental Protection Protection

Two Core Objectives Objectives

Safe Offshore Operations Promote incident free operations during exploration and development on Federal Offshore Lands. Offshore

Environmental Protection Ensure that all activities on Federal Offshore lands are conducted with appropriate environmental safeguards.

Varied Clientele

Program must be responsive to operators Some companies are small and operate single well caissons Others are large multinationals who deal with cutting edge technology

We require the same level of performance Program does recognize that small operator may not have the same support staff as a major player

The U.S. SystemProcess Rich

5-Year Program Outlines size, timing and location of potential sales

Individual Lease Salescompetitive bidding

Primary term for completing exploration Site specific environmental and safety requirements Financial terms (minimum bid, royalties, rentals)

Review of exploration and development plans Adaptations for deepwater activity

Regulatory Strategy Crossroads of developing new regulatory systems Focus on performance while maintaining prescriptive features

Consensus standards development Mutual benefits for government and industry

Industry collaboration Through OOC, IADC, API & ISO

Coordination and collaboration with other regulators around the world

Deepwater Operations Plan

DWOP requires 3 Parts conceptual, preliminary & final Early dialogue - focus on total system MMS approval prior to major financial commitment List alternative compliance and departures

Avoid unnecessary regulatory rewrites

Guiding Principles for Program

Operator responsibility Understanding human factors & mechanical systems interface Measure performance Make sure poor performance carries a price

Accident Investigation

An important responsibility - Industry & MMS Should be integral part of operators SEMP Both should review data & conduct investigations Determine root causes Identify trends Share information to prevent future incidents

Use information to revise requirements and direct research Share results through safety alerts and workshops Information exchange with international colleagues

Human Factors Roles In Accidents

Relationship between human factors and management system failures Negative human interaction with the system Need to find the deepest underlying cause of the accident

Management System Failures Failure may include the following: - failure to identify hazardous aspects of an operation - failure to provide guidelines for the safest way to accomplish a task - failure to effectively implement the corporate safety program Need to address these failure modes to prevent future accidents

Riser Package Accident

Control Panel

A Crane Accident

Crane Base

Annual Performance Reviews

Continuing dialogue - MMS & operators Safety - ensure corporate focus Regulatory practices - feedback for MMS Poor performance - identify/suggest remedies Correct problems before they become serious

In Conclusion

MMS continues to seek way to improve its regulatory program Human Factors aspects of safety management is an integral part of our program We want companies to keep HSE issues a top priority We all have much to gain in maintaining good safety and environmental performance

Is There Room for Human Factor Engineering In Design?

By Kenneth E. Arnold Paragon Engineering Companies April, 2002

What Does HFE Address? Trip, slips and falls Reduce Injuries Simplifying Maintenance and Operations Tasks Reduce Downtime Reduce Injuries Reduce Fatalities (Low to Medium Number/Occurrence) Reacting to Abnormal Situations Reduce Loss of Installation Reduce Injuries Reduce Fatalities (Medium to High Number/Occurrence)

Trips, Slips and Falls Easiest Place to Concentrate (New Design) Well Covered in Literature Standards - Ladders, handrails, stairways, walkways, etc. Implement by Training and Auditing Still Major Problem On Existing Facilities In GoM & North Sea

Simplifying Maintenance and Operations Tasks Medium difficulty to implement Access, Access, Access! Lifting, Lifting, Lifting! Task analysis with help from O&M Staff - Rethink design No longer a matter of simply applying standard. Have to think through and visualize the O&M process.

Reacting to Abnormal Situations The real prize! The most difficult to obtain! Major accidents are almost always caused by a series of escalating events. At any point human interaction can accelerate or decelerate the magnitude of consequences. How do we design so that the natural reaction is to take action which midigates the consequences?

Human Factors 80% of all accidents are caused by human error (Bob Bea) Amato corollary and 80% of these are caused by failure of management systems Arnold corollary yes, but 80% of all accidents are also caused by design which does not encourage the correct human response Examples Three Mile Island ($4B) Ocean Ranger (84 Fatalities) Piper Alpha (167 Fatalities)

Three Mile Island (1979) Popular conception - Operator training What happened Steam System Went Down PV Valve on Pressurizer tank opened As Pressure Decreased Control Room Light Went Out Indicating Signal to Open PV Valve No Longer Existed Pressure Relief Valve Stuck Open, Staff thought it had closed Pressure Decreased Further in Pressurizer Tank. Water Level Rose To keep from packing the pressurizer tank leading to an immediate overpressure. Operators dumped water. 110 alarm lights flashing Fixed on lowering water level in pressurizer tank

Three Mile Island (1979) - Continued Given low pressure in pressurizer tank but high level, multiple alarm sirens and no direct indication of leak, operators fixed on controlling level. Ignored other indicators of loss of water in cooling system: temperature rise in containment building, vibration of circulating pumps (cavitation) Design problems No water level indicator in reactor Temperature of PV drain limited by computer to 280F max output even though actually 600F No direct readout that PV was actually closed Too many alarms

Ocean Ranger (1982) Popular Conception - Operator Training What happened Storm wave breaks port light window shorting ballast control panel Sea valves started opening and closing randomly Shut-Off Power - Valves close Decided to turn on power to deballast to higher level Started settling by bow Screwed in brass by-pass rods to cause valves to close By-pass rods actually caused valves to fail open Could not launch survival craft in storm with list

Ocean Ranger (1982) - Continued Design problems Easy to short out panel in ballast control room No way to isolate panel and still activate pumps or check status Brass by-pass rods opened sea valves No way to launch survival craft with rig tilted down by the bow

Piper Alpha (1988) Popular Conception - Failure of Permit to Work System, Operator Training What happened Day crew isolated pump for maintenance Day crew removed PSV on condensate pump for annual safety check Did not properly install gasket, blind flange and bolts Night crew unaware and put pump in service

Design Problem Decoupled PSV from Pump It Protected Gas Heard Escaping In Compressor Room But Source Unknown

Why Did Paragon Form HFE Group Improve designs by better safety, operability and maintainability The client deserves the option. (Problem: Will he pay?) Implementation Upper Management Support Acquire/Develop Expertise Develop Specifications and Standards Develop Implementation Plan Train Engineers and Designers Convince Project Managers to Include HFE as Integral Part of Team Convince Clients of Value

Need for HFE Professionals Educational Background A thought process and not just common sense Compromises will be made

Paragon Success StoriesBritish Petroleum Mardi Gras Pipeline HFE has been integrated into project from inception Reduced time for redesign by implementing HFE standards and comments into initial design Improved safety for maintenance, materials handling and pigging operations by incorporating HFE principles As a result of this work we are providing HF training and support to project members of the other projects that form part of BP GoM Deepwater Development Program FPSO Project HFE involvement in evaluation and design of LQ save $5 -10 million by reducing square footage requirement

Paragon Success Stories (Continued)Shell Offshore Inc URSA Platform Implementation of redesigned control room has improved worker satisfaction Operability and maintainability of the control room equipment has been improved through well thought out design Environmental characteristics have been improved through application of proper lighting, noise and ventilation control As a result of this work we were also asked to conduct a HF review of Auger control room Survival Capsule Study Research showed that capsules could not accommodate the rated number of persons due to difference in physical size between the average offshore worker and population anthropometrics used in the design and rating of the capsules MMS has issued a safety alert as a result of this work A number of GoM operators have de-rated the capacity of some survival capsules at their facilities due to this research

Where Are We In Design SafetyUse HFE in Design and Operations Early 1990s DevelopSafety

PSM and Implement

Early 1970s Develop API 14 Series

We are today where we were with regard to Hazard Analysis in 1980s Common Sense We do it already Why do we need a separate hazard analysis? It is only good engineering practice

The truth is we needed the discipline of Hazards Analysis to force us to make sure we implement what we knew. The one way to make a step change in safety after implementing SEMP is through HFE. We need the discipline of HFE professionals and an implementation plan.

ExxonMobils Approach to Human Factors

Second International Workshop on Human Factors in Offshore OperationsApril 8-10, 2002 Tom Theriot, Manager Safety, Health & Environment ExxonMobil Production Company1

Presentation Outline

Definition Objectives of Human Factors Efforts Background - Why Human Factors? Human Factors Spectrum Corporate Human Factors Strategy Human Factors Focus Areas New Human Factors Technology2

Human Factors - Definition

Operating Environment and Culture

Facilities(Pumps, control systems, panels, valves, cranes, etc.)

Human Factors are:the integration and application of scientific knowledge about people facilities management systems to improve their interaction in the workplace.

Management Systems(Procedures, risk assessments, incident investigation, training, etc.)

People(Human characteristics and behavior)

3

Objectives of Human Factors Efforts Our goal is to reduce human errors, resulting in . . . safer operations (fewer incidents), fewer production upsets, higher efficiencies, and enhanced quality.

4

Incident Performance Improvement History

Incident Rate

Facilities

OIMS (SHE Management System)

Human FactorsTime5

Why Are We Working on HUMAN FACTORS?Other 16% Weather 9% Equipment 10% Design 10%Implemented Hardware Solutions Protective Systems Added Safety Factors Reduced Operator

Incident Causal FactorsPresumed Human Error 55%

These are the incidents addressed by human factorsBUT PEOPLE STILL MAKE ERRORS WE MUST ADDRESS

Pursued Traditional Approaches Training Motivation Campaigns Discipline for Violators

Implemented SHE Management Systems (OIMS) Management Leadership Risk Assessments Procedures Incident Investigations

"WHY?" 6

The Human Factors Spectrum

Workplace Design Equipment Design Work Environment Physical Activities Job Design Information Transfer Personal Factors7

ExxonMobils Human Factors Strategy

HF efforts are driven by specific needs/opportunities for improvement Improvements are sustained by building HF into existing Management Systems, Engineering Standards, and Operating Practices Effective HF resources and tools are provided to aid implementation Roles and responsibilities for HF are clearly defined; management leadership key Results are evaluated and shared to enhance benefits and effectiveness

8

Human Factors Focus Areas Design of New Facilities Risk Assessment Incident Investigation Training Drilling Application in Existing Operations9

The Cost of Using Human Factors in Design

Relative Costs

Time

Early Design

Plot Plans & GA Drawing

Construction

Commissioning

Normal Operations

10

New HF Technology Applications ExxonMobil research organizations identify new HF technology/tools through: leveraging off other industries (e.g., aviation, nuclear, aerospace) obtaining input from operating/project organizations

3D CAD Projects Incorporate HF considerations (access, spacing, valve location) into 3D CAD models Create guidance document for designers

Automated Control Systems Develop standards for control system interfaces (screen design, alarms, displays, etc.)

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2nd International Workshop on Human Factors in Offshore Operations.

Demystifying Human Factors - Practical Solutions to Reduce Incidents and Improve Safety, Quality, and Reliability

James Card

Senior Vice President, American Bureau of Shipping

Integration of Human Factors into Classification / Certification

1996 Conference Nearly six years since the first workshop in 1996 PTP was getting underway Four pillars of Maritime Safety:

Management Work Environment Behavior Technology Application

ABS, Classification Societies ABS founded in 1862 Mission has been to promoting the security of life, property, and the natural environment

Human Error and Accidents 80% of marine casualties and accidents (IMO, USCG) 90% of ship collisions (NTSB) 85% of ship accidents (Navy Safety Center) 66% of marine oil spills (UK) 62% of hazardous materials spills (OTA) 75% of merchant ship accidents (Republic of Germany)

Human Factors Issues in Classification / CertificationABS has organized its approach around into four human factors areas

People Ambient Environment

Installation Design & Layout

Management & Organizational Issues

ABS - Management and Organizational Issues Reviewing Accident and Near Miss Data Bases Develop a scheme for root cause analysis which includes human factors related causes

12%

0-4

4-8

8 - 12

12 - 16

16 - 20

Number of Claims

10% 8% 6% 4% 2%0%

00

03

06

09

12

15

18

21

ABS - Management and Organizational Issues Installation-to-Marine Vessels, Installation-toHelicopters, Installation-to-Beach and Internal Installation Communications Guide

ABS Installation Design and LayoutGuidance Notes on the Application of Ergonomics to Marine Systems

ABS Installation Design and LayoutABS Guide to Crew Habitability on Offshore Installations

ABS Installation Design and LayoutABS Guidance Notes for Human-Computer Interfaces

ABS Ambient EnvironmentABS Guide for Crew Habitability on Offshore Installations

ABS People Issues Development of Personnel Verification Tools Qualifications Personnel Selection Training Crew Endurance Risk Tolerance

ABS People Issues Workload and Situation Awareness Assessment

Different Models Same Message

Questions?

www.eagle.org + 1 (281) 877 -6000

HFW2002 - Theme Papers

Page 1 of

Theme Presentations

Harrie J.T. Rensink, R.e., Eur Eng. Group Advisor Human Factors Engineering Shell International Health Services The Netherlands, The Hague Dr. James Reason University of Manchester Manchester, UK Jim Spigener Vice President BST Ojai, CA Adam Balfour Managing Director Human Factor Solutions Norway Ron Newton President Flower Mound, TX Mark Shrimpton Community Resource Services Limited Socio-Economic Consultants St. John's Newfoundland, Canada David Dykes MMS Cyril Arney Consultant Houston, TX Return on Investment in Use of Human Factors in Offshore Systems

Analysis of Human Factors Related Accidents and Near Misses

An Integrated Approach to Behavioral Based Safety

Experience Using the Norwegian Petroleum Directorate's (NPDs) Method for Auditing Human Factors Aspects of Command and Control Centers

Capitalizing on Behavior Based Safety to Address Human Resource Development Needs

Working Offshore: Its Effects and Their Management

Accident Investigation Trends - A Safety Management Perspective

Summary of Working Group Activities

file://D:\Miscellaneous\themepresentations.htm

5/22/2003

Shell International Health Services Usability & Human Factors Engineering

Return on investment in use of human factors in offshore systems

Closing the gap between conceptual design and engineering, field construction activities and operations

Harrie J.T.Rensink, R.e., Eur.Erg.Shell International Health Services The Hague

0031- 70- 3771690 or [email protected]


Agenda SI HE Client portfolio Why Usability and HFE in projects? EMIS HFE quality system Examples of Smart design tools Added value & Critical Success Factors

Objectives To improve awareness for human centered design

integrated front end engineering activity first time right principle economical and non-economical benefits


Reduce total delivered costs Cost leadership Create value proposition Client intimacy Operational/HSE excellence Enhancing portfolio Licence to operate Engaging and developing people Enhance profitability

MHMS implementation

Human centred design Green-/ brown field Projects Operational excellence New Systems Technology IT usability engineering

Human Performance Improvement

Shell International Health Services Usability & Human Factors Engineering Client Portfolio & Projects SC, OP Gas and Power E&P Renewables


Business Objectives Eliminate intrinsic Human Machine Interface reliability-, efficiency, usability- and H & S risks Improve project profitability via: Front end engineering Use of first time right smart design tools Use of knowledge floor Structured buy in process of stakeholders



Physical Interface


Cognitive Interface


Business case

Why improving operations and maintenance tasks?

Conclusion pre start-up safety review Hycon (1988)

It has to be concluded that during engineering stage the opportunity could have been further exploited to optimise the design without increasing CAPEX in many cases. This refers particularly to the fields of operability, accessibility and maintainability.


Business case


Lessons learnt RAYONG refinery project (1996) Basic concept not an operationally friendly machine.


Business case


RAYONG project (1996) lessons learnt Instrumentations DCS graphics were designed by main contractor with minor input of Ops. at an early stage too much information on screens to go through 5 screens to get to an alarm far too complex which complicates start up alarms poorly specified risk of panel men loosing confidence in system!


Business case

Why improving operations and maintenance tasks? Project management issues

60 % of bottlenecks identified during Model review sessions are related to Operability and Maintainability

Re-vamp/- design effort first 2 years after start up often related to solve operational and maintenance misfits as a result of insufficient input during Conceptual design


World class Projects

Shell International Health Services Usability & Human Factors Engineering Literature Development HSE improvements in hardware designNo of accidents

Technical measures were dominant Process safety measures were dominant Human factors interface measures will become dominantPast Present Future

Shell International Health Services Usability & Human Factors Engineering Conclusion traditional design process No balanced input of process, safety, OPS. and Maintenance criteria during conceptual design Poor (too late) dilemma handling Limited input in conceptual design of future Ops./M. tasks Insufficient & ineffective input of work floor experience HMI specifications are no part of BOD/BDEP documents Lack of change mgt. approach in critical , i.e new designs Sub optimal design of operational/maintenance tasks Increase of project & life cycle costs

Shell International Health Services Usability & Human Factors Engineering Ergonomic Management & Information System (EMIS)

Policy & Organisation documentsProject Engineering Management tools & QACost/benefit model Procedures Auditing etc. FEEEM IVA Best practices Checklistsetc.

Training

Procurement Construction

Video/CD ROM Engineering workshopsetc.

Plant equipment, Skid Units Tools,etc.

Field run equipment Contractor workshops

International Standards

Shell International Health Services Usability & Human Factors Engineering The Design ProcessScouting phase

HFE Input analysisFEEEM design analysis; end-user driven specificationsBOD PEP PS PIP

Feasibility phase Conceptual design FEEEM input for 3D development Ergonomic controlsEvaluation of system efficiency after start up

Definition phase Basic engineering

Implementation phase DE, procurement, constructionPost Implementation Review


Examples Smart design tools1. Functional Control room building and DCS cockpit design (FEEEM analysis) Link analysis and Relation diagram 3 D CAD visualizations 2. Plant lay out and Valve operations (IVA ) 3. Graphical design lay out process (AH coding )

Upgrader Main Control room Centre and Workshop Building Athabasca Oil Sands Downstream Project Shell Canada, Calgary

Copyright Usability & Human Factors Engineering, Health Services, Shell International BV The Hague The Netherlands 00 31 70 3771690

& Co architectuur en visualisatieBeukelsweg 34a 3022 GJ Rotterdam

Link-analyses CCR / Engineering Functions frequency daily communicationExternal Technician OPS Area engineer External

Plantmanager

Secretary Scheduler Contractors Discipline engineer

Shift assistant

Paneloperator Technician maintenance Lead engineer

Maintenance planner


INTERFACE RELATIONSHIP MATRIX FOR CENTRAL CONTRS up er vi so ry C C o om m m p. . A ux ili S ar hi y ft S u pe rv is E o xt r . E nt ra nc e K itc to B he ld n g fo r O Li ps br ar y/ co pi e P r/f er ax m it C o nt ro lR oo m S to ra ge ( B o ttl E es xe ) rc is e S p a R ce a ck ro om O C (7 x) (s q. m .) * P la nn in g (2 x) U P S F un ct io n S m ok e A re a W a sh ro om s La bM H

(4 x) A M C

A re a

(5 x)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Control Room S Storage (Bottles) Exercise pace Rackroom ( OC (7x) ( AMC 4x) OE 5x) Planning (2x) UPS Supervisory Comp. Comm. Auxiliary Shift Supervisor Ext. Entrance to Bldg Kitchen for Ops Library/copier/fax Permit Smoke Area Washrooms Lab Training/Simulator Showers Maint. Craft Offices** First Aid Cloak Room/ERT Storage for Stationery Meeting Room (2x) Mech/HVAC Common Lunchroom Janitor Vending Machine Optimization

240 3 8 75 105 60 75 30 65 40 30 20 35 25 20 15 55 25 30 10 90 10 50 5 60 300 70 5 5 20

H H M L M L L

M

L

M

L

L

M

L

M

H

L

L

L

L H H H L H L M M L L H H M H H M H L H L H

H

L M M L L M M M M M

M L M H L L M L L

M

M

M

M

M

M

M M M M / H

M M H

H

H

* A reas listed above represent an estimate of the space required for each function. T hese areas were estimated prior to development of layout drawings, and do NOT represent a t ** Maintenance Craft Offices: ( 3x20) + (1x30) = 90

T ra

O E










Smart tool for Improving Plant & Equipment lay out

Identification of Valves analysis (IVA )An up front identification and categorization process of Valves according: - Category 1; Critical valves - Category 2; Operational valves - Category 3; Non operational

Aim : to delete misfits in Critical valve operations and to manage fit for purpose design for all valves operations

Shell International Health Services Usability & Human Factors Engineering Assurance Category 1 valves via color coding in 3 D CAD


Graphical display audit results (reference project) Insufficient discrimination of alpha numeric characters is applied, Irrelevant information to the operator is shown, Generally accepted norms of application of colours are violated, Inconsistencies in static information presentation is present, Display design has been made decorative at the expense of their being readable and interpretable.

ConclusionsGraphical Display designs did not improve e.g. retrieval times, misreadings and intuitive use of controls. The quality of the design of the Graphical Display leads to an unnecessary and unwanted higher risk for miss operations.

Shell International Health Services Usability & Human Factors Engineering0 . S ta r t

1 . L is t s ta tic a n d d y n a m ic d a ta

FLOW SCHEME FOR ERGONOMICS CODING OF PROCESS DATA FOR PICTORIALS

2 . E n u m e r a te d is p la y o p tio n s r e q u ir e d fo r th e s ta tic a n d d y n a m ic d a ta

Benefits

3 . D e te r m in e r e la tiv e a tte n tio n v a lu e s o f d a ta

4 . S ta r t w ith lo w e s t r e la tiv e a tte n tio n v a lu e p e r p ic to r ia l

5 . D e te r m in e th e c o d in g d a ta

6 . R e la t iv e a tte n tio n v la u e c o r r e c t?

No

7 . D e te r m in e a lte r n a tiv e c o d in g

8 . R e c o r d d e c o d in g

9 . C h e c k w h e th e r in te llig ib ility is s u ffic ie n t

No

Elimination of re-work. Reduction of errors in ops. Improved intelligibility of information Reduction of search times. Consistent reproduction of information. Standardization of pictorial layout. Reduction of mental effort. Intuitive and reliable operator control.

1 0 . S to pU U 1 6 4 4 .a f3

ATTENTION HIERARCHY (AH ) CODING SMART tool Information presentationL o w a tte n tio n le v e l

H ig h a tte n tio n le v e l

C O D IN G P O S S IB IL IT IE SL o c a tio nD e c e n tra l

ShapeT h in lin e

S IZ ES m a ll

B a c k g ro u n dN on

C o lo rG re y

D o m in a tio n in c re a s e

C o n tra s t in c re a s e

D o m in a tio n in c re a s e



C e n tra l

T h ic k lin e

S IZ E

B lin k in g

R e d b lin k in g

C o m b in a tio n o f lo c a tio n , s h a p e , s iz e , b a c k g ro u n d a n d c o lo rH ig h a tte n tio n le v e lT T 1 2 6 7 .p p t 2

Leadership and Commitment

EMIS

Policy an d S trategic Objectives Organ is ation , Respon sibilities Resou rces, Stan dards & D oc.

Hazard and Effects ManagementPlan ning & Procedures Corrective Action

Imp lementation

Monitoring

Au dit

Corrective Action & Imp rovement Corrective Action & Imp rovement

HFE (EMIS ) into Facility Lifecycle

IDENTIFY

ASSESS

Managemen t R eview

HEMP HEMPCONTROL RECOVER

HSE Management System

Hazard and Effects Management Process

= least cost effective

Concept Design

Detailed Design

Procurement Construction

Operation

Abandon

Shell International Health Services Usability & Human Factors Engineering Benefit areas Usability & HF Engineering

(reference EMIS.PMQ.07) Relation to stakeholders Operability share holders & clients Safety personnel society government

Health Maintenance Environment Legislation Reliability Labour turnover Quantify and/or rank

Shell International Health Services Usability & Human Factors Engineering Economical benefits User Centered DesignBased on historical data so far

Reduction CAPEX Reduction engineering hrs. Reduction re work: less rework, less late changes Reduction project duration time reduced approval cycles Reduction Ops./Maintenance TCoO

0.25% - 5% 1% - 10 % 1 % - 5% up to 40 %

3 - 6 % per year

Shell International Health Services Usability & Human Factors Engineering Non-economical benefitsBased on historical data so far

Improvement HSE/working conditions Improvement commitment end users Improvement of client buy in Improvement functional design; versus gold plated design Improvement competence of project team Competence improvement project team re. Ops./maintenance requirements Improvement communication Owner / Project team & EPC contractor* impact ranking on issue: Low, Medium, High, Very High as per client feedback

H* H H H VH VH H


Typical costs Usability and HF Engineering

Based on historical data so far

Depending on complexity of project scope 0.004 - 0.9 % of Engineering costs (= 15 % CAPEX)


Critical Success Factors Awareness of cost/benefits CAPEX reduction potential & TCoO commitment

Management commitment front end loading early availability of operational philosophy, staff Competence project participants Integration in Project QA system (Owner & EC!) Front end user participation capture work floor knowledge via FEEEM analysis process

Multi-disciplinary dilemma handling Fit for purpose tools and procedures


When astronaut John Glen was asked what he was thinking about just before lift off from Cape Canaveral, he replied: Here I am sitting on top of thousands of critical components and all of them made by the lowest bidder !

2cnd International Workshop on Human Factors In Offshore Operations. April 8-10, Houston.

Analysis of Human Factors Factors Related Accidents and Near Near Misses Misses

James Reason Reason Emeritus Professor Professor University of Manchester, UK UK

Two kinds of bad event event

Individual accidents: high frequency/low severity eventsslips, trips, falls, bangs and knocks usually resulting in a few days absence from work (lost time injuries).

Organizational accidents: low frequency/high severity eventsexplosions, collisions, collapses, releases of toxic substances, etc. Is system vulnerability adequately assessed by LTIs? NO!

Two ways of looking at human human factors problems The PERSON approach approach The SYSTEM approach approach

Individual & organizational ax ax have different causal sets sets

Individual accidents OrgAx Arise from linked failures of multiple system defences (System model)

Failure of limited personal protection against injury (Person model)

Common ground: Inadequate resources Poor safety culture Commercial pressures

The Swiss cheese model model of accident causation causation

Some holes due to active failures Hazards

Losses

Other holes due to latent conditions (resident pathogens)

Successive layers of defences, barriers, & safeguards

How and why defenses failDefenses

HOW?Hazards Latent condition pathways

Losses

CausesUnsafe acts

Investigation

WHY?

Local workplace factors Organizational factors

Matrix for defensive failures failures

MODE FUNCTIONAwareness Detection Warning Protection Recovery Containment Escape Engineered Standards Procedures Training Personal safety policies Instruction briefings protective features equipment controls Supervision drills

Piper Alpha: Defensive failures failures

MODE FUNCTIONAwareness Detection Warning Protection Recovery Containment Escape Engineered Standards Procedures Training Personal safety policies Instruction briefings protective features equipment controls Supervision drills

Unsafe acts acts

Slips, lapses, trips and fumbles fumbles Rule-based mistakes Knowledge-based mistakes Violations Routine Optimising Situational

Rule-related behaviours Correct compliance Mistaken compliance (mispliance) Malicious compliance (malpliance) Mistaken circumvention (misvention) ) Successful violation Mistaken improvisation Correct improvisation

Workplace factors factors

Error factors Change of routine Poor interface Ambiguity Educational mismatch Negative transfer Poor S:N ratio Inadequate tools Etc.

Violation factors Violations condoned Equipment problems Time pressure Unworkable procedures Supervisory example Easier way of working Poor tasking Etc.

Organizational factors factors

Training Tools & equipment Materials Design Communication Procedures Pressures Maintenance Planning Managing operations Managing safety Managing change Budgeting Inspecting, etc.

Accident investigation steps What defenses failed (mode/function)? How did each defense fail? Were there contributing unsafe acts? Workplace factors for each unsafe act? act? Organizational factors (latent conditions) contributing to defensive failures and workplace factors?

(Single or multiple events) events)

Organizational factors Failed defenses Workplace factors

System contributions contributions

Latent condition profile

Aims of HF event analysis analysis

Identify recurrent error traps Identify how and why defenses fail fail Identify upstream pathogens Rectify systemic weaknesses

TAKE HOME MESSAGE: YOU CANT CHANGE THE HUMAN CONDITION, BUT YOU CAN CHANGE WORKING CONDITIONS.

Behavior-Based Safety Presentation Human Factors Conference Houston, TX April 8th - 11th 2002

Behavioral Science Technology, Inc. All Rights Reserved

CS0002 - 1

3 Types of At risk Enabled = within persons control conditions and systems support support Difficult = can be done but takes extra effort Non-enabled = not within persons control


CS0002 - 2

Behavi alSci or ence Technol ogy,I nc.The behavi or based per or ance i pr f m m ovem entengi ne

Producti oduction on Pr quali i ty qualty Err ror Er or reducti eduction on rBehavi or Behavi -based or based Per orm ance Perf m ance for I pr Im provem ent m ovem ent

Custom er Custom er servi vice ser ce

Spil l l Spil preventi evention on pr

Safety ety Saf

1SBBS (0106) L1

1999 BST, Inc. All rights reserved May not be reproduced without written permission. Behavioral Science Technology, Inc. All Rights Reserved

3

CS0002 - 3

Pr m ar Concepts i y Concepts Pr cess notPr am ProcessnotProgr o ogram Adapt on vs adopti Adaptati Ad ap tation vs adoption on Empl Em oyee I Em p loyee Invol nvolvem ent vem ent D on am e em pl D ontbl e em ployees tblam oyees Pa lel w i qualty Par l s th Paralelsw ith quali al ity D evel i ernalr D evelop inter op nt nalresour for esources f ces or i pl entati im plem entation m em on O bj tive: Conti bj ve: O b jecti ContinuousIm provem ent ec nuous I pr m ovem ent M gm t& w or orce m ustunder M gm t& w orkf ce m ustunderstand and kfor stand and buy-n buy-i in


CS0002 - 4

Barriers To Continuous Safety Improvement

Hazard recognition and response Business systems Rewards/recognition Facility and equipment Disagreement on safe practices Personal factors Culture Personal choice


CS0002 - 5

Saf y ety Tr ni ai ng

Polci i es Polci

Sl ogans ogans

Rep r m and s i

Few er Acci nts de ?Cont ests & Aw ard s ds

Regul i at ons

Saf y et M eeti ng

C om m i tees t ees Co & Councis l uncis

CS0002 - 6


Saf ety Acti ti vi es

Few er er At- sk Behavi s Ri ors

Few erAcci dents dents


CS0002 - 7

Fatalti i es Lost Ti e Acci m dents M edi calTr eatm ent Fi st Ai r ds N earM i sses

N onenabl ed Enabl ed D i f cul fi t

At- sk Ri Behavi s or

Enabl ed D i f cul f i t

N onenabl ed


CS0002 - 8

Behavi or or

An An O bser vabl e Act Act


CS0002 - 9

ABC Anal s ysi s

Ant ecedents Antecedent

Anythi w hi pr ng ch ecedes and sets the stage stage f orBehavi or or

Beh or avi Behavi or

An obser vabl act e act

C onseq uenc es onseq uence

Anythi w hi di ectl f l s f om the Behavi ng ch r y olow r or or


CS0002 - 10

U nder standi System I l ng nf uences uences

ABC Anal s ysi s

Ant ecedents Antecedents

G oggl don i es tf t t G oggl ar i poorcondi on es e n ti on

Behavi or or

W or kerf l to w eargoggl w hen gr ndi ais es i ng ng

C onseq uenc es onseq uence

Com f t or

BetterVi on si

Exposur to I ury e nj yCS0002 - 11


Consequences Consequences

Saf Behavi e or or

?Antecedents Antecedents

.

At- i behavi r sk or

Consequences


CS0002 - 12

The CBI Tools List of behaviors that have caused accidents Extracted from accident data Extracted from accident data Steering committee adds others based on their knowledge of based on their knowledge of workplace behavior


CS0002 - 13

Part One CBI Data Sheet

Cr ti i calel ents em ents No names no discipline No names // no discipline Behaviors grouped into categories Behaviors grouped into categories Selected variables used for sorting Selected variables used for sorting data data Comment section Comment section


CS0002 - 14

Part Two CBI Definitions Definitions Establishes in observable terms a consistent measurement of workplace behavior Ensures consistency between Ensures consistency between observers and observations observations Definitions are not a rewrite of rules Definitions are not a rewrite of rules and regulations


CS0002 - 15

4. Li ofFi e: 1 ne r I t per s toni ft d I the person posii ng sel o avoi s he son posii ng sel o avoi toni ft d geti cont ed,sprayed,over ng gettng contact ti acted,spr ayed,overexposed, exposed, stuck orhi tby som et ng i tl s go, ng fi et str orhi ruck tby som ethi i tl s go, hi fi et gi w ay,r eases orfals? ves eases orf l l gi w ay,rel ves el als? ForExam pl e ForExam pl e1.I per s son avoi ng st di andi under ng suspended l oad? 2.I per s son st andi outofpat of ng h fyi debrs? l ng i 3.W hen br eaki fange does t per ng l he son br eak nut f t s ar hestaw ay fr ? ist 4.Does per son avoi l d ooki i o pi ng nt pe bei r ng odded out ?

Example Definition 4. Li ofFi e: 1 ne r


CS0002 - 16

O bser s ver

TO START: Tr n a Cor G r up ai e o up ofHoury W or or l kf ce G O AL: 100% of Sie t Popul i Tr ned aton ai ned

Typi calFr equency ofO bser vati on on

TO START: 2 perw eek PerO bser er se ver D U RATI N : 5 30 M i es O nutes


CS0002 - 17

Anal yze D ata /Sel ectFocus /D evel Acti Pl op on an


CS0002 - 18

As Saf Behavi ncr e orI eases, Recor dabl Rates D ecr e ease

Recor dabl Rate e Per centSaf e

25

96 95 94

e dabl Rate Recor

15

93 92

10

91 90

5 89 0 88

Period 1

Period 2

Period 3

Period 4

Period 5 5


CS0002 - 19

e cent Saf Per

20

Hand Pr otecti on on I eased f om 80% Saf to 98% Safe ncr r e e

100

95

Percent Saf e

90

Acti Pl on anni ng85 80

Feedback

75

70

Period 1

Period 2

Period 3

Period 4

Period 5


CS0002 - 20

I ndustr alHygi i ene Behavi s ors I eases i Per ncr n centSaf overTi e e m

100

95

90

Per cent Saf e

85

Probl Sol ng obl vi Pr em Sol ng em vi80

Feedback Feedback75 70

0

Period 1

Period 2Hearng Pr ecton i ot i

Period 3Eye/Face Pr ecton ot i

Period 4Hand Pr ecton ot i

Period 5


CS0002 - 21

Lum berM il l l

H i Per gh centSaf Scor ar Associ e es e ated w i th th Low Recor dabl Rates e Rates

12. 00 11. 89 10. 00

9. 40

Recor e dable Rate Recordabl Rate

8. 00

6. 00 3. 95 4. 00

2. 00

0. 00 91% to 92% 93% to 94% 95% to 96%

Per centSaf e


CS0002 - 22

Sustainability of Implementations Implementations

100% 88 % 92 % 73 % 80 % 69 % 98 % 79 % 93 % 100% 99 % 98 % 98 % 100%

Years Years Years Years Years Years Years Years Years Years Years Years Years Year

13

12

11

10

9

8

7

6

5

4

3

2

1

This

Percentage Still Using Their Processes Processes


CS0002 - 23

BAPP Technology Process Flow Chart Chart

DATA MANAGEMENT

PROBLEM SOLVING JOB DATA COLLECTION/ FEEDBACK

MANAGEMENT SPONSOR

STEERING COMMITTEE


CS0002 - 24

MMI-2

Revised method for reviewing Human Factors in the design of CCR`SAdam Balfour Human Factors Solutions - Norway

Human Factors Solutions 2002

MMI-2

Human Factors Solutions - NorwayIdeaABB NPD Safetec

ConceptSuper Eva Kristin

DetailedGrane Balder West Future II

OperationJotun A

ModificationEldfisk Petrojarl MMI-2

V&VKristin Kvitebjrn Oseberg C


MMI-2

ABBREVIATIONSMMI-1A method for reviewing Human Factors in Control Centre Design, NPD June 2000.

MMI-2Revision of A method for reviewing Human Factors in Control Centre Design , NPD October 2002


MMI-2

HFW 2002 GOALS

MMI-2 - October 2002 Share experience - MMI -1 Gain YOUR experience - reviewing HF in CCR design


MMI-2

AGENDAMMI-1 Background Goals Preliminary results MMI-2 Goals Project plan Preliminary requirements Preliminary Concepts ISSUES1. 2. 3.


MMI-2

MMI-1


MMI-2

BACKGROUND MMI -1 - NPD - AUDITS Too many alarms New functions in CCR Increased complexity and demand on staff New technology challenges established safety philosophy Reduced manning in CCR Remote control - onshore

Illustration: Courtesy of Maritime Hydraulics, Norway


MMI-2

Consoles

Space for paper, pens Location - contrast Large fixed keyboards Not adjustable


MMI-2

Alarm systems No philosophy Alarm list Too many Inconsistent No priority No grouping Incomprehensible


MMI-2

Navigation

Inconsistent Difficult - hierarchical Remember screen nr. Limited search functions


MMI-2

Colour /graphics


MMI-2

CCR Layout


MMI-2

GOALS MMI-1Goals : Provide NPD & industry with common basis for: - safe working practices in CCR - acceptable total workload in CCR - reduction - human error - structured HF methods - evaluation of solutions vs regulations Systematic CCR audit tool (design - mod -incidents) Authority- revision, incidents Industry - management, planing, development revision, updates, modification Based on: ISO 11064 structure and requirements

Product: Users & Use:


MMI-2

MMI 1 = ISO 11064 +Step 0: HF Programme ManagementSet performance parameters

Phase A

Step 1: Clarify Goals and Requirements Step 2: Analyse Functions

Introduction Information sourcesPhase B

New designs: all functions analysed

Modifications/upgrades: changes in function analysed, collect data on existing functions/constraints

Step 3: Function Allocation Step 4: Analyse Tasks Step 5: Analyse Job and Work Organisation Step 6: V & V Phase B

Review guidancePhase C

Step 7: Design Conceptual FrameworkDoes the design meet requirements?

Step 8: Approve no Conceptual Designyes

no

Audit questions 167 pages in English

Step 9: Detailed Design and BuildControl suite layout Control room layout Workstation layout Displays and control design Environment Operational and management requirements Procedures Training

Phase D

Does the design meet requirements?

Step 10: V & V of Detailed Designyes

no

Compare with performance parameters. Does the control room work as intended ?

Step 11: Operational Feedback

Phase E


MMI-2

MMI-2


MMI-2

GOALS MMI-2

As for MMI -1 Revise and update, simplify and improve


MMI-2

DELIVERABLES MMI-2

1. Revision - Norwegian and English 2. Presentation material - MMI-2 3. Project plan - other cabins

MM I-2


I-2 MM

MMI-2

PROJECT PLAN MMI-21. Clarify goals, requirements and specification 2. Interview stakeholders 3. Observe use/audit of MMI-1 4. Test use of MMI-1 5. Review alternative methods, standards etc. 6. Develop and test concepts 7. - Develop MMI-2 - Presentation material - Project plan for other cabins Human Factors Solutions 2002

ISO . 20 02

OK RS NO 2 200

MMI-2

PRELIMINARY RESULTS - MMI 1+ Systematic / useful Professional content Where to start ? Checklists useful Iterative process unclear Puts HF on map Not related to oil industry No change - human error -Not easy to use / Too large


MMI-2

PRELIMINARY REQUIREMENTS 1/2TECHNICAL CONTENTS Reduce volume - BUT more examples, checklists, guidance ! Simplify / userfriendly - navigation Prosess vs results based ? Audit tool / design guide ? Add Human Error Assessment, HCI, Alarm Philosophy, +++ MMI-2 - tool to get 1 answer from 10 different operators


MMI-2

PRELIMINARY REQUIREMENTS 2/2ORGANISATION Experience transfer first Merge chapters Emphasize iteration Seperate parts: Users INTRODUCTION MMI-2 Involve industry: (Ref. group) Overview & detailed workshopsTest Design


MMI-2

PRELIMINARY CONCEPTSORGANISATION Requirements Regulations Topic Design prosess Users Examples Combinations Etc.

Picture book / Designguide / Revision tool


MMI-2


MMI-2

ISSUES

Who should own HF / MMI -2 ? How should HF requirements be presented? (process, performance criteria, detailed specs.) Your experience with ISO 11064 ? Your experience reviewing Human Factors in CCR design prosess?


HFW2002 Workshop On Human Factors In Offshore Operations

Capitalizing On Behavior Based Safety To Address Human Resource Development Needs

Ron Newton Peak, Inc. www.peaksbest.com

. . . Recruitment and retention problems are barriers to quality improvement initiatives, a driving factor in personal injuries and accidents, and a drain on crew performance.

American Waterway Operators Task Force

All areas of human resource development and management are now interlinked more than ever safety, personnel recruitment and retention, quality, fatigue, teamworkall. How Can We Capitalize on the Behavior Based Safety Process to Improve Total Human Resource Development?

A Model For Examination

Peaks 10-Year Experience With Offshore Service Companies

Offshore Marine Industry: 1992-Present 8 Offshore Service Providers & 3 E&P Companies 1992-1995 Extensive Research Into Safety Behavior Culture: InlandUS OffshoreWorld Offshore To Date: Personality and Behavior Data From +6,000 Vessel Officers, Deck Ratings & Shore Staff Serving In The Offshore Marine Industry

Capitalizing For HR Needs

Peak, Inc.

Task #1

Define Behavioral Tendencies Of Mariners. Personality and Behavioral Measures

What Is Personality And Behavior?

BEHAVIOR(OBSERVABLE SURFACE TRAITS)

PERSONALITY

(HIDDEN ROOT TRAITS)

Socio-Economics, Parenting, Culture, Etc.

BEHAVIOR(SURFACE TRAITS)

DiSC Personal Development Profile

Sample Population: 437Taylor-Johnson Temperament Analysis

PERSONALITY(ROOT TRAITS)

Population 103 Shore Staff 334 Vessel Officers

52.7% Captains, or first officers 27.2% 2nd Captain/Mate, or second officers 20.1% Engineers


Peak, Inc.

Mariner Personality Traits100 G O O D 90 80 70 60 50 I M P R O V E 40 30 20 10 0 A B C D E F G

Vessel Shore

H

I I

9 Personality (Root) Traits

TRAIT STRENGTHS100 G O O D 90 80 70 60 50 I M P R O V E 40 30 20 10 0 C Active Social F Objective G Dominant I Self Discipline

COMMAND BEHAVIORS

TRAIT WEAKNESSES

100 G O O D 90 80 70 60 50 I M P R O V E 40 30 20 10 0 A B D E H

COMMUNICATION BEHAVIORS

Nervous Discouraged Inhibited Indifferent Hostile

What Else Does It Tell Us?

100 G O O D 90 80 70 60 50 I M P R O V E 40 30 20 10 0 A B C D E F G H I

A = AWOL

A

A

A

A

A

A

Personality (Root) Traits

Marine Offshore Temperament = High Turnover

100 G O O D 90 80 70 60 50 I M P R O V E 40 30 20 10 0 A B C D E F G H I

A = AWOL

A

A

A

A

A

A

Personality (Root) Traits

DiSCD = Dominance: Fast-Paced & Task-OrientedMotive = Get Results Done

i = Influence: S = Steady: C = Correct:

Fast-Paced & People-Oriented Motive = Influence Others Slow-Paced & People-Oriented Motive = Create Teamwork Slow-Paced & Task-Oriented Motive = Insure Quality & Accuracy


Peak, Inc.

Fast Paced quicker/ initiator

Task Oriented purpose/ task

D C

i S

People Oriented relationship/ people

Slow Paced slower/ responder

Capitalizing For HR Needs Peak, Inc.

Almost 73% Of Work Task Force: Oriented D or C purpose/ Behavior task Task Before People

Fast Paced quicker/ initiator

D C

i S

People Oriented relationship/ people

Slow Paced slower/ responder Peak, Inc.


1st Officer - 72% 2nd Officer - 68% Engineer - 75% Shore -74%


Peak, Inc.

Mariner Behavioral Tendencies

Repetition Of Traits In Retention Strong Command Behaviors Poor Interpersonal Communication Behaviors Non-verbalization Of True Emotions, Thoughts Self-centered, Prejudiced Behavior Affecting Teamwork Passive-Aggressive Tendencies: us vs them

Misery Loves Company


Peak, Inc.

Mariner BehaviorsWhat Do They Look Like In The Workplace?

Lack of conflict resolution Toleration of ongoing conflict Lack of verbal sympathy/empathy Over reliance on authoritarian leadership Reliance on hard-core skills for competency Pervasive us vs them verbalization Little interpersonal relationship guidelines Consistent turnover or desire to leave job Hesitancy to listen to personal insights/needs Hesitancy to share personal insights/needsCapitalizing For HR Needs Peak, Inc.

Task #2

Turn Behavioral Conclusions Into Effective Behavior Based Training Measures But Not Without First Defining The Larger Picture Of HR (or Human Factor) Needs That Could Be Impacted

Ask

Is not resolving interpersonal conflicts a safety behavior? What else does it affect? Is over reliance on authoritative leadership a safety behavior concern? What else does it affect?

Need

A behavior based process which will work hand-in-glove with a strategic human resource development model. A Comprehensive Viewpoint.

Strategic Human Resource Develop

Human Factor in Offshore Safety

Documents