Introducing Two Methods for Improving Human Factors

© The Keil Centre, 2014

Introducing Two Methods for

Improving Human Factors

Human Factors Maturity Model (HFMM) &

Team Error And Violations Analysis Method (TEAVAM)

Johnny Mitchell

Occupational Psychologist - The Keil Centre

1 v1.0 0614


About The Keil Centre…

• Based in the UK & Australia

• 20 staff & associates

• International client base

v1.0 0614 2 Therapy & Counselling –Human Factors Analysis Tools® - Organisational development - StressTools® - 360 degree feedback - Safety Culture Maturity® - Coaching


About me..

14 years experience as applied psychologist

Occupational Psychologist who is Chartered by the British

Psychological Society and Registered with the Health

Professions Council.

Human Factors in Incident Investigations specialist

Safety Culture & safety behaviours

Psychological Health

Johnny

Mitchell


Human factors…what is it?

• HSE Definition

“Environmental, organisational and

job factors, and human and

individual characteristics which

influence behavior at work in a way

which can influence health and

safety. This includes the jobs people

do, the individuals doing the jobs,

and how they are organised and

managed.” (Health and Safety Executive, 1999)


How do human factors impact on

performance?

• fatigue

• Personal

issues

• Design of

equipment

• procedures

• communication of

critical information

• Inadequate

appreciation of risks

• Equipment not

maintained

• Over

confident

with task

• Manager/supervisor

expectations • Awareness of

safety role/

expectations

Performance

gauge: Likelihood of

error:


6

Why are these topics important?

Significant

Event

Individual Error

(walking under a

suspended load)

Active

Error

Lack of

training

•When there are gaps in the barriers, they may line

up resulting in an incident.

Poor maintenance

Poor design

Procedures

incorrect

Human Error


• US Chemical Safety Board DVD reconstruction

– View sections of DVD to illustrate topics

• Review in two sections

– Identify how the hf issues contributed to the incident

– identify the main ways the selected hf areas could be improved

Practical session


Developing a model of Human

Factors Maturity – key questions..

• What topics would it include?

• What constitutes a mature level of Human

Factors? (& what is a poor one)

• How should it be measured? (e.g. survey;

workshop etc..)

8

© The Keil Centre, 2014 9

What human factors (hf) topics

should be measured?

Key human factors topics

Health & Safety Executives

(HSE) - Top 10 Human Factors

Issues

Health & Safety Executives

(HSE) review of incidents

The Energy Institute e.g. Managing

organisational change, 2005.

Institute of Ergonomics &

Human Factors


• Managing human failure

• Procedures

• Training and competence

• Staffing

• Organisational change

• Safety-critical communication

• Human factors in design

• Fatigue & shiftwork

• Organisational culture

• Maintenance, inspection and testing

10 Key UK HSE human factors issues

What do we mean by ‘human

factors’ in hazardous industries?



Developing a model of human

factors • Health & Safety

Executives (HSE) -

Top 10 Human

Factors Issues

• Health & Safety

Executives (HSE)

review of incidents

• Managing human error

• Procedures

• Safety roles & performance expectations

• Human Factors in incident investigations

• Contractor Management

• Safety-critical communication

• Human factors in design

• Fatigue & shift-work

• Maintenance, inspection and testing

• Organisational Change

• Additional

articles on

human factors


What constitutes a mature level of

hf? 13

Framework for

assessing human

factors capability.

Prepared by Nickelby

HFE for HSE.

• The levels are not just about

behaviors

• They involve having suitable

procedures & processes in

place e.g. to actively manage

fatigue

• It often involves following

best practice guidelines e.g.

procedure design

• It involves creating a plan to

manage each of the 10

elements

• At higher levels an

organisation is applying ‘best

practice’ methods e.g.

hazard analysis.

• At higher levels the impact of

these tools & processes is

monitored


Human Factors Maturity Model

Level 1

Emerging

Level 2

Transitional

Repeatable efforts

made, but not planned

Level 3

Planned

Planned, systematic &

somewhat effective

Level 4

Proactive

Engaged, proactive &

preventative

Level 5

Leading

Leading edge &

constantly improving


Assessing Human Factors Maturity

• Take set of 5 cards, shuffle and spread in front of you

• Through discussion with your colleague, select the card(s), which in your experience best describes the current situation at this asset/site (not essential that you both agree)

• Put the card(s) selected to the top of the pile and return to the folder


Discussion / actions

• Discussion – explain (not justify) why level

chosen for each element, and

expand on card descriptions

– positive features?

– what needs improved?

• Actions required – in your opinion, the type of

practical actions which would

make a real difference

– may involve actions by:

– management

– your team

– you personally


Human Factors

Themes

17

Contractor management

Managing human Error

Human Factors in Incident investigation

Safety-Critical Communication

Human Factors in Design Fatigue & shift work

Maintenance inspection &

testing

Safety roles & performance expectations

Procedures


• Knowingly broken the speed

limit on site

• Pressed the wrong button by

mistake

• Not worn a harness for a

quick job

• Used a piece of machinery in

the wrong way without

knowing

• Not followed procedure in

order to improve the quality of

the job

• Stubbed their toe on a forklift

truck

• Left early from shift to go to a

family appointment

• Mis-heard an instruction

• Not completed a maintenance

check to speed up the job

• Forgotten where you are in the

procedure and started in the

wrong place

Have you ever done the following…?


Introducing ‘Error types’

Intentional Unintentional

Sensory Memory Decision Action

Mis-heard an

instruction

Forgotten where you

are in the procedure

and started in the

wrong place

Used a piece of

machinery in the

wrong way without

knowing

Pressed the wrong button

by mistake

Other slip Human

variability Confusion Distraction

Preoccupation

Intrusive

thoughts /

habits


What are Performance Shaping

Factors?

•Process Isolation

•No independent check

•Time limit

• Process Isolation

• No independent check

• Process Isolation

• Independent check Probability of failure: 81 in

1000

Probability of failure: 9 in

1000

Probability of failure: 3 in

1000

PSF


Performance Shaping Factors

Type of Factor Example Your Example

The task Workload – rushing to finish

a job

Communications Poor handwriting

Procedures &

documentation Ambiguous wording

Environment High background noise

Training & experience New start

Human-Machine

Interaction Alarm flood

Personal Recent bereavement

Social & team Personality clash


Team Error And Violation Analysis

Method comprises: 22

METHOD

• Dedicated team train-the-trainer – 1 day

• Dedicated teams run sessions with their teams

CONTENT

• Short training with company (or industry)

examples of conditions and behaviours that

make error/violations more likely e.g.

• Ergonomic set-up (e.g. confusing design)

• Housekeeping – placement of equipment

• Lack of knowledge/experience

• Not engaging “system 2” thinking

• Complacency

• Performance shaping factors (time) etc.

• Exercise to analyse tasks & identify

potential sources of error/violations and

actions to address


Examples of ‘solutions’

Examples of ‘One-off’ actions • Increased clarity of objects/equipment e.g. distinguish objects; improve layout

& sequencing

• Enhance the signal strength when an error occurs E.g. a louder alarm

• Introduce a physical barrier that prevents errors or makes people stop & think

• Improve usability of procedures & review with workers

• Coaching on the job

23

Examples of ‘daily’ actions • Stop, Stand back and check assumptions (what if?)

• Set more realistic expected finish times on safety critical work

• Avoid doing two things at once

• Observation of task by 2nd person


Using the TEAVAM database 24

Insert data into the

spreadsheet

Complete actions

Pre-job brief

Workplace observations

Workplace reminders

Induction

Post-job brief

© The Keil Centre, 2014 25 v1.0 0614

ANY QUESTIONS?

The End..

Introducing Two Methods for Improving Human Factors

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