Introducing Two Methods for Improving Human Factors
Transcript of 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
© The Keil Centre, 2014
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
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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
© The Keil Centre, 2014
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)
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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:
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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
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• 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
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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..)
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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
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• 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?
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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
© The Keil Centre, 2014 13
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
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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
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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
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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
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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
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• 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…?
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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
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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
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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
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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
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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
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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
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Using the TEAVAM database 24
Insert data into the
spreadsheet
Complete actions
Pre-job brief
Workplace observations
Workplace reminders
Induction
Post-job brief