Human Factors and Changing

perspectives

If this was March 22nd 2005 the day

before the explosion and I was

standing here addressing this audience
the day before the explosion, my
remarks to you would have been much
different.

Changing perspectives (2)

my confidence in the BP Groups safety

culture, safety standards, safety management

systems and safety audit programmes would
have been evident.
Id have pointed to some statistics for
example, how in the previous five years the
company had reduced its OSHA recordable
injury rate by almost 70 percent and its fatality
rate by 75 percent.

Changing perspectives (3)

Id have argued that this positive trend

reflected a concerted, systematic

approach to safety.
Im sure Id have mentioned how
everyone working in a BP facility is
empowered and expected to raise
safety concerns and to stop work if they
think conditions are unsafe.

Changing perspectives (4)

.. I would have described our efforts to

continuously drive up safety standards
regardless of our improving record.
on March 23rd 2005 it became clear that
none of this was enough.
John Mogford, 24 April 2006, Senior Group Vice
President, Safety & Operations, BP, CCPS Congress

Methods for Human Error Assessment

The U.K. Health and Safety Executive has

identified more than 70 methods
32 are relevant to Major Hazards
The next page lists some common ones and
then we move into one of the simple
accepted methods

Common methods for Human Factor

(error) Assessment

Human Error Assessment and Reduction

Technique (HEART)
Technique for Human Error Rate Prediction
(THERP)
Success Likelihood Index Method (SLIM)
Tecnica Empirica Stima Errori Operatori
(TESEO)

HRA Assessment

Using the Human Error Assessment

and Reduction Technique (HEART)

Pre-processed HRA method
First published 1985
One of 40 or so other HRA methods
Based on Human Factors literature

HRA accuracies achieved so far

60-87% of all predictions within factor of 10 of

true value over range 0.00001 to 1.0
Average 72% within factor of 10
Average 38% within factor of 3
Kirwan (1997)
cf. for Systems Reliability Assessments,
64% of predictions within factor of two,
93% within factor of four (Snaith, 1981)

After Kirwan, 1997

Understanding the method

Generic Task Types (GTT)

Human reliability is dependent on
the nature of the task being
performed
Under perfect conditions the
associated level of reliability is fairly
consistent
Error Producing Conditions (EPC)
May degrade reliability

Generic Task Types (GTTs)

For example
(A) Totally unfamiliar task, performed at speed
with no real idea of the likely consequences of
actions taken (0.55)
(E) Routine, highly-practised, rapid task
involving relatively low level of skill(0.02)
(M) Miscellaneous task for which no description
can be found(0.03)

Error Producing Conditions (EPCs)

38 EPCs described in HEART

Examples
Unfamiliarity (x17)
Time shortage (x11)
Operator inexperience (x3)
Unreliable instrumentation (x1.6)
Assessment of how important each is

Human Failure Scenario to Assess

Part of a procedure to establish the start
up of a piece of plant:
Failure of Operator to establish rundown to
tankage (set Splitter tower level control to
Auto with 50% set point) prior to adding
heat to Splitter

Human Reliability Assessments

Under normal conditions

Under conditions that can degrade
human reliability

Failure to establish rundown

(normal situation)
Generic Task Type
Task F: Restore or shift a system to original
or new state following procedures, with
some checking this task is mission
oriented and could include up to five
discrete elements or actions, but would
normally only involve one basic activity

Failure to establish rundown

(normal situation)
Generic Task
Task F

Nominal Human
Unreliability
0.003

Failure to establish rundown

(Conditions affecting human reliability)

Not following procedures

No independent checking (e.g. supervisor)
Unreliable instrumentation
Impoverished quality of information (e.g. shift handover)
Unclear allocation of function and responsibility
Disruption of normal sleep cycles
Operator inexperience
Low workforce morale

Failure to establish rundown

Conditions affecting human reliability
Generic Task

Nominal Human Unreliability

Task F

0.003

Error Producing Conditions

Factor
Total HEART
Affect

Assessed Proportion
of Affect (from 0-1)

Procedures

x2

0.8

(2-1) x 0.8 + 1 = 1.8

Checking

x3

0.8

(3-1) x 0.8 + 1 = 2.6

Instrumentation

x1.6

0.4

(1.6-1) x 0.4 + 1 = 1.24

Impoverished info.

x3

0.2

(3-1) x 0.2 + 1 = 1.4

Assessed nominal likelihood of failure

0.003 x 1.8 x 2.6 x 1.24 x 1.4 = 0.024

Assessed
Affect

Conditions affecting human reliability

Uncertainty bounds
Generic Task
Task F

Nominal Human Unreliability

0.003
Uncertainty Bounds
0.0008 0.007

Assessed nominal likelihood of failure

0.003 x 1.8 x 2.6 x 1.24 x 1.4 = 0.024
Uncertainty Bounds
0.0065 0.057

A fundamental need

Task Analysis is a very important part of

understanding the potential for HUMAN
ERROR.
RG opinion suggests that the potential for
most error reduction can be achieved by
actually understanding what the operator
needs to do
Make the right way the easy way reducing
the incentive to do it wrong, take short cuts

Texas City

Error Reduction

Can GTT be changed?

Relative importance of assessed proportion

of affect of the EPCs

Cost-effective measures

Error Reduction

Inexperienced
operator
Low morale

Checking

Sleep cycles
Unclear roles
Instrumentation

Procedures
Impoverished
information

Summary

Explained why Human Reliability

Assessment (HRA) is important

Explained how Human Error
Assessment and Reduction Technique
(HEART) works
Outlined key principles and evidence
Worked through some scenarios to aid
understanding

HRA contribution from the HSL

Julie Bell and Jerry Williams

Health and Safety Laboratory
Harpur Hill
Buxton, SK17
julie.bell@hsl.gov.uk