Human Error and Calculated Risks

1. Human Error and Calculated Risks Stephen Harris Amcham HSE Conference – Guyana 17/7/19

2. Definition of calculated risk • A hazard or chance of failure whose degree of probability has been reckoned or estimated before some undertaking is entered upon • An undertaking or the actual or possible product of an undertaking whose chance of failure has been previously estimated Merriam-Webster

3. Definition of calculated risk A chance that is taken after a careful estimation of the possible outcomes. People use this expression when the possible gain is worth more than what will be lost if the action fails. Business Dictionary

4. Risk management process • Step 1: Identify the hazards. • Step 2: Decide who might be harmed and how. • Step 3: Evaluate the risks and decide on precautions. • Step 4: Record your findings and implement them. • Step 5: Review your assessment and update if necessary.

5. Process Hazard Analysis (PSM) A process hazard analysis (PHA), or evaluation, is one of the most important elements of the process safety management program. A PHA is an organized and systematic effort to identify and analyze the significance of potential hazards associated with the processing or handling of highly hazardous chemicals.

6. Human Factors Defined HSE “Environmental, organizational and job factors and human and individual characteristics which influence behaviour at work in a way which can affect health and safety”

7. Physical Factors vs Human Factors • Past legislation focused primarily on the physical elements of safety rather than the human element • Whilst this strategy has improved the physical work environment, they have not always eliminated workplace accidents. • Changes in the physical environment must include the human factors. • Human factors have to do with integrating in the workplace the relationships between people, processes and equipment.

8. It Is Estimated That Human Error Accounts For At Least 80% Of Accidents Safe Place Strategy Safe Person Strategy No. of fatal Accidents/annum Physical Guards Safe Systems Personal Factors 1945 1985 2005 HSE

9. Human Factors – Focus Facilities and Equipment Equipment design, control systems, human computer interface, labeling etc. People Training, environmental factors, communications, manual handling, workloads etc. Systems Culture, procedures, MOC, risk analysis, SWP, PTW etc.

11. Conclusion Human Error Was often one of the main explanations given for the cause of these accidents/disasters. However, examination of all the facts suggests that several things such as: • Poor design, • Poor maintenance, • Equipment failures, • Organizational failings and human fallibility usually combined to produce the end result.

12. Elements which influences Human Behavior • Personal Factors – Includes training, selection, motivation, risk perception, safety attitudes, skill, memory • Organizational Factors – Includes Mgt commitment, control, co-operation, communication, culture, policies • Job Factors -Includes job content, workload, design of human-machine interfaces, procedures, workplace environment.

13. In order to address human factors in workplace, peoples’ capabilities and limitations must first be understood.

14. Classification of Human Error

15. Key Messages • Everyone can make errors no matter how well trained and motivated they are. • Through a failure a person can directly cause an accident. • People do not set out to make errors deliberately. • People are often ‘set up to fail’ by the way our brain processes information, by our training, through the design of equipment and procedures and even through the culture of the organization we work for.

16. Key Messages • People can make disastrous decisions even when they are aware of the risks. • We can also misinterpret a situation and act inappropriately and as a result lead to the escalation of an incident. • Paying attention to individual attitudes and motivations, design features of the job and the organization will help to reduce violations. • The challenge is to develop error-tolerant systems and to prevent errors from occurring.

17. Key Messages • Failures arising from people other than those directly involved in operational or maintenance activities are important. Managers’ and designers’ failures may lie hidden until they are triggered at some time in the future. • There are two main types of human failure: errors and violations. Controls will be more effective if the types are identified and addressed separately. • Reducing human error involves far more than taking disciplinary action against an individual. There are a range of measures which are more effective controls including design of the job and equipment, procedures and training.

18. Summary • Significant Improvement achieved in Health and Safety with the introduction of machine guarding and Safety Systems. • Regulations in the past focused mainly on Physical Factors. • Workplace incidents continues despite these improvements. • Recent thrust on Human factors for further reductions includes focusing on the interrelationship between equipment , people and systems.

19. Summary Sources HSE publications CCPS publications • Understanding why human makes mistakes is a key element in preventing Human errors. • Personal, Organizational and Job factors are the main contributors to safety performances. • Human Factors integrates the key elements necessary for further reducing workplace incidents.

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