Investigating and analysing human and organisational factors aspects of incidents and accidents Presented by Bill Gall

1. Investigating and analysing human and organisational factors aspects of incidents and accidentsPresented by Bill Gall New Guidance published May 2008

2. The Guidance was developed by the Energy Institute’s Human and Organisational Factors Working Group See website for details of the HOFWG’s work: www.energyinst.org.uk/humanfactors

3. This presentation explains why new guidance is needed and introduces the document with some selected extracts including general and specific examples of problem areas Introduction

4. The petroleum and allied industries investigate and analyse both incidents (‘near misses’) and accidents – whether with major hazards or occupational potential, but… • Human and organisational factors aspects are rarely addressed sufficiently • That is, investigations/analyses often fail to establish root causes and thus fail to identify effective actions in response Background

5. Investigation – gathering information, reconstructing events, for example, using a time-line, to make sense of the incident Analysis – thorough and systematic review of the information to identify root causes Investigation - Analysis

6. The guidance focuses on analysis but also advises on the investigation process/data gathering • Faults in the conduct of an investigation can make subsequent analysis difficult or its results invalid Investigation - Analysis

7. Evidence to justify the above statement: • Reviewing incident investigation reports for this study and two other studies - one in the petroleum industry the other in the nuclear industry - it was not possible to establish: • The type of human failure involved • The basis for the analysts’ conclusions “HOF aspects are rarely addressed sufficiently”

8. Several incident analyses indicated: • Immediate Cause – Human Error • Root Cause – Human Error Further Evidence

9. A checklist provided by a major hazard industry to assist investigators in their task proposed the following ‘root causes’: • Lack of competence • Inadequate procedures • Inadequate tools or equipment • These are not root causes: the investigator can and should continue to ask questions A Problem with Checklists

10. ‘Lack of competence’ – Why? What organisational processes have failed? • Selection procedures? • Methods for identifying training needs? • Training delivery or assessment? • ‘Inadequate procedures’– explain ‘inadequate’? • Are they difficult to find when they are needed? • Unclear or poorly worded/illustrated? • Out of date? Again, what failed here/what do we need to fix? Questions

11. A road tanker driver refuelling his vehicle left it unattended with the trigger locked. Ten litres of diesel spilled onto the forecourt of the refuelling bay, requiring clean-up and causing delay to other drivers Why? Case Study – a spillage incident

12. Why? The driver did not comply with company procedures for refuelling. He had left his vehicle unattended to speak to a colleague. He also stated that he had done this before without incident. Example – analysis of incident Why? What was so urgent? Why? What was the ‘payoff’ for violating?

13. The investigation did not seem to explore the underlying causes of the driver’s violation. • Did he need something from his colleague? • Did he feel under time pressure and could not stop after refuelling to talk to his colleague? • Was he simply bored? • The analysis also failed to explore the issue of ‘safety culture’: the role of his colleague and other observers – why did no-one else intervene? Example – further analysis

14. From the incident report Driver was made aware of what can happen when not taking full care when carrying out any operation within the terminal = “Be more careful”? Proposed solution

15. Discipline the driver and warn others about this hazardous practice • Explore the site’s safety culture • Consider removing the locking trigger on filler nozzles or add an automatic cut-off • BUT – removing the locking trigger could encourage drivers to improvise. An automatic cut-off could create false sense of safety Better solutions?

16. An incident or accident has to be seen as a learning opportunity and one not to be wasted by unless the true HOF root causes are established The more thorough the level of analysis, the better the response in terms of focused improvements This is what you see Learn from Incident and Accidents This is what you don’t see – until you start to dig

17. Which investigation/analysis methods are the most useful in identifying HOF root causes? The guidance does not tell you The guidance provides criteria for you to choose And before that, gives some information you will need to get the best from the methods Improving investigation and analysis

18. The Guidance Describes: • Human failure types • Slips, Lapses, Mistakes, Violations • Safety Management • Safety Culture Basic Understanding of HOF Issues

19. Direction of Events A Useful Failure Model Direction of Analysis

20. The need for a fair system of sanctions and rewards Too punitive – reporting/cooperation will be reduced Too lenient – complacency, low motivation conform to rules The Need for a ‘Just’ Culture

21. The Guidance provides advice and cautions for each lifecycle stage and advises on how best to address HOF issues. The stages are: • Report • Investigate/analyse • Make recommendations • Assign, track and close out actions • Share information Lifecycle of an Investigation

22. Key Factors Affecting Human Failure • Workplace – design and layout of workspace and equipment, work environment • Task – poorly designed, workload • Personnel – competence, fitness, motivation • Organisation – supervision/leadership, change management Brief Checklists/Aides Memoire

23. Cautions • Be realistic about the team’s expertise in HF; may require training • Checklists – can help as an initial prompt but - as shown already - can mislead the user Selecting an Appropriate Method

24. Training requirements • Paper or software-based method • Retrospective analysis of incident reports • Used in petroleum industry • Generates graphical content e.g. timeline • A complete method for incident analysis • Provides solutions • Includes checklists or flowcharts Criteria for Selection of a Method

25. Matrix – Criteria Against Methods

26. 28 methods described briefly in the Guidance • Included because they: • Were cited by interviewees as methods they had successfully used • Feature prominently in incident investigation literature or • Clearly offer a sound approach to identifying HOF aspects Methods

27. 6 additional methods are described but not in detail because they: • Do not appear to be ‘mainstream’ methods • But they are cited in the literature and • Have potential for application in the petroleum and allied industries (and others) Further Methods

28. ARCA – APOLLO Root Cause Analysis Black Bow Ties DORI – Defining Operational Readiness To Investigate ECFA – Events and Causal Analysis (Charting) and ECFA+ - Events and Conditional Factors Analysis Fishbone diagram HERA – Human Error Repository and Analysis System HERA-JANUS – Human Error Reduction in ATM (Air Traffic Management) HFACS – The Human Factors Analysis and Classification System HFAT – Human Factors Analysis Tools HFIT – Human Factors Investigation Tool HSYS – Human System Interactions and allied industries (and others) Incident/Accident Investigation/Analysis Methods

29. ICAM – Incident Cause Analysis Method MEDA – Maintenance Error Decision Aid MORT – Management Oversight and Risk Tree PEAT – Procedural Event Analysis Tool PRISMA – Prevention and Recovery Information System for Monitoring and Analysis SCAT® – Systematic Cause Analysis Technique SOL – Safety through Organisational Learning SOURCE™ – Seeking Out the Underlying Root Causes of Events STEP – Sequentially Timed Events Plotting Storybuilder TapRooT® (Kelvin) Top-Set® Incident/Accident Investigation/Analysis Methods

30. TRACEr – Technique for Retrospective and Predictive Analysis of Cognitive Errors Tripod Beta WBA – Why-Because Analysis 5 Whys Why Tree Additional Methods CALM – Combined Accident anaLysis Method ISIM Integrated Safety Investigation Method PROACT® SACA – Systematic Accident Cause Analysis STAMP Systems Theoretic Accident Modelling and Process TOR – Technique of Operations Review Incident/Accident Investigation/Analysis Methods

31. The Guidance describes sources of information used including useful websites References and Bibliography

32. Free download (PDF) available from www.energyinst.org.uk/humanfactors/incidentandaccident Printed copy from EI Publications online section of the Energy Institute website (£10) ISBN 978 0 85293 521 7 Obtaining a Copy

33. The Energy Institute gratefully acknowledges the valuable contributions that the following individuals and companies made to this project: Dr Kathryn Mearns Aberdeen University Prof Rhona Flin Aberdeen University Lee Vanden Heuvel ABS Consulting Denise McCafferty American Bureau of Shipping Andrew Livingston Atkins Global John McCollom BAe Systems Prof Graham Braithwaite Cranfield University Les Smith DNV Dominique van Damme Eurocontrol Dr Barry Kirwan Eurocontrol Rachael Gordon Eurocontrol Acknowledgements

34. Peter Ackroyd Greenstreet Berman John Chappelow Human Factors Investigations Dr Claire Blackett Human Reliability Euan Dyer Kelvin Top-Set Ronny Lardner Keil Centre Richard Scaife Keil Centre Prof Trevor Kletz Loughborough University Stuart Withington Marine Accident Investigation Branch Rainer Miller Mensch-Technik Organisation Louise Farrell National Grid Chris Mostyn National Grid Dr Steve Shorrock NATS Acknowledgements – continued

35. Rudolf Frei Noordwijk Risk Foundation Prof Ann Mills RSSB Declan Kielty Pfizer Gerry Gibb Safetywise Solutions Mark Paradies System Improvements Inc Tjerk van der Schaaf Technical University Eindhoven Gerard van der Graaf Tripod Foundation Dr Linda Bellamy White Queen BV Step Change in Safety Organisation The Energy Institute would also like to acknowledge the HSE for their financial contribution to the development and dissemination of this publication. Acknowledgements – continued