Human factor in the context of fulfiling the requirements of the Directive Seveso II

1. Human factor in the context of fulfiling the requirements of the Directive Seveso II reflection by Ing. Martin K r š k o RISK CONSULT Ltd. Račianska 72, 831 02 Bratislava,SLOVAKIA

2. Introduction SK Act n. 261/2002 Z.z. on the prevention of major major industrial accidents and on changing and amending other acts + 2 dcrees (489/2002 Z.z. and 490/2002 Z.z. ) EU Directive 96/82/EC Seveso II One of the reasons for “upgrade“ has been the changing attitude from considering exclusivetly technical safety aspects forward to find its real causes – in most cases the HF HF influence on safety is recognised and covered by several articles and in the safety documentation. However, HF analysis is often neglected. Sice 1st of january 2004 an amendment of the Directive 96/82/EC has been in force – technical and organiastional safety easures are far from being perfect and more improvements are to come. Focus on the required safety documentation • - few reasons for getting concerned… • where is HF involved? • “how to” approaches and tips. • - documentation writing.

3. Few reasons for getting concerned / experience from abroad The Seveso II requirements fulfilment differ in the different countries. Current practice is that some requirements are neglected. Most of the Safety reports worked out by the operators has been returned for insufficient stress on various fields. Certain requirements are often completely ignored / omitted. HF is considered very superficailly, more qualitatively than quantitatively, but the most of all cases ignored / omitted even if the HF is recognised to be the most contributing factor in the major industrial accidents which took place. HF importance is underlined by recnet major industrial accidents, each had had a considerable contribution from the human failure point of view.

4. Accident causes -general distribution • Human factors has seemed • too ambiguous • too involved • too comprehensive • too difficult? technical failure, vis major… HF • For the industry to embrace human factors in a committed way, we need: • More education • More practical guidelines • Additional technical information • Benchmarking tools • To do something about it - now!

5. Where in the safety documentation is the HF involved? • The safety documentation in the field of the prevention of major accidents is • required by the act n. 261/2002 Z.z. • major accident prevention policy - MAPP • safety management system - SMS • risk assessment/ analysis • emergency planning (internal / external) • safety report Hidden responsabilities – MAPP and SMS MAPP and SMS are managing documents, which provide the basis for dealing with the HF in relation to the potential major accident occurrence. This documentation is supposed to be the output of the HF analysis – measures resulting from the HF assessment and analysis. • Covered fields: • organisational structure • risk identification and assessment • operation management • change management • emergency planning • performance monitoring • audits

6. Risk assessment / analysis Observation – the notification and the risk sources identification does not care about the influence of the HF on the safety level. Risk assessment and analysis Proper quantitative risk assessment is a matter of evaluating both - technical failures resulting into an accident - human failure resulting into some technical failure causing an accident In general, technical aspects are easier to cope with (generic databases, methods for processing failure data, availabilities, etc.) than human failure aspects. This fact is caused mainly by the complex and unpredictable nature of the human failure parameter. cause of thechnical failure cause of human failure • wrong reflexion • insufficient training, education • insufficient instructions • unsuitable control systems • etc. • mismatch of control operations • disconnection of safety mechanisms • communication errors • process control failures • etc.

7. Dilemma • There are two main streams in integrating the HF into the quantitative risk assessment: • an attempt should be made to treat the HF explicitely so that the QRA directly reflects • the influence of the technology operators and maintenance on the occurrence of • accidents. • the QRA should be hardware-focused and the HF should be “hidden” in the failure • rate of a certain component in order to reflect an average standard of human • performance …a bit of heuristics… • These two approaches can be combined in order to obtain a very representative • qualitative assessment reflexing the “status quo” of the system. • This can be achieved by careful choice of the basic events: • detailed development of the failure tree where appropriate • integrate the HF into equipment where suitable

8. PHA HEA Identify activity and tasks Select Section to Study Breakdown tasks into necessary steps Apply Deviation/Guideword Identify human errors that could occur during each step Identify Causes/What If’s Evaluate Consequences of Deviation/Cause Determine the consequences of the error Determine likelihood of scenario Determine Likelihood of Scenario Rank the consequences and likelihood Perform Risk Ranking Identify remedial measures for high risk scenarios Identify Possible Recommendations

9. Some examples HF HF

10. Some examples HF HF HF

11. Some examples

12. Some examples

13. Error mechanisms

14. Performance shaping factors

15. Emergency planning

16. So, how to write it down? All this theory has to be found in the safety documentation of an establishment. An universal approach may look like: Description of the work position Its potential to cause an accident Evaluation of the human-technology relationship Quantitative evaluation of the human failure influence Suggestion of corrective / preventive actions

17. Proposal of guidelines In order to include the HF assessment and analysis into the safety documentation, one can follow these steps: • identification of work positions which can be directly responsible for the generation of a • major accident • identification of common events that may be generated by the technical system and by the HF • assessment and analysis of the HF liability • critical points in the human-technology system • possible failures, errors and its causes • qualitative analyses of the human factor reliability (like HRA, THERP, HAZOP, SHERPA • etc.) • categorisation of the system demandingness (technology complexity, operation management • complexity, communication, etc.) • workforce selection based on relevant criteria, selected behavior shaping factors, etc. • regular (time scheduled) evaluation of the employee suitability • regular control of the working environment (ergonomy, user friendly software, etc.) • regular information to the employees, “work-caused risk awareness”, risk perception, etc • regular exercices and formation • possible back-up of the most sensitive positions (personal or technical)

18. Final remarks HF is involved through the entire safety documentation. HF can be included in the safety documentation in a variety of ways, no unified concept is adopted. The Seveso II requirements concerning the human factor are to be assessed and considered separately, depending on the establishment nature, the dangers / risks emanating from the technology, etc… The output of the HF analysis is to be incorporated into management documents, so that the improvements designed are really improved… Thank you for your attention!