Understanding the human factor in high risk industries. Dr Tom Reader

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1 Understanding the human factor in high risk industries 4 th December 2013 ESRC People Risk Seminar Series Dr Tom Reader 1

2 Presentation outline 1. Human Factors in high-risk industries 2. Case study: The Deepwater Horizon accident 3. International Human Factors: Safety culture in Air Traffic Control 4. Other areas of interest 5. Discussion 2

3 1. Human Factors in high-risk industries 3

4 2. Human Factors in high-risk industries HF research investigates the relationship between organisational safety and: Human error Human-computer interaction Teamwork and communication Situation awareness and decision-making Leadership Emergency management Risk/safety culture HF specialists examine how problems in the above contribute to safety failures 4

5 The Swiss Cheese model (1997) The accident causation model shows how activities and systems within a high-risk organisation interact to influence safety: The model is used to: i. Explore the chains of activity that result in success and failure ii. Isolate and explain safe or unsafe organisational performance iii. Predict future failures and successes 5

6 ACTIVE failures directly impact upon organisational performance LATENT failires shape organisational systems and environment STRATEGIC FAILURES POLICY FAILURES TACTICAL FAILURES OPERATIONAL FAILURES Each layer of cheese represents activity within an organisationa that protect against failure (a defence ) 6

7 The problems across the organisation mean the hazard cannot prevented from causing harm Within each defence layer, holes appear due to problems in human activity or organisatonal systems Hazard Losses..occur where a hazard is not prevented This leaves the organisation susceptible to hazards or unexpected events 7

8 2. Case Study : BP Deepwater Horizon Reader, T, & O Connor, P. (In Press). The Deepwater Horizon explosion: Non-technical skills, safety culture, and system complexity. 8

9 Offshore drilling for oil and gas 9

10 What happened? i. The cement casing used to contain the flow of oil cracks ii. Gas flows up the well iii. Gas enters the rig and ignites iv. The blowout preventer fails (used to seal the well), meaning oil flow unstoppable 10

11 Consequences? 4.9 barrels of crude oil released into gulf Clean-up cost in excessive $20billion 126 workers on board: 11 fatalities Destruction of $200million dollar drilling rig Near collapse of BP 11

12 ACTIVE decisions LATENT decisions STRATEGIC DECISIONS POLICY DECISIONS TACTICAL DECISIONS OPERATIONAL DECISIONS 12

13 Safety testing involved assessing whether hydrocarbons would flow up the well a1) Errors during safety testing The team switched to another data source (the kill line) Pressure test on drill line failed (meaning test unsuccessful). This worked, and the team assessed the well as safe (ignoring earlier failure) 13

14 a2) Failing to recognise a blowout was occurring Crew monitoring the well failed to notice indicators of a kick (gas flowing up the well) Several kick s occurred but no action was taken This was due to: Crew members conducting multiple tasks Design of monitoring equipment Lack of awareness for problems in safety testing (a3) Gas entered the platform and ignited 14

15 Operational Failures a1) Decision errors on safety testing a2) Failing to recognise blowout a3) Communication breakdowns -Biases in DM -Situation awareness -Information sharing Hazard Tactical problems? 15

16 b1) Design of the well flawed: b2) Poor communication on safety: Design decisions made ad-hoc and not systematically Junior staff had concerns over the well-design and safety testing Decisions focused on production longevity, but this created short-term risks In some cases, these were ignored or decisions were made onshore 16

17 b2) Poor communication on cement: Halliburton knew of problems with the cement used to construct the well b3) Rejection of safety data: BP decided not to pay for extra safety-related data on cement However, concerns not communicated to BP, compromising future DM Performance of safety tests (a1) potentially compromised 17

18 Operational Failures a1) Decision errors on safety testing a2) Failing to recognise blowout a3) Communication breakdowns -Biases in DM -Situation awareness -Information sharing -Group DM -Risk perception -Structure of DM processes Tactical Failures b1) Problems in assessing risk b2) Poor communication b3) Rejection of safety data on cost grounds Hazard Strategic and political failures? 18

19 c1) Distributed decision-making Service providers Personnel on the platform Engineering and senior management on the beach/hq Regulators Logistical support Company man Contract staff 19

20 c2) Prioritisation of production vs. safety Decisions relating to risk shaped by safety culture Did this impact upon operational DM? E.g. Design of the well to ensure production longevity Refusing safety tests Outsourcing safety activities Lack of investment in safety equipment 20

21 Government policy decisions that shaped the operating environment d2) Not adopting international standards on safety management d1) Decision by industry regulators to not introduce safety cases d3) Lack of investment by the regulator in training and inspection 21

22 Operational Failures a1) Decision errors on safety testing a2) Failing to recognise blowout a3) Communication breakdowns -Biases in DM -Situation awareness -Information sharing -Group DM -Risk perception -Structure of DM processes Tactical Failures b1) Problems in assessing risk b2) Poor communication b3) Rejection of safety data on cost grounds Hazard Policy Failures Strategic Failures c1) Distributed decision-making c2) Safety culture d1) Light regulation d2) Not adopting international safety standards d3) Reduced safety investment - Expertise for DM - Evaluation of risk - Decision environment 22

23 Developing more complex HF models of accident causation 23

24 E.g. accidents develop over time Months/ Years E.g. safety/production, investment, training, thirdparties, regulation Weeks/Months STRATEGIC/ POLICY TACTICAL E.g. Well design, communication during decision-making, risk assessments Days/ Hours/ Minutes OPERATIONAL E.g. conducting maintenance tasks, monitoring equipment, risk Dr T Reader. LSE. 24

25 E.g. distributed decision-making Service providers Personnel on the platform Engineering and senior management on the beach/hq Regulators Logistical support Company man Contract staff 25

26 Interactions between events leading to the Deepwater Horizon mishap Deepwater Horizon destruction and oil spill Event/accident mechanisms 1. Failure of Cement Barrier 2. Hydrocarbons enter well and travel up the riser 3. Hydrocarbons enter /ignite on rig floor 4. Blowout Prevent (BOP) failure Unsuccessful cement job Incorrectly performed negative pressure test (NPT) Senior staff not questioning cement job/npt Drilling crew fail to notice kick Emergency procedures not implemented Fire damage Faulty batteries Conditions Flaws in temporary abandonment procedure design Flaws in design of cementing process Error data not evaluated Inappropriate foam cement slurry Lack of information on cement job NPT team errors/ confirmation bias Lack of training for performing the NPT Lack of awareness of problems in NPT Poor communication between NPT team and crew members on drill floor Crew attention spilt between tasks Instrumentation and display problems for monitoring the well Lack of automated fire and detection system Inadequate maintenance Flaws in design of well Informal risk assessment procedures Minimal communication on operational decisions Poor info sharing between operator and contract companies Rejection of cement evaluation log Lack of clear procedures for running NPT Not learning from previous incidents System Factors Production/cost -saving pressure Third party companies conducting safety critical work Industry standards/ regulation Communication culture between operational, management, and contract staff Human factors engineering Events directly preceding mishap Conditions that allowed mishap to occur System factors underlying mishap Reader, T, & O Connor, P. (In Press). The Deepwater Horizon explosion: Non-technical skills, safety culture, and system complexity.

27 3. International Human Factors: Safety culture in Air Traffic Control Reader, T. W., Noort, M. C., Kirwan, B., & Shorrock, S. (under review). Safety san frontières: An international safety culture model 27

28 Safety Culture...research examines relationships between employee beliefs about safety management...emerges from the notion that organisational values, norms, activities, management, and history shape organisational safety...develops through group and organisational processes, and within the context of cultural (e.g. national) practice 28

29 Air Traffic Management High-risk industry International Requires cooperation High-pressure 29

30 Research Questions i. Can you measure safety culture in different cultural contexts? ii. Are variations in safety culture explained by national cultural traits? iii. Do occupational groups develop sub-cultures of safety culture? 30

31 Research Design Bottom-up development of safety culture survey Measurement of staff attitudes towards safety culture across Europe ATM centres in 27 countries surveyed 11,700+ participants Norm data on national culture Project funded by EUROCONTROL (European Commission) 31

32 i. Testing measure reliability Qualitative meaning Response patterns Q1 0 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 F1 F2 F3 32

33 i. Testing measure reliability 33

34 i. Testing measure reliability Six stable dimensions of safety culture identified 34

35 ii. Safety culture and national culture? Four distinct regions of Europe (as identified by UN) Data on national culture indicates the four European regions (N,E,S,W) to have quite distinct national cultures (e.g. power distances, collectivism) Does safety culture vary according to region, and is it associated with national culture? 35

36 ii. Correlations between SC and national culture Dimension Collectivism Power Distance Uncertainty Avoidance Masculinity Short-term Orientation Management commitment to safety -.22* -.30* -.48* -.24* -.57* Collaborating for safety -.24* -.30* -.52* -.43* -.55* Incident reporting -.31* -.40* -.57* -.37* -.62* Communication about Change -.27* -.33* -.53* -.27* -.59* Colleague commitment to safety -.08* -.14* -.27* -.18* -.21* Safety support -.27* -.34* -.53* -.33* -.59* * P <.001 (2-tailed). n = 3498 (Listwise). 36

37 ii. Safety culture across Europe Management commitment to safety Collaborating for safety Incident reporting Communication about change Colleague commitment to safety Safety support N = 6404 (1 = least favourable, 5 = most favourable) 37

38 ii. Safety culture in different European regions, for ATM Operational staff Southern Europe 2.00 Eastern Europe Management commitment to safety Collaborating for safety Incident reporting Communication about change Colleague commitment to safety Safety support Western Europe Northern Europe N = 5176 (1 = least favourable, 5 = most favourable) 38

39 ii. Safety culture in different European regions, for ATM Management staff Southern Europe Eastern Europe Western Europe 1.00 Management commitment to safety Collaborating for safety Incident reporting Communication about change Colleague commitment to safety Safety support N = 1230 (1 = least favourable, 5 = most favourable) 39

40 iii. Safety culture differences between operational staff and management 40

41 Conclusions i. Human Factors concepts are shaped by national cultural traits ii. HF researchers must better understand how this impacts upon safety management iii. HF measurement should be conducted with an understanding of cultural norms iv. Different occupational groups can generate sub-cultures v. Cross-cultural learning? 41

42 4. Other domains of interest 42

43 Additional Human factors research i. Applying Human Factors techniques to understand errors in financial trading ii. Teamwork and leadership measurement in intensive care teams iii. Learning from patient complaints in healthcare systems iv. Relationship between workforce health and organisational safety (oil and gas) 43

44 5. Discussion 44

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