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Integrating human factors within MAE

control measures: Error and ALARP in


offshore petroleum activities
Joelle Mitchell
APPEA HSE Conference, Perth, September 2015
Human Factors and MAEs

• Humans interact with control measures


• Error can be a barrier-defeating factor
• Error risk can be addressed through adapted
traditional risk management approaches

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Reducing error risk

Error Prevention

Error Management

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Typical approach
Hazard Consequence

Hazard Consequence

Training &
Prevention Mitigation
Error
Hazard
competency
Controls
EVENT
Controls
Consequence

Hazard Consequence

Hazard Consequence

Elimination Prevention Reduction Mitigation

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A more accurate approach
! Error
! Error
Control

Control
Control
Control
Control
Control

Control Control

Control
Control
Control ! Error

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A deeper exploration
Performance
shaping
factor

Performance
shaping
factor

Performance
Prevention Mitigation Control
shaping ERROR measure
factor Controls Controls failure

Performance
shaping
factor

Performance
shaping
factor

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Example – Texas City Refinery

• March 23, 2005


– Isomerization unit start-up
– Operators overfilled the
raffinate splitter tower
– Pressure relief devices activated
– Flammable liquid spurted from
a blowdown stack
– No flare installed
– Ignition, explosion and fire
– 15 deaths, 180 injuries

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Error analysis
Incorrect
knowledge

Fatigue

Misleading
Knowledge- Control
Overfilling
measure
HMI tower
based mistake failure

Poor
handover

Insufficient
personnel

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Possible controls
Incorrect
knowledge
Training

Simulation
Fatigue Drills
FRMS

Misleading HF in Knowledge- HF in Maintenance Drills Tower


Maintenance Tower overfill
HMI design design Error training Trip
Overfill

Comms
based mistake
conventions
Poor Procedure
handover

Risk indicators

Insufficient Planning rules


personnel

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Benefits of error analysis

• Classify potential high-risk errors


• Identify critical PSFs
• Develop targeted control measures
• Focus on prevention and mitigation
• Facilitate risk reduction to ALARP

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Which errors?

• “Critical human tasks”


• Activities people are expected to perform:
– as barriers against an incident
– to prevent incident escalation
– to support or maintain barriers during an incident

• OGP (2011). Human factors engineering in projects.

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A suggested process
Identify
critical human
tasks

Develop
Identify error
additional
potential
controls

Evaluate
existing Identify PSFs
controls

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Identify critical human tasks
Identify critical
human tasks

• Tasks where: Develop


Identify error
a procedure is a single point failure
additional
– controls
potential

– people interact with control measures


– error can lead to barrier failure Evaluate
existing Identify PSFs

barrier failure can lead to MAE


controls

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Identify error potential

• Task analysis can help Identify critical


human tasks

– What errors are possible? Develop


Identify error
additional
potential
controls
– Classify errors by a taxonomy
– What are the potential consequences?
Evaluate

– What are the high-risk potential errors?


existing Identify PSFs
controls

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Identify PSFs
• People-level
– Knowledge, skills, experiences Identify critical
human tasks

– Health
Develop

• Job-level
Identify error
additional
potential
controls

– Procedures
– Equipment
Evaluate
– Supervision existing
controls
Identify PSFs

• Organisation-level
– Culture & climate
– Corporate strategy
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Evaluate existing controls

• Prevention controls? Identify critical


human tasks

Develop
Identify error
additional

• Mitigation controls?
potential
controls

• Is error risk ALARP? Evaluate


existing
controls
Identify PSFs

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Develop additional controls

• Layered defences targeting error: Identify critical


human tasks

– Eliminate the opportunity Develop


Identify error

– Prevent the error


additional
potential
controls

– Reduce the impact – error


identification and recovery Evaluate
existing Identify PSFs

– Mitigate the consequences controls

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Where to start?

• Evidence of uncontrolled error:


– Events and dangerous occurrences
– Existing controls have failed to mitigate error risk
• Performance-shaping factors:
– Latent conditions
– Broader implications

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Summary

• Human error can facilitate barrier failure


• Error is most significant within
critical human tasks
• Layered defences can reduce error risk
• Effective risk reduction includes:
– error prevention
– error mitigation
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Online resources

www.nopsema.gov.au
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Questions