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Human and organisational factors:
Preventing the causes of incidents before
they happen?
13 October 2014
Stuart King, Technical Products Manager
sking@energyinst.org
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About me
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Energy Institute
Membership
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Todays topic:
Human and organisational factors:
Preventing the causes of incidents before
they happen?
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Tripod
Beta
Tripod
Delta
Hearts and
Minds
Bow Tie
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Jop
Groeneweg
Patrick
Hudson
Jim Reason
Answer: Yes!
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Underlying
causes
Preconditions
Creates
SMS
Leadership
Culture
To take
action or
inaction
Error /
violation
promoting
conditions
An
organisation
Immediate
causes
Performance
influencing factors
(PIFs)
- Competence
- Fatigue
- Environment
- Supervision
- Task
- Etc.
That causes
barriers to
fail
That
result in
Accidents,
incidents and
business upsets
Human action or
inaction
slips, lapses,
mistakes,
violations
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Underlying
causes
Preconditions
Creates
SMS
Leadership
Culture
To take
action or
inaction
Error /
violation
promoting
conditions
An
organisation
Immediate
causes
Performance
influencing factors
(PIFs)
- Competence
- Fatigue
- Environment
- Supervision
- Task
- Etc.
That causes
barriers to
fail
That
result in
Accidents,
incidents and
business upsets
Human action or
inaction
slips, lapses,
mistakes,
violations
Knowledge.energyinst.org
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environmental, organisational
and job factors, and human and
individual characteristics which
influence behaviour at work. 1
Piper Alpha (1988)
Texas City (2005)
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Unintended
actions
Intended actions
Violations
Mistake
Lapse
Slip
Errors
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Job
Individual
Organisation
Personality,
psychology,
height,
weight,
competency
, fatigue
Culture,
leadership,
supervisors,
rules and
procedures
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Individuals
Management systems
Design of facilities and
equipment
Burden of risk
management
Best
possible?
ALARP?
Current?
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Todays topic:
Human and organisational factors: Preventing
the causes of incidents before they happen?
Tools to help us
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Investigation
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Underlying
cause
Immediate
cause
Preconditio
n
Agent
Event Event
Agent
Failed
barrier
Event
Object
Failed
barrier
Failed
barrier
Object
Event
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www.energyinst.org.uk/humanfactors/incidentandaccident
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Risk assessment
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Bow Tie
- Promote barrierbased thinking
Tripod Delta
- Questionnaire survey
- Tries to uncover performance
influencing factors
- Determines the underlying
causes before they cause an
accident
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Introduction to SCTA
SCTA methodologies.
Launched at IChemE Hazards XXII
(April 2011)
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Awareness
Basic
https://
www.energyinst.org/technical/human-and
-organisational-factors/complete-train
ing-resource
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Established
https://www.energyinst.org/humanfactors
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Fatigue
Managing fatigue using a fatigue risk
management plan (FRMP)
Advocates the management of
fatigue using a management system,
in the same way other risks are
managed.
Ultimately it is about ensuring the
workforce can sleep, and carrying out
high risk activities during periods of
alertness (or building in safe guards
so that fatigue cannot cause major
incidents.
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Cognitive
Social
Personal
What is CRM
Its benefits
Situation
Awareness
Decision
Making
Leadership
Team Work
Communicatio
n
Fatigue
Stress
Know the
situation. Know
the solution
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Measurement
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Summary
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Thank you
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