Human Factors

HUMAN FACTORS How to take the first steps...
Human rather than technical failures now

represent the greatest threat to complex and
potentially hazardous systems
James Reason, 1995
Making the UK the safest place to work

in the worldwide oil and gas industry
Step Change in Safety vision
Human Factors: History tells us
Bourbon Dolphin Capsize

No chain is stronger than its weakest link. Where human beings are
involved, experience shows that mistakes are made. That is why it is
necessary to have safety systems that detect human error and make sure
that it does not lead to accidents.
The Commission of Inquiry into the loss of the Bourbon Dolphin, NOU
Official Norwegian Reports 2008:8.
Space Shuttle Challenger Loss

The Space Shuttles Solid Rocket Booster problem began with the faulty
design of its joint and increased as both NASA and contractor management
first failed to recognise it as a problem, then failed to fix it and finally
treated it as an acceptable flight risk.
Presidential Commission on the Space Shuttle Challenger Accident.
(Photograph courtesy of NASA).
Texas City Refinery Explosion

The Panel found instances of a lack of operating discipline, tolerance
of serious deviations from safe operating practices, and apparent
complacency toward serious process safety risks.
The Report of the BP U.S. Refineries Safety Review Panel, January
2007.
Piper Alpha Disaster

It was caused by a massive fire, which was not the result of an unpredictable
act of God but of an accumulation of errors and questionable decisions.
Most of them were rooted in the organisation, its structure, procedures,
and culture.
Learning from the Piper Alpha Accident: A Postmortem Analysis of
Technical and Organisational Factors, M Elisabeth Pat-Cornell, Risk
Analysis Vol.13, Issue 2, April 1993.
Longford Gas Plant Explosion

A combination of ineffective management procedures, staffing oversights,
communication problems, inadequate hazard assessment and training
shortfalls combined to result in a major plant upset with consequential
tragic loss of life.
Have Australias Major Hazard Industries Learnt from the Longford
Disaster? , J Nicol, Institute of Engineers Australia, October 2001.
Contents
Introduction and the first steps
Human Factors in accident prevention
Human Factors: introducing the key topics
How to use this report
Case Study 1:
People will put up with what theyre given...
Case Study 2:
The best people DO make big mistakes...
Case Study 3:
Managers are human too...
10
Case Study 4:
Right job, wrong equipment...
11
Case Study 5:
Assumptions arent always right...
12
Case Study 6:
Knowing that a hazard is there DOESNT always protect youFact.
13
Case Study 7:
Controls dont always do what you expect them to do...
14
Case Study 8:
Close-enough procedures arent close enough...
15
Case Study 9:
Time to stop...
16
Case Study 10: When sleep comes nothing can stop it...
17
Case Study 11: Find a way to do it by hook or by crook...
18
Case Study 12: Helpful guys get hurt...
19
How others have taken the first steps...
20
Finding out more some useful resources
Introduction and the first steps
Introduction
the first steps...
Were all human. We make mistakes and

forget things. Our attention span is limited.
We overlook crucial evidence when making
decisions.
We believe were cleverer,
stronger and faster than we actually are.
Evolution has given us brains that flip into
automatic mode to help us be creative,
efficient and adventurous. There are things
about us that are impossible to change.
Unfortunately, despite our best intentions,
these things can end up putting us, and our
colleagues at risk.
for Everyone
We try and make the human mind and body

do things for which it is not suited. We
design plant and equipment that doesnt take
account of our human fallibilities. We use
procedures, rules and behavioural processes
to attempt to mould peoples behaviour to fit
our expectations. Some of these processes
can be very complex and demanding in their
own right. Permits can become unwieldy,
procedures can become over-complicated.
There can be too many rules. Technology can
become so clever that human beings struggle
to understand it when it goes wrong.
Encourage others to think about human factors
Human factors is about explaining how human

behaviour at all levels of an organisation
can cause accidents. Investigations from
across our industry tell us that human and
organisational factors lie at the root of serious
incidents. If we can recognise when these
factors arise in our activities, we can learn
how to manage them and prevent harm to
our people.
This publication presents twelve case studies
from our industry. They describe the deepseated human and organisational factors that
allowed the incidents to happen. Some are
incredible, some predictable. All are true.
Each case study is an opportunity for you
and your colleagues to recognise how human
factors impact on your work. It gives you a
chance to use your expertise in what you
do, to prevent human factor incidents from
happening. To encourage you further we
have provided some examples of how other
organisations have tackled human factors
issues.
This publication will help you to identify some
simple first steps that will help you, your
team and your organisation manage human
factors. YOU can make a difference.
Now read on and commit to taking the first
steps.
I will.
Challenge procedures that are difficult to follow

Report any human factors concerns talk to your supervisor
about problems you recognise in the case studies.
Take the time to consider how my actions and decisions can
affect others now and in the future
Report plant and equipment that is difficult to operate,
maintain, inspect and test safely
for Managing Directors and Management

I will.
Appoint a Human Factors Champion someone whose job it

is to understand what human factors is about, how it applies to
your business and who can help you.
Make a simple plan to tackle human factors issues use this
document to help identify where you want to start. Choose one
topic and deal with it.
Take the time to listen to the workforce they know best where
the problems are. Get their views on the case studies and how
they apply to your business.
Give feedback to the workforce tell them what issues youre
working on and how you intend to deal with them.
for Supervisors
I will.
Use the case studies to identify human factors topics under

my control and deal with them involve your team in the
process.
Ensure human factors topics are discussed during work
planning, preparation and execution
Incorporate human factors into my incident investigations
dont be content with human error or procedural violation as a
conclusion. Look for the reasons behind the actions.
Take the time to listen and give feedback to my team on human
factors topics - your team knows best where the problems are.
Ask their views on the case studies and how they apply to your
workplace. Tell them how you are going to deal with any issues.
for Safety Representatives

I will.
Take human factors concerns to the relevant safety forums

Talk to my constituents about human factors issues and
concerns in their areas
Human Factors in accident prevention

Human factors refer to environmental, organisational and job factors, and human and individual
characteristics, which influence behaviour at work in a way which can affect health and safety
Health and Safety Executive
Human Factors covers a huge range of topics, which can be grouped under three key headings:
Plant and Equipment:
Processes:
People:
Plant and equipment

should be designed,
located and modified to
reduce errors during use,
maintenance, inspection
and testing. The effects of
the environment in which
plant and equipment is
operated must also be
considered. Design should
consider emergency
situations when errors are
more likely.
Procedures should be
clear and practical.
Risk assessment and
incident investigations
should consider human
factors. Safety critical
communications must be
clear, unambiguous and
understood by all involved.
Organisations must manage
change. Staffing levels
and workloads must not
jeopardise safety.
People need the right

training and competence
along with the right level of
supervision. Strong safety
leadership should underpin
everything. Human error
and its management should
be understood along with
influencing factors like fatigue.
Good working practices
should be reinforced. Poor
practices should be identified,
understood and then changed.
Human Factors and the barrier model

In our industry the most widely known model of accident causation is the barrier or Swiss Cheese model. In its simplest terms
we have three barriers preventing accidents Plant and Equipment, Processes and People. The presence of one or more of
the barriers will prevent accidents happening. If we have a gap in one or more of the barriers then an accident can occur. The
effectiveness of all three barriers can be influenced by a range of human factors. If we fail to take account of these human
factors then gaps may open up in one or more of the barriers thereby increasing the chances of an accident. To minimise
the impact of human factors we should always be looking to eliminate hazards through good engineering, clear and effective
processes and procedures, and only then relying on the individual.
Organisational Culture
An organisations safety culture is the collective values and attitudes of its people towards safety. It is often described as the
way we do things around here. Organisational culture influences human performance and human behaviour at work, and
whether we judge a behaviour as good or bad. It will have an important influence on the effectiveness of the barriers and
their vulnerability to human factors issues. It will also determine an organisations approach to learning lessons from past
accidents.
Human Factors: introducing the key topics

The UK Health & Safety Executive has identified the human factors issues most closely associated
with the Oil and Gas industry. They are:
Plant and Equipment:

Human Factors in Design:
The design of control rooms, alarm systems, plant
and equipment can have a huge impact on human
performance. The work environment (lighting, thermal
comfort, working space, noise and vibration) also impacts
human performance in unexpected ways. Designing tasks,
equipment, processes and the work environment to suit
the user can reduce human error, accidents and ill-health.
Processes:
Procedures:
Procedures include method statements, work instructions,
permits to work etc. Incomplete, incorrect, unclear or
outdated procedures can lead to short cuts and errors.
Procedures should be managed and use a format, style
and level of detail appropriate to the user, task and
consequences of failure.
Risk Assessment and Incident Investigation:
Risk assessments need to recognise the limits of what
humans can and cant do and take into account the impact
of job, personal and organisational factors when deciding
on control measures. Incident investigations need to
dig down to establish the conditions that allowed human
failures to occur. The investigation needs to take account
of all aspects of human factors that may have contributed
to the incident.
Safety Critical Communications:
Frequent and clear two-way communication (spoken and
written) is essential for safety in any task. The method
of communication, language, timing and content are all
important factors in effective communication. Checking
understanding is also critical.
Learning Organisations
A learning organisation values and encourages learning
from its own and other organisations experiences.
Learning is linked to corporate memory, which must
withstand organisational changes. Learning organisations
are characterised by constant vigilance and seek out bad
news as well as good. Understanding human factors can
turn organisational learning into preventative solutions.
People:
Leadership:
Setting of expectations, leading by example and decision
making that takes safety into consideration is essential
in creating a strong safety culture. This means taking
personal responsibility for safety.
Maintenance, Inspection and Testing:
Maintenance is heavily reliant on human activity. The
actions and decisions of maintenance personnel should
not leave equipment or systems in an unsafe state. Even
experienced, highly-trained, well-motivated technicians
can make simple errors that can cause an incident. Human
error in maintenance is largely predictable and therefore
can be identified and managed.
Supervision:
Effective supervision has a significant positive impact
on a range of human factors such as compliance with
procedures, training and competence, safety critical
communication, staffing levels and workload, fatigue and
risk assessment.
Fatigue:
Fatigue refers to the issues that arise from excessive
working time or poorly designed shift patterns. It can lead
to errors, slower reaction times, and reduced ability to
process information, memory lapses, absent-mindedness,
and losing attention.
Organisational Change:
Organisational change covers a range of issues e.g.
staffing levels, use of contractors or outsourcing, combining
departments, changes to roles and responsibilities etc.
Similar to plant or process change, organisational change
can have direct and indirect effects on the control of
hazards. Organisational changes need to be planned and
assessed.
Managing Human Failures:

This topic is about predicting how people may fail through
errors or intentional behaviours. If you are relying on
people to prevent a serious accident, what would happen
if they missed a step in a procedure? What would happen
if they missed an alarm, or pressed the wrong button? If
the consequences are serious then it is something you
should manage.
Staffing Levels and Workload:

Changes in staffing levels and increase/decrease of
workload often occurs as part of organisational change. It
is important to consider the impact of this change on the
control of hazards.
Training and Competence:

Training gives people new knowledge and skills, but people
need to apply and practice these to become competent.
Training and competence can reduce errors caused by
lack of knowledge and teach people behaviours that will
keep them safe. This is not a universal safeguard though.
Even the most experienced and competent individuals
can make mistakes.
Contractor Interfaces:
Contractors (including suppliers and third parties) face
the same human factors issues as their clients. Some of
these issues are critical at the client-contractor interface,
e.g. communication, supervision, organisational culture,
competence.
Behavioural Safety:
Behavioural safety is an approach which tries to promote
safe behaviours and eliminate unsafe behaviours.
Behavioural safety programmes typically involve
observation of workplace practices followed-up by
individual feedback and reinforcement of good practices.
How to use this report...
Recognising ourselves in case studies

This report is designed to help you recognise where Human and Organisational Factors appear in your workplace.
We have taken real incidents and looked at the human factors that lay at the root of them. The conclusions are not
exhaustive: you will probably find other causes and solutions that we have not thats because you know more about
human factors than you realise.
Case Study 5
What happened?
Read the brief description

of the incident. All are
based on real events.
The work-team were using a high pressure water jet cutting system to
cut redundant steelwork and pipework. The job was additional work
that had been added to the scope after the team had arrived at the
platform. The work-pack made only a general reference to removing
equipment in the area. The team were instructed to cut all material
in the area and the toolbox talk did not indicate which items should
be cut or left. Various pieces of steelwork and pipe were marked with
red-and-white tape.
The team began cutting steelwork and pipes away from the deckplate. Shortly after cutting a pipe an oily smell was noticed and the
team stopped work. The area authority confirmed that they had cut
through a live drain line.
Understand what people

did intentionally. What
motivated them to act like
this?
Understand what people
did unintentionally. What
caused them to make this
error?
What barriers would help to
prevent this incident?
In the absence of any other indication, the team had assumed that
the red-and-white tape marked the lines and steel which needed to
be cut. In fact it marked trip hazards on the worksite.
Barriers
What did people do intentionally?
The team were asked to do work which was not in the original scope
The work was not in the original scope so had not been properly planned.
Items of equipment to be cut were not clearly identified. There was no
Management of Change.
The supervision did not communicate the scope and hazards properly
The toolbox talk didnt discuss the items to be cut, or point out the hazards from
the live lines in the area.
3
5
Understand the human

characteristics that lie at the
root of the case, and how to
manage them
What did you recognise?
What can you do?
What human factors were involved?
What did people do without meaning to?
The team thought the red-and-white tape marked the items to be cut
Having been given the instruction to cut everything in the area, the team
presumed that red-and-white tape marked the items to be cut.
Managing Human
Failure
What can we learn from this incident?

The operations team assumed people would understand that red-and-white tape marked trip hazards. This wasnt
confirmed with the workparty.
When we make decisions we interpret the information available to us. Our interpretation is influenced by what has
happened before, and what we expect to happen this time. This sometimes leads to incorrect conclusions.
A clear work-pack is a good start, and an effective tool-box talk helps to get everybody clear on what needs to be done.
Talk about the job at the worksite. Walk, point and mark the plant to be worked on. Those doing a job should be able
to explain the job and their role in it.
Late changes and additions often lead to incidents - thats why Management of Change processes are important.
Those raising the change need to think carefully about the possible consequences, and work-teams should challenge
work that comes in without good quality work-packs.
What does this make you think of in your workplace?

Take the first steps now...
You can use this report in different ways; we have made some suggestions below.
In a tool-box talk
In a team or safety meeting
To engage safety leaders
When planning a job
To identify your first steps
Safety Critical
Communication
Procedures
Risk Assessment
Case Study 1
People will put up with what theyre given
What happened?
A driller was operating a top drive drilling unit. There was a stand of drill pipe
clamped in the slips, and the top drive was raised and held on the brake. The
driller saw a roughneck step into a hazardous area of the rig floor, and reached
for the microphone to tell the roughneck to step back. As he did so he slightly
released pressure on the brake. The top drive descended, bending the drill pipe
which fortunately did not spring out. A 27kg pipe-guide fell 90 feet to the floor,
narrowly avoiding the roughneck.
Investigation found that at the time the incident occurred, the driller had all four
limbs utilised. To stop personnel from entering the drill floor, the driller had to
lean towards the microphone, use his left knee to operate the talk-back system,
use his right foot on the manual brake, whilst still trying to maintain control of the
top-drive using the hydraulic brake. The brake did have a dead-man position
that applied the brakes if the handle was released. However, simply easing off
hand-pressure actually removed the brake. This was a counter-intuitive design.
The system was known to be difficult to operate.
Barriers
People accepted the poor layout and controls, and got on with the job
As different items of equipment were added, controls were placed wherever
they could be, without considering how they would have to be used together.
Many different people knew about the problems in the dog-house, but a can
do attitude meant that people just put up with poorly designed equipment and
controls.
Human Factors in
Design
Risk Assessment
The driller released hand-pressure on the brake control

If the brake-control had been entirely released the brake would have applied
automatically. Unfortunately, a small release in hand-pressure was enough to
remove the brake.
Keeping your arm steady during a task requires concentration and balance.
Changing your position affects this fine-control. The movement towards the
microphone reduced pressure on the brake and the top drive descended.
Managing Human
Failures

Older equipment has sometimes been subject to incremental change, without any thought to how changes will interact.
Apply a good quality management of change process to each change, to identify these interactions before they become
a problem.
Our ability to carry out physical fine-control tasks is influenced by our body position and balance, and requires
concentration. An ergonomist can advise on what people will be physically capable of in different situations.
People will put up with poorly designed equipment and make the best of it. Designers cant foresee all situations.
Speak up if there is equipment which is difficult to operate.
Get experienced end-users involved in the design and commissioning of equipment.

Case Study 2
The best people DO make big mistakes
What happened?
The most senior electrician on an installation was asked to perform a
multi-point isolation on one of two gas turbines.
He took his permit, went to the switch-room and correctly identified the
turbine to isolate. He was familiar with the switch-room and the layout of
the turbine electrical systems. He began isolating the correct turbine.
He then received a call on the public address (PA) system to come to
the galley, which he ignored because the job he was working on was
important. A second announcement called him urgently to the galley. The
electrician went to the galley where he found the chef standing next to an
open fridge complaining that the fuse had blown. Annoyed that the chef
had interrupted an important job with one that could have waited, the
electrician replaced the fuse and then returned to the worksite.
He completed the remaining isolation points, but on the wrong turbine.
The error was discovered days later when the electrician had left the installation. When he was told of the mistake
he immediately offered his resignation, which was not accepted. An investigation found that the distraction during an
important job had led to the error, which in this case was discovered before any harm was caused.
Barriers
Intentional behaviours were not the main cause of this incident.
The electrician applied the isolation to the wrong machine

The electrician made an error - he performed the right action (applying
isolations) on the wrong equipment. This was made more likely to
happen because he was distracted during a complex job. Becoming
angry at being called away may also have contributed to the error.
Safety Critical
Communication
Managing Human Failure

Supervision

Performing the right action on the wrong piece of equipment is a common problem in our industry.
The most experienced and competent personnel are sometimes more prone to error because they can do things
automatically without thought.
When we get distracted we may forget things, e.g. where we were in a sequence of steps or a procedure. This can lead
to mistakes with serious consequences.
You can prevent this type of incident by double-checking against the permit or asking another person to confirm that
you are working on the right equipment. When the jobs complete, have it independently checked to detect errors.
Supervisors can help by recognising those jobs which could have serious consequences if someone makes a mistake.
Minimise distraction for those carrying out complex or critical tasks. Encourage people to have their work checked for
errors.

Case Study 3
Managers are human too
What happened?
After going through a difficult downsizing a company decided to
restrict recruitment and personnel moves, in an attempt to avoid
painful redundancies in the future.
At the time there was great demand for personnel in the oil and gas
market. One installation lost a number of its operational leadership
to another company. For a while the installation managed. It was
able to maintain its minimum manning levels, and less experienced
personnel were asked to step-up into leadership positions. The
Offshore Installation Manager (OIM) and offshore engineer began
micro-managing work on the installation.
Unfortunately the recruitment restrictions introduced lengthy delays

into the process of replacing personnel. Twelve months later the
installation was still without replacements. When the attention of the
OIM and engineer was distracted by another major issue, those standing-in could not maintain the safety standards.
A cluster of serious incidents (including a large gas release) led to an investigation which revealed the situation. The
company accelerated replacement of the missing personnel.
Barriers
Leaders made it difficult to recruit and move operations personnel

They did this with the best of intentions, to prevent people having to suffer the
threat of redundancy in the future. Unfortunately this prevented the recruitment of
new operations leaders to replace losses to other companies.
Site managers made the best of the situation
Whilst pursuing replacements, the OIM and engineer found a way to work through
the problem by increasing the time they spent on site supervising and coaching.
Stand-ins didnt have the experience and skills to maintain standards

Often we take technically gifted people and promote them into a leadership
position. However, the two roles often require very different skills. Its even harder
for stand-ins who are in the role only temporarily, and may still feel a member of
the team they are having to supervise. In this case temporary stand-ins could
probably have been adequately supported over a short period of time, but this
became difficult over the longer period.
Organisational
Change
Staffing Levels &
Workload
Leadership
Supervision

The resourcing of the right people to your worksites is essential. There should be sufficient flexibility to allow your
assets to have the right people at the right time.
Managers and leaders are human too. It is difficult to see all the potential consequences of a decision or change.
Equally, managers and leaders should be cautious of making blanket rules or decisions.
Temporary personnel changes need to be monitored closely. Stand-ins are likely to require coaching and mentoring.
The effect on supervisors providing this additional supervision also needs to be considered. Workload or job demands
may need to be reduced, or more staff provided.

Case Study 4
Right job, wrong equipment
What happened?
A work party unbolted the wrong valve on a flare line causing a large gas release.
Relief valves were being removed for recertification during a shutdown. Normally a
breaking-containment permit would have been issued, but because the plant was
hydrocarbon-free, this rule was relaxed, and a cold-work permit was issued for the task.
The recertification programme over-ran, and it was decided to complete the
maintenance of some valves after the plant was back in production. However the
rule requiring a breaking-containment permit, was not reinstated. The workscope was
also handed over from project to operations leading to uncertainty of ownership and
responsibilities.
The permit listed four valves. When the work team went to the site they found
scaffolding erected next to relief valve PSV1068. They believed this to be the correct
valve. Unfortunately it was not - they were supposed to be removing PSV1066 which
was on the deck above.
They attempted to remove the bolts from the live-side of the valve, but the high pressure in the vessel prevented the bolts
from releasing. Instead they removed all of the bolts from the flare-side of the flange. Gas was released as they split the
two halves of the flange. They tried to remake the flange but could not as the valve had become misaligned with the pipe.
The control room was informed of the gas leak and several gas alarms triggered. A full plant blowdown was initiated by
the control room operator. Several tonnes of gas were released from the open flange which, had an ignition source been
present, would have generated a serious explosion.
Barriers
The permit rules had been relaxed and not reinstated

During the shutdown the rule requiring a breaking-containment permit was
relaxed. It was not reinstated when the shutdown was complete.
Change of responsibility led to uncertainties of ownership
Uncertainty existed around who was responsible for the relief valve work
post-shutdown i.e. production or maintenance supervisor.
The work party selected the wrong valve

The permit stated that all the valves were on the same deck. The scaffolding
access had been erected next to this valve. Furthermore, the valve tag
was similar, and difficult to read. This was enough to suggest to the work
party that they were working on the right valve.
Procedures
Safety Critical
Communication
Maintenance, Inspection
& Testing
Managing Human Failure
Supervision

Breaking containment on hydrocarbon systems is a high risk activity, involving people making judgements. Simple
errors, assumptions or misjudgements can have disastrous consequences. Checking can catch errors.
When breaking containment, you must confirm that you are working on the right equipment. You should also have a
way of checking that the right steps have been taken before opening up the hydrocarbon system. When identifying
equipment - walk - point - check!
If something is not as you expected, step back and ask why?. The difficulty in removing the live-side bolts should
have indicated that something was wrong. Applying basic principles in breaking bolted joints could have recovered this
situation.
Changing conditions, scopes of work and responsibilities must be managed to ensure responsibilities and ownership
are clear at all times.
10

Case Study 5
What happened?
The work-team were using a high pressure water jet cutting system to
cut redundant steelwork and pipework. The job was additional work
that had been added to the scope after the team had arrived at the
platform. The work-pack made only a general reference to removing
equipment in the area. The team were instructed to cut all material in
the area and the toolbox talk did not indicate which items should be
cut or left. Various pieces of steelwork and pipe were marked with redand-white tape.
The team began cutting steelwork and pipes away from the deck-plate.
Shortly after cutting a pipe an oily smell was noticed and the team
stopped work. The area authority confirmed that they had cut through
a live drain line.
In the absence of any other indication, the team had assumed that the
red-and-white tape marked the lines and steel which needed to be cut.
In fact it marked trip hazards on the worksite.
Barriers
The team were asked to do work which was not in the original scope
The work was not in the original scope so had not been properly planned. Items
of equipment to be cut were not clearly identified. There was no management
of change.
The supervision did not communicate the scope and hazards properly
The toolbox talk didnt discuss the items to be cut, or point out the hazards from
the live lines in the area.
The team thought the red-and-white tape marked the items to be cut
Having been given the instruction to cut everything in the area, the team
presumed that red-and-white tape marked the items to be cut.
Safety Critical
Communication
Procedures
Risk Assessment
Managing Human
Failure

The operations team assumed people would understand that red-and-white tape marked trip hazards. This wasnt
confirmed with the workparty.
When we make decisions we interpret the information available to us. Our interpretation is influenced by what has
happened before, and what we expect to happen this time. This sometimes leads to incorrect conclusions.
A clear work-pack is a good start, and an effective tool-box talk helps to get everybody clear on what needs to be done.
Talk about the job at the worksite. Walk, point and mark the plant to be worked on. Those doing a job should be able
to explain the job and their role in it.
Late changes and additions often lead to incidents - thats why management of change processes are important.
Those raising the change need to think carefully about the possible consequences, and work-teams should challenge
work that comes in without good quality work-packs.

11
Case Study 6
Knowing that a hazard is there DOESNT

always protect youFact.
What happened?
During installation of a temporary piping system an employee sustained
serious injuries when he stepped through an opening in the deck and
fell 35 feet to the deck below. The deck opening was fully enclosed by a
scaffolding barrier at the time of the accident.
A new drilling service team were working on the platform. It was not
clear whether operations or drilling were responsible for monitoring the
work. Consequently no-one checked what was happening at the worksite. It later emerged that the team were regularly violating rules and
procedures.
A supervisor was preparing light-weight plastic pipe to clean up a spill.
He needed help to run the pipe across the barriered area. The employee
crossed the scaffolding barrier with the supervisors knowledge. As the
work proceeded the employee gradually moved closer to the opening.
Whilst the employee was moving the pipe he took a step backwards and
fell through the opening.

The supervisor allowed him to cross the barrier

Within this team barriers may have been crossed routinely without any
comment from supervisors.
The employee crossed the barrier
The supervisor was involved in the job and asked the employee to help. When
the boss asks you to do something people may not even think to say no.
Barriers
Human Factors in
Design
Contractors
Risk Assessment
The employee stepped back into the opening

The employee knew the opening was there but believed he could avoid it.
When his attention became focused on the job he stopped thinking about the
hazard from the opening. The brain ignores information which is irrelevant
to the immediate task, so it can concentrate mental resources on the job.
Leadership
Supervision
Managing Human
Failure

People falling through openings that they know about is a common and often fatal incident.
Paying very close attention to one thing means we pay less attention to other things - like nearby hazards. Dont rely
on people paying attention to prevent a serious hazard.
We are all influenced by the behaviours of our managers, supervisors and team mates. Leaders and supervisors that
allow unsafe actions or conditions send a strong message to others that this is acceptable.
A worksite may have the best safety culture in the world, but you cant rely on that culture rubbing off on a new team.
Keep an eye on new teams to verify that your high standards are being adopted.
12

Case Study 7
Controls dont always do what you expect

them to do
What happened?
A new supply vessel was being delivered from its manufacturing
shipyard in China to the North Sea. On its voyage across the ocean the
crew discovered a quirk in the control system. Under manual control
the ships thrusters could be controlled using a joystick. However, the
joystick had been configured to apply the thrusters in the direction that
the joystick was pushed. This meant that if the joystick was pushed right,
the thrusters were applied to the right, and the boat moved to the left. If
the joystick was pushed left, the thrusters were applied to the left, and
the boat moved to the right. Having discovered this, the crew decided this
was acceptable and continued to use this control on several occasions
throughout the voyage.
The ship was working off a fixed installation when it struck the jacket at
some speed. The vessel had started to move towards the installation
and the Master tried to move the vessel away by moving the joystick
away from the vessel. Unfortunately this applied thrust in the opposite
direction, accelerating the ship into the installation. The ship struck the
installation leg, but no damage was caused.

The crew accepted the non-intuitive controls

Although the joystick didnt behave as they expected, they believed
that they would get used to moving it in the opposite direction and put
up with it. This should also have been detected in acceptance trials.
The Master pushed the joystick in the natural direction

When the Master was focused on maintaining the ship on station he
automatically pushed the joystick in the direction that made sense
to him.
Barriers
Human Factors in Design
Risk Assessment
Managing Human Failures

Well-designed controls should map onto the things they control. For instance, some cooking stoves have four rings
controlled by a line of switches down one side. Others have the switches positioned in the same pattern as the rings
so that you can easily see which switch operates each ring.
Controls should make natural sense. If you want it to go left, push the joystick left. In this case the joystick control did
not map onto the direction that people would normally expect the control to take them.
Operator interfaces are often the last things to be installed, and some suppliers have been known to cut corners in
order to meet delivery deadlines. Clients should specify requirements for well-designed, usable operator controls in the
contract, and ensure these are met in acceptance tests.
Dont put up with non-intuitive controls, change them and apply management of change.

13
Case Study 8
Close-enough procedures arent close enough...
What happened?
Burning fluids ran down the outside of the lit flare stack after a knock-out
drum filled with crude oil.
While preparing for a shutdown, a drain valve was opened to depressurise
a meter skid. The operator didnt realise that the meter skid was still
connected to the process via an open skid discharge valve which he
should have isolated. Crude oil flowed into the skid though the open
drain valve and into the flare line. It overflowed the flare knock-out drum
and passed on into the lit flare.
There was no procedure for draining the skid so the supervisor asked
the operator to use a maintenance procedure. The steps required to
isolate and drain the skid were in different parts of the document. The
supervisor and operator discussed which parts of the procedure could
be used. The operator misunderstood the instruction and started at the
wrong step. He missed the step where the outlet valve was closed.
The high level trip on the drum should have shut down the process.
Unfortunately the switch had been incorrectly calibrated, and allowed
liquid into the flare where it was ignited.
Barriers
The supervisor asked the operator to use a procedure which

was not suited to the task
Although the procedure could be used to drain this skid, it included lots
of other unnecessary steps which were likely to cause confusion.
The operator opened the vent valve without realising the outlet
valve was open
The operator became confused about where to start the procedure,
and picked the wrong place.
Procedures
Safety Critical
Communications
Training & Competence

Supervision

Procedures should be specific to the task being done.
The sequence is vital, so anything which disrupts that sequence (such as jumping from one section to another)
increases the chance of error.
Where a procedure is not right, take time to amend it. Do a risk assessment to ensure that you know what hazards
you need to control. Involve the people that have to carry out the job and technical staff who understand the process
hazards that the procedure should address.
Dont rely on automatic shutdowns to protect you. Safety systems can fail in all sorts of unpredictable ways - many
associated with human error!
14

Case Study 9
Time to stop
What happened?
An offshore installation suffered a gas release after gas from a Third Party
subsea system was accidentally allowed into the Platform Seawater
Injection system (SWI). The SWI pumps high pressure seawater into
the reservoir and is not designed for hydrocarbon gas.
Engineers planned to empty a subsea gas-lift flowline that had been
filled with water for maintenance (Figure 1). The plan was to push water
out of the line and down a seawater injection well using production gas.
It was calculated that 6 hours of gas-flow would be required to push the
water into the SWI well at a well-head pressure of 35 barg (Figure 2).
A procedure was written by the Third Party, and provided shortly before
the job was due to start. There was no time made available to review the
procedure and it was considered routine as a similar type of operation
had been done, previously. Buried in the middle of the procedure was a
warning that the gas-flow should not exceed 6 hours.
Gas
system
SWI
system
Gas
system
SWI
system
Gas
system
SWI
system
Subsea gas-lift line
SWI line
SWI
well
SWI line
SWI
well
SWI line
SWI
well
Operators started the gas flow, but then it took 9 hours to get the 35 barg well-head pressure. Operators then continued
flushing for a further 6 hours. Consequently, gas flowed for 15 hours rather than the 6 hours intended (Figure 3). After
the water was flushed out a volume of gas flowed back into the seawater system and remained undetected for several
weeks whilst the system was offline for maintenance.
On the day of the incident an operator opened a drain valve whilst restarting the SWI. Gas blew out of the drain, setting
off gas alarms in the vicinity. The operator immediately shut the valve and the module was made safe.

The procedure was not reviewed

The procedure was supplied at the last moment, and had not been reviewed by
a competent person, even though this was an unusual operation. It hadnt been
written with those doing the job, and no review or HAZOP (Hazard and Operability
Study) was carried out.
The operators didnt stop the job and take time to get the procedure reviewed
They had not been involved in writing the procedure, and had no assurance that the
procedure was correct. However the job had been planned for some time and they
were reluctant to delay it.
The operators did not detect the warning

Although the operators did use the procedure, their actions didnt reflect the engineers
intention to only flow gas for 6 hours. The crucial information was buried in the text
of the procedure.
Barriers
Human Factors
in Design
Procedures
Safety Critical
Communications
Contractor Interface
Managing Human
Failures

There have been several very serious incidents involving gas being accidentally routed into plant not designed to cope
with it.
Procedures need to be prepared in advance and reviewed by a competent person(s).
Describe possible abnormal situations in procedures and clearly state what actions should be taken if they occur.
Conventional hazard assessment techniques like HAZOP can detect errors made by designers and predict errors by
operators. Specific HAZOP checklists may ask what would happen if a step is omitted or done out-of-order, or too late.
Interfaces (communication and procedures), between Third Parties and the Operator, can be a weakness, recognise this
and manage the associated risk.

15
Case Study 10
When sleep comes nothing can stop it
What happened?
A drilling company was to drill its first High Pressure High Temperature (HPHT)
well. A significant amount of new equipment had been fitted to the drill rig for
HPHT service. The company found it hard to recruit tool pushers with HPHT
experience in the UK as not much HPHT drilling had been done before in the
North Sea. They were able to recruit one tool pusher experienced in HPHT
equipment from the US and one from the UK with experience of the standard
rig and UK procedures but without HPHT experience. The plan was for the one
with HPHT experience to work as day tool pusher and the one without to work
as night tool pusher.
Once drilling started it soon became clear that the only way they could work the
equipment was for both to be on duty with one maintaining the drill operations
while the other concentrated on the HPHT equipment. They came up with a
plan that they would both work 20 hour shifts and take alternate 4 hour breaks.
They managed this for three days before one fell asleep at a critical stage and
they lost control of the well.
Barriers
The tool pushers worked longer shifts believing they could remain alert
and in control of the situation
The tool pushers thought that the work was so hazardous and demanded so
much concentration that it was bound to keep them awake. They underestimated
the impact on their mental and physical capabilities. Relying on each other to
stay awake was doomed to failure.
The tool pushers decided to continue with the work pattern even though they
recognised they were getting very tired and may fall asleep.
One of the tool pushers fell asleep

Nobody has conscious control over the point when they fall asleep.
Risk Assessment
Staffing Levels
& Workload
Fatigue
Leadership

People arent superhuman. Organisations and individuals need to understand how mental and physical limitations can
impact on safe activities. Manning levels must be properly assessed to ensure safe operations. New equipment and
processes may require a temporary over-manning and increased levels of supervision.
We know that it is possible to fall asleep while driving, even though the consequences are severe. Often we push on
despite the warning signs. Once the body decides to sleep we have very little conscious control. Falling asleep is not
the only consequence of fatigue. Fatigue also reduces a persons mental capabilities and makes them more prone to
making mistakes and poor decisions.
If you are doing a safety critical job or task and are at risk of falling asleep stop, get some help and get some rest.
There is a lot of good advice on how much rest to get, how to improve the quality of sleep and how to assess working
patterns for fatigue risk.
16

Case Study 11
Find a way to do it - by hook or by crook
What happened?
Whilst replacing lifting runway beams, the willingness of a rigging crew
to get the job done endangered their own lives.
A beam was being removed from the module roof by the rigging crew.
A supervisor was inspecting the site and noticed that the chain blocks
being used to lower the beam had been attached to the beam by using
a technique known as back-hooking (i.e. wrapped around the beam
and hooked back on itself). This was a technique prohibited on the
site because there had been incidents when the hook had twisted and
released the load. Operations were not being carried out according to
the lifting plan for the job.
Work was stopped immediately and the load made safe. The supervisor highlighted that back-hooking was unacceptable
practice and the work-party agreed. However, in their opinion, there was no other way to do the job. When they looked
again at the job there were safer ways of completing the lift and these were written into a new lifting plan.
Had the hook released, one of the rigging crew could have been killed.
Barriers
The work party decided to use a technique which was

prohibited
When challenged, they realised that the technique was not safe, but
believed it was the only way of getting the job done.
Unintended behaviours were not the main cause of this situation.
Risk Assessment
Procedures
Supervision
Managing Human Failures

We love to find a way to do the job were given. Sometimes we will accept greater risk to achieve the goal.
We often have to solve problems in our job. However, when were about to do the job with the materials available to
us, we often make unwise compromises - compromises we wouldnt make when we are planning the job.
When we think about risks as a group, we can end up taking bigger risks than we would as an individual. This is called
groupthink. We reassure each other and give each other confidence to do something that we wouldnt do alone.
When planning a job, assess the practical problems you will encounter and how you will deal with them. Test whether
this is something that you would take responsibility for if you were doing it alone.

17
Case Study 12
Helpful guys get hurt
What happened?
The hand of a member of the catering crew was badly damaged when it
became trapped beneath a heavy steel plate.
An engineering contractor work party was working on fitting a new bed
plate for an industrial spin drier in an installations laundry. The team were
lifting the heavy bed plate (weighing around 200kg) onto the six raised
securing points. The work had been going on for two days, under a Work
Permit. The catering crew were aware of the nature of the work and the
need to take care in the vicinity.
One half of the plate was supported on stacked planks. The other half was
being lowered onto the securing points by three of the work-party. The
laundryman rushed forward to assist just as the plate was being lowered.
His hand became trapped between the plate and the raised securing
points. The crush amputated the laundrymans middle finger.
Barriers
The laundryman rushed in to help

Although he wasnt part of the job and hadnt been involved in the risk
assessment and preparation for the job, he rushed in to help without
thought.
Risk Assessment
The laundryman placed his hand in a trap point

He was unaware that there were raised supports against which his hand
would be trapped.
Behavioural Safety
Supervision

We employ many good, enthusiastic and well-meaning people in our workplaces. People will rush in to help without a
second thought. Lifting operations are particularly prone to this: something goes wrong, everyone takes a step back,
but the novice steps forward.
Recognition-based problem solving is a feature of human beings. We recognise something we think we can fix or
help with and we go straight into action without any thought.
Dont jump in to help and dont allow people to jump in and help. In this case a tape barrier may have been enough to
stop the laundryman from getting involved.
18

How others have taken the first steps...
Tackling human factors is simpler than you think and there are all sorts of ways you can make a difference.
The examples below show how companies have tackled some of their human factors issues.
Plant and Equipment

Getting it right in control rooms
A company operated a number of fixed oil and gas platforms with 20-year old control rooms. Many had been modified
and upgraded over time. This was causing difficulties for Control Room Operators (CROs). A review found that
the layout of the controls, displays and annunciators made it difficult for CROs to understand developing situations.
Control rooms were hot and noisy making concentration difficult. Lighting caused glare and reflection on display
screens. Alarms werent prioritised making it possible for operators to miss a crucial alarm. There were too many
alarms during normal operations many of which were nuisance alarms. The company redesigned the control room
layout, lighting and air conditioning. Alarms were prioritised so that important information was easier to spot and
nuisance alarms were engineered out. The company recognised that the control room was compromising the CROs
ability to guarantee the integrity of the systems barriers. Poor human factors in the design of successive control room
modifications was corrected with a complete redesign to strengthen the system barrier.
Processes
Learning HF lessons through an Accountability Framework
To improve the human factors learning from incidents/near-misses, a company introduced an Accountability
Framework, which provided a consistent method for interpreting human factors issues, as well as management
system failings. The framework helped investigation teams to better understand not only what happened, but why
it happened. Drawing on published HSE guidance on human factors, the framework provided a clear and logical
approach to the characterisation of unsafe acts and their underlying causes. This is leading to better outcomes in
terms of corrective actions and the subsequent learning from events. The offshore workforce has also welcomed the
consistency and transparency that the framework brings.
People
Making hydrocarbon leaks important
A company wanted to change a culture of tolerating hydrocarbon leaks. It had a good record of reducing personal
injuries but struggled to tackle leaks. The company adopted a simple four-part model of the ingredients of a good
safety culture: management commitment, two-way communication, wide participation and organisational learning.
Using the model the company designed a programme that prioritised leak reduction, consulted with the workforce on
areas to improve and involved all the departments of the business. It also learned from other operators about how to
reduce releases. There was a 25% reduction in leaks in the first year, and an 80% reduction during the second. This
is great human factors behaviour on the part of the employees of this company. When a leak occurs both mechanical
and systems barriers have been breached and only the final barrier, the human, stands in the way of a potential major
incident. Let us all do everything we can to keep dangerous substances contained.

19
Finding out more - some useful resources
Publications
Web
Step Change in Safety have produced a number of

publications that link into human factors.
Health and Safety Executive

Find out more about the HSEs Human Factors key
topics and available resources on their website:
www.hse.gov.uk/humanfactors
These include:
Personal Responsibility for Safety - Guidance
ISBN 978-1-905743-01-8
Look this Way - Safety Observational System
Guidelines
Changing Minds - A practical Guide for Behavioral
Change in the Oil and Gas Industry
Task Risk Assessment Guide
ISBN 978-1-905743-12-4
Hydrocarbon Release Reduction TOOLKIT
ISBN 978-1-905743-14-8
Fatality Report - How will you be making your next
trip home?
ISBN 978-1-905743-03-2
International Association of Oil & Gas Producers

Guidance, case studies & tools
http://info.ogp.org.uk/hf
Energy Institute
Guidance on many HF topics relevant to the oil &
gas industry
www.energyinst.org.uk/humanfactors/
Institute of Ergonomics & Human Factors
Guidance on finding an expert who can help with
your specific problem
www.ergonomics.org.uk
Petroleum Safety Authority Norway
Advice on HF topics from the Norwegian Regulator
www.ptil.no/hto-human-factors/category140.html
Training
Institute of Chemical Engineers
Human Factors in Health & Safety - training
targeted at people who will be HF Champions
www.icheme.org/human_factors/
20

Dont forget to take those first steps...start now
Acknowledgements
Step Change in Safety would like to thank everybody - the workforce networks who provided valuable feedback and
the human factors workgroup who gave of their time and resources to develop this guidance.
designed by foyer graphics
ISBN No. 978-1-905743-16-2
address

3rd Floor
The Exchange 2
62 Market Street
Aberdeen
AB11 5PJ
telephone
fax
01224 577268
01224 577251
email
website
[email protected]
www.stepchangeinsafety.net

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What are some examples of major accidents discussed in the document?

What are some examples of major accidents discussed in the document?

What factors contributed to the accidents according to investigations?

What factors contributed to the accidents according to investigations?

HUMAN FACTORS How to take the first steps...

Human rather than technical failures now

James Reason, 1995

Making the UK the safest place to work

Human Factors: History tells us

Bourbon Dolphin Capsize

Space Shuttle Challenger Loss

Texas City Refinery Explosion

Piper Alpha Disaster

Longford Gas Plant Explosion

Introduction and the first steps

Human Factors in accident prevention

Human Factors: introducing the key topics

How to use this report

People will put up with what theyre given...

The best people DO make big mistakes...

Managers are human too...

Right job, wrong equipment...

Assumptions arent always right...

Knowing that a hazard is there DOESNT always protect youFact.

Controls dont always do what you expect them to do...

Close-enough procedures arent close enough...

Case Study 11: Find a way to do it by hook or by crook...

Case Study 12: Helpful guys get hurt...

How others have taken the first steps...

Finding out more some useful resources

Introduction and the first steps

the first steps...

Were all human. We make mistakes and

We try and make the human mind and body

Encourage others to think about human factors

Human factors is about explaining how human

Challenge procedures that are difficult to follow

for Managing Directors and Management

Appoint a Human Factors Champion someone whose job it

Use the case studies to identify human factors topics under

for Safety Representatives

Take human factors concerns to the relevant safety forums

Human Factors in accident prevention

Plant and equipment

People need the right

Human Factors and the barrier model

Human Factors: introducing the key topics

Plant and Equipment:

Managing Human Failures:

Staffing Levels and Workload:

Training and Competence:

How to use this report...

Recognising ourselves in case studies

Assumptions arent always right...

Read the brief description

Understand what people

What did people do intentionally?

Understand the human

What human factors were involved?

What did people do without meaning to?