HUMAN FACTORS

How to take the next steps

CASE STUDY 1 - People will put up with what they’re 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.

What human factors were involved? Barriers

What did people do intentionally?

• Human Factors in
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
Design
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.

What did people do without meaning to? • 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 • Managing Human
pressure on the brake and the top drive descended. Failures

What can we learn from this incident?

• 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 can’t 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.

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 HUMAN FACTORS
How to take the next steps

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.

What human factors were involved? Barriers

What did people do intentionally?

Intentional behaviours were not the main cause of this incident.

What did people do without meaning to?

The electrician applied the isolation to the wrong machine • Safety Critical
The electrician made an error - he performed the right action (applying isolations) on Communication
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. • Managing Human
Failure
• Supervision

What can we learn from this incident?

• 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 job’s 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.

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 HUMAN FACTORS
How to take the next steps

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.

What human factors were involved? Barriers

What did people do intentionally?

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 • Organisational

Whilst pursuing replacements, the OIM and engineer found a way to work through the Change
problem by increasing the time they spent on site supervising and coaching. • Staffing Levels &
Workload
What did people do without meaning to?
Stand-ins didn’t have the experience and skills to maintain standards
Often we take technically gifted people and promote them into a leadership position.
• Leadership
However, the two roles often require very different skills. It’s even harder for stand-ins
• Supervision
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.

What can we learn from this incident?

• 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.

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 HUMAN FACTORS
How to take the next steps

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.

What human factors were involved? Barriers

What did people do intentionally?

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.
• Procedures
Change of responsibility led to uncertainties of ownership
• Safety Critical
Uncertainty existed around who was responsible for the relief valve work post-shutdown
i.e. production or maintenance supervisor.
Communication

What did people do without meaning to?

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

What can we learn from this incident?

• 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
23 times.
 HUMAN FACTORS
How to take the next steps

CASE STUDY 5 - Assumptions aren’t always right...

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 red-and-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.

What human factors were involved? 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.
• Safety Critical
The supervision did not communicate the scope and hazards properly
Communication
The toolbox talk didn’t discuss the items to be cut, or point out the hazards from the live
lines in the area.
• Procedures
• Risk Assessment
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 • Managing Human
red-and-white tape marked the items to be cut. Failure

What can we learn from this incident?

• The operations team assumed people would understand that red-and-white tape marked trip hazards. This wasn’t 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 - that’s 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.

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 HUMAN FACTORS
How to take the next steps

CASE STUDY 6 - Knowing that a hazard is there DOESN’T always

protect you…Fact.
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 work-site. 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 supervisor’s 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.

What human factors were involved? Barriers

What did people do intentionally?

• Human Factors in
The supervisor allowed him to cross the barrier Design
Within this team barriers may have been crossed routinely without any comment from
supervisors.
• Contractors
The employee crossed the barrier
• Risk Assessment
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”.

What did people do without meaning to?

The employee stepped back into the opening

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

What can we learn from this incident?

• 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. Don’t 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 can’t 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.

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 HUMAN FACTORS
How to take the next steps

CASE STUDY 7 - Controls don’t 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 ship’s 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.

What human factors were involved? Barriers

What did people do intentionally?

• Human Factors in
The crew accepted the non-intuitive controls Design
Although the joystick didn’t 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.
• Risk Assessment
What did people do without meaning to?

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.
• Managing Human
Failures

What can we learn from this incident?

• 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.
• Don’t put up with non-intuitive controls, change them and apply management of change.
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 HUMAN FACTORS
How to take the next steps

CASE STUDY 8 - Close-enough procedures aren’t 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 didn’t 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.

What human factors were involved? Barriers

What did people do intentionally?

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.
• Procedures
What did people do without meaning to? • Safety Critical
Communications
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. • Training &
Competence
• Supervision

What can we learn from this incident?

• 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.
• Don’t rely on automatic shutdowns to protect you. Safety systems can fail in all sorts of unpredictable ways - many associated with
human error!

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 HUMAN FACTORS
How to take the next steps

CASE STUDY 9 - Time to stop…

What happened?
1 Gas Subsea gas-lift line
system
An offshore installation suffered a gas release after gas from a Third Party
subsea system was accidentally allowed into the Platform Seawater Injection SWI SWI
system SWI line well
system (SWI). The SWI pumps high pressure seawater into the reservoir and is
not designed for hydrocarbon gas. 2 Gas Subsea gas-lift line
system
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 SWI SWI
system SWI line well
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 3 Gas Subsea gas-lift line
well-head pressure of 35 barg (Figure 2). system
A procedure was written by the Third Party, and provided shortly before the job SWI SWI
was due to start. There was no time made available to review the procedure system SWI line well
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.
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.

What human factors were involved? Barriers

What did people do intentionally?

• Human Factors
The procedure was not reviewed in Design
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 hadn’t been written with those
doing the job, and no review or HAZOP (Hazard and Operability Study) was carried out. • Procedures
The operators didn’t stop the job and take time to get the procedure reviewed • Safety Critical
They had not been involved in writing the procedure, and had no assurance that the Communications
procedure was correct. However the job had been planned for some time and they were • Contractor
reluctant to delay it. Interface

What did people do without meaning to?

The operators did not detect the warning
• Managing
Although the operators did use the procedure, their actions didn’t reflect the engineers Human
intention to only flow gas for 6 hours. The crucial information was buried in the text of Failures
the procedure.

What can we learn from this incident?

• 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.
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 HUMAN FACTORS
How to take the next steps

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.

What human factors were involved? Barriers

What did people do intentionally?

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 • Risk Assessment
their mental and physical capabilities. Relying on each other to stay awake was doomed • Staffing Levels
to failure.
& Workload
The tool pushers decided to continue with the work pattern even though they recognised
they were getting very tired and may fall asleep.

What did people do without meaning to?

• Fatigue
One of the tool pushers fell asleep • Leadership
Nobody has conscious control over the point when they fall asleep.

What can we learn from this incident?

• People aren’t 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 person’s 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.

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How to take the next steps

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.

What human factors were involved? Barriers

What did people do intentionally?

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.
• Risk Assessment
What did people do without meaning to? • Procedures
Unintended behaviours were not the main cause of this situation.

• Supervision
• Managing Human
Failures

What can we learn from this incident?

• We love to find a way to do the job we’re given. Sometimes we will accept greater risk to achieve the goal.
• We often have to solve problems in our job. However, when we’re about to do the job with the materials available to us, we often
make unwise compromises - compromises we wouldn’t 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 wouldn’t 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.

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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 installation’s 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 laundryman’s middle finger.

What human factors were involved? Barriers

What did people do intentionally?

The laundryman rushed in to help
Although he wasn’t part of the job and hadn’t been involved in the risk assessment and
preparation for the job, he rushed in to help without thought.
• Risk Assessment
What did people do without meaning to?

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

What can we learn from this incident?

• 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.
• Don’t jump in to help and don’t allow people to jump in and help. In this case a tape barrier may have been enough to stop the
laundryman from getting involved.

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