The Problem is People - Dilbert and the Curious Case of Human Factors Engineering in your Plant

I read a neat little article on the often underestimated topic of Human Factors Engineering by Fabrizio Gambetti et al. (Attached at the end) which got me thinking.

How apt is this Dilbert cartoon! No, not that it IS the people. That's all too easy to say. But that we as design engineers, and plant engineers create designs that are as fantastical as they are inoperable. Add to that the impact of process safety culture and you have a winning recipe for disaster.

Before we truly address human behaviour, major hazard sites like yours must first address the management of human performance in relation to these major hazards. I havent detailed the HOW, but a little guidance from my little experience in the field engineering.

As we analyse some of Engineering's Greatest failures, the contribution of the people aspect to the incident though widely accepted, very few will proactively seek out WHY. Unintentional errors like ‘not doing what you meant to do’ or mental errors, where you do the wrong thing believing it to be right (viz. making the wrong decision). In addition, there are intentional errors called or violations – knowingly taking the shortest path of safe work instructions.

In my humble opinion we investigative engineers tend to (sometimes exclusively) to focus on the behavior of the front line operators or maintenance technicians. How tunnel-visioned! Management/organisational failures have historically influenced several major accidents/

The Longford disaster is an incident I hold as a case study in Human Factors. Some of the contributing factors in hindsight : 

? failure to conduct a HAZOP study or similar to identify hazards

• lack of operating procedures for the situation experienced;

? inadequate training of personnel;

? a reduction in supervision;

? Loss of experienced engineers offsite to Melbourne;

? cost cutting exercises operating costs.

Institution of Engineers, Australia concluded that :‘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’ 

Cultural interventions will only be useful if engineering, technical and systems aspects are in place and adequately managed. Therefore, before major Human Factors analysis the ff is vital imo:

? HAZOPs, or similar, have been completed in order to identify hazards;

? The identification and management of human performance in relation to major hazards has been completed;

? The hierarchy of control has been applied to minimize or prevent their consequences of hazards;

? Accurate and up-to-date operating procedures are available for all eventualities, including process upsets and emergencies (e.g. detailing the specific response to critical alarms);

? Operators must be prepared to deal with all conditions, including process abnormalities. This must include training needs, assessment, simulation and periodic re-assessment. Training must underpin knowledge of the process, to allow troubleshooting - identify and respond to abnormal situations as they develop – it should not just provide the minimum knowledge required to operate the plant. This manages ‘residual risk’ arising from hazards that were not identified, or effectively addressed.

? The site has adequate engineering, operating and maintenance capability and experience (including appropriate staffing levels);

? Lessons have been learned from site, company and wider industry experience. The corporate memory is indeed poor;

? Succession planning ensures that corporate knowledge is retained;

? Safety management arrangements and risk control measures have been reviewed to ensure that they remain usable and relevant.

What are doing about the impact of Human Factors, Organisational Culture on your Process Safety Culture. Attachment in Comment

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