Ergonomics society oil and gas conference - part 2

I was a speaker at the Ergonomics Society's conference on 'Human and organisational factors in the oil, gas and chemical industries' on 27-28 November 2007. I am blogging key messages from some of the presentations.

Trevor Kletz gave a presentation titled '25+ years of human factors and process safety.' Although I have heard him speak many times and read some of his books, his message is still (unfortunately) still very relevant to many.

In this presentation he recounted that in the 1960s it was believed that 80% or more of accidents were due to people not taking enough care, and so methods were used following an accident were to 'persuade' people to be more careful. The actual action taken depended entirely on the consequences, not potential consequences and ranged from a 'friendly word' through to dismissal "pour encourage les autres."

Trevor's key message was that one element of human factors that is still not getting enough attention is design. Lessons about design are not being learnt, and so opportunities to engineer-out human error are being missed. His examples included:

* Avoid people falling down stairs by only building bungalows. OK, so this may not be possible, but by stair cases have one or turns in them, the distance that can be fallen is significantly reduced;
* At Bhopal the substance that caused the harm to so many people was an ;intermediate. It was convenient to store it , but not essential
* Piper Alpha occurred in part because oil and gas is separated offshore, yet it is technically possible to carry this step onshore;
* Nitration is a common but very hazardous reaction used to make amines. No other process is known, but no one has ever looked for one;
* The new Pendolino trains have a major problem with toilets leaking. This is because the waste materials (which are corrosive) are stored at roof level and when they leak create very bad smells.

Trevor's message was that we are still missing simple fixes during design. Perhaps if accident reports were discussed critically by designers, some of these problems that cause human error would be avoided.

Andy Brazier