Monday, March 17, 2014

Moving towards Safety-II: ensuring thing go right

High lights from an article in The Ergonomist March 2014 by Steven Shorrock and Tony Licu.  A far more in-depth 'White paper' is available from

It has been suggested that safety management should move from ensuring that "as few things as possible go wrong" to ensuring that "as many things as possible go right."  This is being described as a move from Safety-I to Safety-II.

One of the main reasons for this change is the massive developments in technology over the last couple of decades.  You just have to look at what you can do on an iPad now compared to computers of the past.  The impact has been increased demand on systems leading to more complexity.  The rate of change is rapid, and the reality is that thinking on safety and the causes of accidents is not keeping up.

The complexity and connectivity of modern systems means it is impossible to fully understand how they work or predict how they can failure.  One outcome of this is that the human factor remains important as people have to be flexible to adjust to changes in demand and conditions.

Safety-II focusses more on the fact that things go right most of the time, whilst acknowledging they can still go wrong.  It requires us to understand how systems made up of technical and human resources really work in practice.  This means we need to understand how people, procedures and equipment interact, and the variability in these in these interactions.  This will allow us to anticipate developments proactively and understand how things occasionally go wrong.

One outcome from a move to Safety-II is that we have to stop saying that accidents occur due to 'human error.'  People are having to constantly adjust their performance constantly (think about driving a car) and most of the time they do this brilliantly.  But sometimes things do not perform as expected (this includes the human element) and this can result in an accident.  If we really want to improve safety we have to understand all the variations that the system (technical and human) deals with, and not just the ones where it fails.  If there is an accident our investigation should start with developing an understanding of how things normally work and not just the isolated case of where it has gone wrong.

Friday, February 28, 2014

Thinking, fast and slow

BBC Horizon 'How do we really make decisions?'  originally aired on BBC 2 on 24 February 2014

Referred to a lot from the book by Daniel Kahneman 'Thinking, fast and slow.'

Most of the time, our fast, intuitive mind is in control, efficiently taking charge of all the thousands of decisions we make each day. The problem comes when we allow our fast, intuitive system to make decisions that we really should pass over to our slow, logical system. This is where the mistakes creep in.

Our thinking is riddled with systematic mistakes known to psychologists as cognitive biases. And they affect everything we do. They make us spend impulsively, be overly influenced by what other people think. They affect our beliefs, our opinions, and our decisions, and we have no idea it is happening.

It may seem hard to believe, but that's because your logical, slow mind is a master at inventing a cover story. Most of the beliefs or opinions you have come from an automatic response. But then your logical mind invents a reason why you think or believe something.
A useful list of Cognitive Biases is available at Wikipedia

Friday, February 14, 2014

Expert witnesses

Notes from a presentation by Alex Sandland of Dyne Solicitors Limited

An expert is:

* Suitably qualified - possessing suitable profession qualifications
* Suitable experienced - possessing suitable professional experience
* Scale and extent of qualifications/experience is proportionate to the scale and seriousness of the dispute
* Independent - have to pass the test 'would they give the same opinion if instructed by the other party?'

In legal proceedings opinions are inadmissible and witnesses must only present facts.  However, an expert is able to state opinion proceedings (provided they fall within their particular area of expertise). 

An experts duty is to the court ONLY.  They cannot promote the case of the instructing party.

A Protocol for the Instruction of Experts to give evidence in civil claims has been published by the civil justice council.

There are a number of associations/registers including:

* The Expert Witness
* Expert Witness Institute
* Directory of Expert Witnesses

A number of organisations offer professional courses, including the Law Society

The criteria used to choose an expert usually include letters after name, years of experience, papers written, standing within the profession (are you approached by people in your industry for advice) and reputation.

Obviously, expert witnesses want to get paid.  It is normal to get an advance fee of 50%, with the remainder paid when the case has been closed.

Thursday, February 13, 2014

Silencing Many Hospital Alarms Leads To Better Health Care

SHOTS by Richard Knox 27 January 2014

Analysis at Boston Medical Center found that 7 North was experiencing 12,000 alarms ­a day, on average. This had led to "alarm fatigue," which occurs when there are so many noises on the unit that it actually desensitizes the staff," says Deborah Whalen, a clinical nurse manager at the Boston hospital. "If you have multiple, multiple alarms going off with varying frequencies, you just don't hear them." 
That can be dangerous. Patients can die when an important alarm is missed, or an electrode on a patient's chest comes unstuck, or a monitor's battery goes dead.

Boston Medical Center hasn't recorded any patient deaths because of alarm failure, but, Whalen says, "we were lucky." A Boston Globe in 2011 found more than 200 deaths nationally related to alarm problems. Last year, the Joint Commission, a national quality-control group, of 98 alarm-related instances of patient harm, including 80 deaths and 13 cases of permanent disability.

The known alarm-related problems are just the tip of an iceberg, according to , the Joint Commission's chief medical officer, because such cases are seriously underreported.

"It is pervasive in almost any accident that occurs in a hospital," McKee says. "If you look carefully, you will most likely find that there was an alarm as a contributing factor."

That's why the Joint Commission has at the top of its current list of issues that hospitals are expected to tackle. McKee says technology has gotten out of control. "We have devices that beep when they are working normally," she says. "We have devices that beep when they're not working."

Boston Medical Center is attracting national attention as a hospital that apparently has conquered alarm fatigue. Its analysis showed the vast majority of so-called "warning" alarms, indicating potential problems with such things as low heart rate, don't need an audible signal. The hospital decided it was safe to switch them off.

The hospital also upgraded some low-level "warning" alarms to a higher level, signifying "crisis" — for instance, a pause in heart rhythm. And nurses were given authority to change alarm settings to account for patients' differences.

"Once that happened," nurse Deborah Whalen says, "many, many, many alarms disappeared. And instead of 90,000 alarms a week, we dropped to 10,000 alarms a week." That's on 7 North alone.

These days you can easily hear how quiet 7 North and all of the adult medical-surgical units at Boston Medical Center have become. Instead of a steady stream of beeps, minutes can pass without an alarm. So when a "crisis" alarm sounds, the staff can easily hear and respond.
"It's a lot more manageable," says staff nurse Amanda Gerety. "It's a lot more pleasant being at work." And when she sleeps, she says with a laugh, "I don't hear alarms in my dreams anymore."

The hospital says patients like it better, too. For one thing, when they press the nurse-call button, the nurses are more likely to hear it.

Rules, Regulations, Policies and Practices (RRPP) - learning from Costa Concordia by Geoffrey Gill 12 March 2013

It is important we learn from the Costa Concordia accident.  But new lessons are unlikely to emerge and it is more likely that the common failure to apply existing Rules, Regulations, Policies and Practices (RRRP) will emerge from the investigation, including the International Safety Management Code and its attendant Safety Management System.
For example, passenger evacuation from the grounded Costa Concordia was impeded and inefficient because passengers had not received muster instruction and guidance within the few hours from boarding until the grounding.  This, despite an informed maritime industry knowing for years that ships generally are at greatest risk from collision, allision, and grounding when close to land, such as when leaving port, than when under way on the open sea. Given this knowledge, one asks why were the conditions on Costa Concordia necessary to trigger the new common sense policy requiring mandatory emergency drills be conducted prior to a passenger vessel departing an embarkation port.

RRPP: the Panacea?
Danger lurks to the extent that new and existing RRPP will be accepted and relied upon as adequate to the risks and, trusting in that reliance, the industry will proceed “business as usual.” But reality is that RRPP are not a panacea capable of remedying risk and human error within the maritime domain, despite politicians’ and regulators’ enthusiasm for reacting to media orchestrated popular concerns as well as even the well-intentioned separate efforts on the part of maritime management.

At least one trade journal has reported existence of a culture of Italian passenger vessels sailing close to shore, a practice of such long standing as to have received the Italian title “inchino.”  Shipboard morale benefitted from close passage off towns where many crew members lived and public relations benefitted from passengers’ enjoyment of the novelty of the experience.  Under such circumstances, credulity is strained when management disavows knowledge of its masters’ participation in the practice. Inchino may present little risk if performed at a safe distance stated in promulgated RRPP.  But existence of such RRPP does not, of itself, ensure adherence.

Given the implied beneficent purposes of inchino, more likely than not, human nature together with cultural and personality factors suggest that over time shipboard justifications would result in the prescribed safe distance observed being progressively decreased and so shrinking the margin of error initially factored into the determination of what distance a safe distance would be and so coming ever closer to land hazards. What initially may have been idiosyncratic behavior becomes shared as more and more sharp end practitioners perceived a benefit from coming closer to the island without experiencing peer or management criticism or punishment.  This type of gradual RRPP erosion is styled “normalization of deviance,” a pernicious undermining of RRPP.

Deliberate violation of RRPP, especially of those that are inartfully worded or are perceived as incompatible with the operational environment, is not infrequent. The violators’ rationales include a misguided desire to advance the company’s economic interests, lack of peer or managerial criticism as well as the personality of the violator. Therefore, RRPP adherence cannot be presumed, even where simulator or audited competence is confirmed.

Even in the absence of violations, there is the potential for violation “coming out of the blue.”  A recent study, where sheep are persons normally disinclined to violate RRPP and wolves have no such scruples, reveals the propensity for RRPP violation:

Sheep in Sheep’s’ Clothing (confirmed non-violators) – 22.5% of respondents, guardians of the standards.

Wolves in Sheep’s’ Clothing – 33.8% of respondents have not yet violated but would violate if circumstances are “appropriate”.

Sheep in Wolves’ Clothing – 14.1% of respondents are violators but not happy violators.

Wolves in Wolves’ Clothing – 29.6% of respondents would not hesitate to violate RRPP.

Strikingly, 77.5% of respondents either reported violating or would have no qualms violating when the opportunity arrives.

The maritime domain is unique in its long tradition of mariners’ recognition and pride in their professional knowledge and competence combined with an environment in which the variety of potential risky circumstances is so extreme that no catechism of RRPP can account for all situations.  The rigidity of RRPP must be balanced against a flexibility that encourages critical thinking and exercise of sound judgment. This necessity is recognized by Rule 2(a) of the COLREGS that, though inartfully worded, allows recourse to “the ordinary practice of seamen or … the special circumstances of the case.” There is real danger that overly detailed and embracive RRPP, however well intentioned, undermine development of necessary judgmental skills. The issue is well stated by a shipmaster quoted as saying:  “… when you are at sea, you have to be able to think, and you can’t [think] when you must slavishly look up [written procedures] in a book.  …  No matter if your own thought is better or not, you have to do what is written.”  Unlike biblical Pharisees bound to the letter of a law, mariners require and deserve reasonable latitude allowing them to accomplish their primary duty of vigilance to protect the lives and material assets entrusted to their keeping.

The challenge that RRPP inhibit critical thinking runs from the sharp end operator upstream to management, where there may be misplaced reliance that RRPP, with little more, satisfies management’s responsibility to ensure a functional Safety Management System. The folly of relying exclusively or excessively upon formal RRPP as providing an appropriate level of safety can be demonstrated from the 2007 sinking in Antarctic waters of the Liberian flagged passenger vessel Explorer, fortunately without casualties. The vessel was in compliance with class requirements for a vessel of her age, type and geographic operating area. However, the classification society and SOLAS rules were unrealistic in view of the harsh Antarctic conditions regularly to be encountered.

Effective RRPP
RRPP innovation is easiest in response to particular past or presently existing situations, where relevant facts are discrete and known. But effective RRPP must address future eventualities to minimize their adverse occurrence and mitigate their consequences if they do occur. A curious and informed mind, willing to explore future possibilities and proactive risk assessment is required for drafting prophylactic RRPP and also a willingness objectively to determine with what response the RRPP are received by those persons intended to apply them and how the RRPP function in practice, i.e. an impact and sustainability assessment.

Remarkable strides have been made, since Titanic’s loss one hundred years ago, in bridge-to-bridge and ship-to-shore (and vice versa) communication, ECDIS, ARPA, AIS, GPS and the like, as well as ship design and construction.  And promulgation of well-intentioned safety oriented RRPP has flourished.
Remaining relatively consistent, however, has been the shipboard authority gradient (despite various incantations of bridge/crew resource management), a degree of nautical daring-do, and organizational competition between protection and profit; the latter no doubt exacerbated by the current challenging economic situation. And while there has developed greater awareness of scene-setting errors and omissions upstream from the front line operator and greater understanding of cognitive limitations, there has been no corresponding advance modifying cognitive limitations of human behavior, such as confirmation and other biases, situational awareness assessment, assimilating information of varying reliability and relevance from multiple sources, dealing with multiculturism and decision making, to name but a few.

When considering what “new” lessons may be learned out of the Costa Concordia casualty, worthy of consideration would be a critical examination of maritime domain RRPP and their limitations and also expanded operator and management education addressing cognitive factors and how those factors influence what occurs on the bridge, in the engine room, and in the boardroom.


Human Centric Design: How Pushback From the FDA Is Driving Innovation

WIRED by Reade Harpham of Battelle Humanic Centric Design 29 January 2014

The following exert from IEC 62366:2007 is being credited with driving improvement "The design of a usable Medical Device is a challenging endeavor, yet many organizations treat it as if it were just “common sense”. The design of the user interface to achieve adequate (safe) Usability requires a very different skill set than that of the technical implementation of that Interface."
– International Standards Organization: IEC:62366:2007, Application of usability engineering to medical devices, pg.6
(see complete standard here).

In the last 36 months medical devices have been tested, re-designed and re-tested with over 2,000 actual users.  These are people off the street, never seen the device before, don’t care how it looks/works/feels users; the people who open a needle, drop it on the dirty bathroom floor, blow it off and inject.
Users, who no matter how much you paid your design firm to develop a great “user experience,” rip open the box; toss the instructions in the trash and get down to business. The unhappy marketing and development teams behind the two-way glass are ever frustrated by how the users used it “wrong,” without really considering the very real possibility they designed “wrong.” Until now…

The FDA is becoming aggressive with their enforcement of good Human Factors, and rightfully so. In 1999, the Institute of Medicine released “to Err is Human,” which outlined the fact that up to 98,000 deaths resulted from medical error at a cost of $29 billion. Since then, they have been steadily beating the drum, releasing new guidance and tirelessly training companies on how to appropriately incorporate human factors. Developers are finally starting to respond, albeit mostly as a result of an application being rejected to lack of human factors.

They are adding “Human Centric Design” line items to their budgets, opening the door for user feedback from the beginning. They are recognizing that a small, well executed usability activity in the early stages of design will save ten times in time and money downstream, not to mention drastically increase the likelihood their device will be approved the first time around.

More importantly, device manufacturers are beginning to recognize the value of a human centric approach from the inception of the idea. Enabling users to have a voice beyond “I prefer this one” can drive design decisions across the entire develo

Wednesday, November 20, 2013

Pilots Rely Too Much on Automation

The Wall Street Journal by Andy Pasztor 17 November 2013

Many Aviators Have Difficulty Manually Flying Planes, Study Commissioned by FAA Finds

Commercial airline pilots have become so dependent on automation that poor manual flying skills and failure to master the latest changes in cockpit technology pose the greatest hazards to passengers, an international panel of air-safety experts warns
A soon-to-be-released study commissioned by the Federal Aviation Administration determined, among other things, that "pilots sometimes rely too much on automated systems and may be reluctant to intervene" or switch them off in unusual or risky circumstances, 

The study found that some pilots "lack sufficient or in-depth knowledge and skills" to properly control their plane's trajectory, partly because "current training methods, training devices and the time allotted for training" may be inadequate to fully master advanced automated systems.

Among the accidents and certain categories of incidents that were examined, roughly two-thirds of the pilots either had difficulty manually flying planes or made mistakes using flight computers.

Relying too heavily on computer-driven flight decks—and problems that result when crews fail to properly keep up with changes in levels of automation—now pose the biggest threats to airliner safety world-wide, the study concluded. The results can range from degraded manual-flying skills to poor decision-making to possible erosion of confidence among some aviators when automation abruptly malfunctions or disconnects during an emergency.

The observers found that in most instances, pilots were able to detect and correct automation slip-ups before they could cascade into more serious errors. But when pilots "have to actually hand fly" aircraft, according to one section of the narrative describing interviews with trainers, "they are accustomed to watching things happen…instead of being proactive."

Pilot lapses and automation were implicated in the high-profile 2009 crash of an Air France Airbus A330 that stalled and went down in the Atlantic Ocean, killing all 228 aboard, just as they are suspected of causing last July's crash of an Asiana Airlines Inc.Boeing 777 during a botched landing in San Francisco.

With the reliability of engines and flight controls continuing to improve, airline pilots spend the vast majority of their time programming and monitoring automated systems—typically relegating manual flying to barely a few minutes during takeoffs and right before touchdowns.

Overreliance on automation, however, has been recognized for years as an industrywide problem, with numerous earlier studies delving into the consequences.

The 34-member committee, for example, agreed that "pilots must be provided with opportunities to refine" manual flying skills, while receiving enhanced training in computer complexities and automation modes. In addition, the draft recommended training for rare but potentially catastrophic malfunctions "for which there is no specific procedure" or readily available checklist.

The panel also called on manufacturers to develop cockpit designs that are "more understandable from the flightcrew's perspective" and specifically guard against technology failures resulting from integration of various onboard systems.

Tuesday, November 19, 2013

Problems with training

A couple of links picked up from Twitter today about the limitations of training.

The surprising science of workplace training
Training is not as intuitive as it may seem.  Eduardo Salas, professor of psychology at the University of Central Florida states that “There is a science of training that shows that there is a right way and a wrong way to design, deliver, and implement a training program.”

Here are some pointers
  1. It is not just what happens during training that matters. Actually, what happens before and after training can be just as important.
  2. Trainers need to distinguish between content that is “need-to-know,” and that is “need-to-access.” For the latter training should teach people where and how to find that information rather so they don’t have to rely on memory
  3. Testing may not be an effective part of training.  Research shows that training is more effective when it’s presented as an opportunity, rather than as a test.
  4. Skill decay is a major problem in training.  Trainees lose up to 90 percent of what they learned within a year.  This can be prevented by giving workers frequent opportunities to practice their new skills, and by scheduling “refresher” training.
  5. Employers can act to increase workers’ motivation: by being clear about the link between what’s being taught and how it will be used on the job, and by making sure employees feel supported in their efforts to learn.
  6. Workbooks, lectures, and videos are usually poor for learning when compared to practice and feedback components.  Training can be improved by making it more active and engaging for participants.
  7. Workers will get the most out of practice when they are provided with constructive and timely feedback that identifies what they may be doing wrong and how to fix it.
  8. Research shows that conditions that maximise performance during training are often different from those that maximise the transfer and retention of those skills.  
  9. Because errors often occur on the job, there is value in training people to cope with errors both strategically and on an emotional level.  Guiding workers to make errors, and then providing them with strategies to correct their mistakes, will lead them to understand the task in greater depth and will help them deal with errors on the job.
  10. Technology must be implemented in a thoughtful way, in accordance with scientific findings, in order to add to the effectiveness of training.
  11. Left to their own devices, workers may not be knowledgeable or motivated enough to make wise decisions about how and what to learn.
  12. Training using simulations does not require the virtual setting to be precisely the same as the one the worker will encounter on the job. What matters is not the “physical fidelity” of the simulation, but its psychological fidelity—how accurately it evokes the feelings and the responses the worker will have on the job.
Centre for Leaning and Performance Technologies by Jane Hart 7 June 2013

In most cases this training requires participants to take time out of their daily jobs – often going to a separate place or room. Although more recently learners have been able to sit at their own desks and complete online courses, they have still had to stop what they were working on in order to study the course. And more and more people are now beginning to question the validity of this model to address all learning problems, citing its ineffectiveness, the fact that it relies on study and memorisation, as well as the cost and time requirements of developing instructional solutions.  
“A recently-published report by the UK’s National Audit Office (NAO) estimates that the Civil Service wastes hundreds of millions of pounds every year – some £275m in the last year alone – putting staff through training courses that “do not work”. Less than half of the staff questioned by the NAO felt the training they received in the past 12 months had helped them to do their job better.” (Bob Little, Checkpoint eLearning, November 2011)
“Companies’ spending on training and development accounts for hundreds of billion pounds globally each year. But every year, according to successive empirical studies, only 5 to 20 per cent of what is learnt finds its way back into the workplace. While this failure to transfer and apply new learning in the workplace has long attracted academic interest, practitioners have been slow to change their ways. Despite the imperative that things cannot be managed without being measured, training has been getting off lightly. Surely a training industry that delivers less than 20 per cent cannot be fit for purpose?” Accountability needed for workplace training, Robert Terry, FT, 12 December 2011

Learning in the Social Workplace by Jane Hart (Blog) 23 March 2013

Here are the 10 reasons why you should not produce a elearning course:
    You don’t want to take your people out of the workflow unnecessarily.
    You don’t want to bore your people to tears with page-turner/click-next solutions.
    You don’t want to treat your people like idiots making them click on every link or action button in a course – because their manager thinks that’s proof they’ve read something and hence learned it!
    You don’t want to dumb down the learning process and make your people have to  work through trivial interactions – in a desperate attempt to engage them.
    You don’t want to force your people to stay on a course for a prescribed amount of time – just to prove they’ve had the required length of training.
    You don’t want to require your people to communicate with one another in a course – because that’s what others think “social learning” is all about.

Monday, November 04, 2013

Tributes paid to Trevor Kletz

From IChemE 1 November 2013

IChemE president Judith Hackitt has paid tribute to safety pioneer Trevor Kletz who passed away yesterday at the age of 91.

Kletz was one of industry’s most respected figures following a celebrated career as an industry safety advisor, lecturer and writer.

Hackitt, who is also Chair of the Great Britain Health and Safety Executive said: “Trevor’s impact on industry was striking. His ability to convey safety information succinctly, and effectively, was central to his success. On behalf of IChemE, I extend our sincere sympathies to his family and friends. We will ensure the memory and work of Trevor lives on within the chemical engineering community.”

IChemE chief executive David Brown says that the impact of Kletz’s work will be felt for many years: “Trevor unquestionably saved lives. There are people working in the process industries today who will go home safely to their families and loved ones, thanks to Trevor. He had a profound impact on industrial safety.”

Kletz worked for ICI from 1944 to 1982. In 1968 he was appointed as one of the process industry’s first technical safety advisors with a broad remit which included advising designers and operators about how to avoid accidents, specifically with regard to process accidents. On leaving ICI, Trevor built a second career as a process safety consultant, writer and lecturer. He was elected a Fellow of IChemE in 1978, a Fellow of the Royal Academy of Engineering in 1984 and awarded an OBE for services to process safety in 1997. He authored fourteen books and more than one hundred peer-reviewed papers on process safety.

Kletz remained active professionally until earlier this year where a formal retirement reception was staged at IChemE’s Hazards 23 conference in Southport, UK.

A full obituary will be published in the December issue of tce.

Wednesday, May 22, 2013

RAF Valley helicopter technical issues 'delayed ship rescue'

BBC Website 22 May 2013

The Marine Accident Investigation Branch (MAIB) issued a number of recommendations after the MV Carrier ran aground off Llanddulas, Conwy in April 2012.  The Antigua and Barbuda-registered vessel had been carrying stone when it ran aground at night, close to the main A55 coast road.

Technical problems with all four rescue helicopters at RAF Valley on Anglesey delayed the rescue of a stricken ship's crew, an accident report has said.  It was 'extremely unusual' for all RAF Valley helicopters to be unservicable.

Two lifeboats, a Royal Navy helicopter from Prestwick, South Ayrshire and an RAF helicopter from Leconfield in North Yorkshire were involved in the rescue in heavy seas.

The report found the ship's master's unfamiliarity with UK maritime weather forecast terminology led to a delay in his departure from the Raynes quarry jetty in Llanddulas.

This in turn meant wind speeds had risen dramatically while the ship was moored at the jetty.
When it tried to move away from the jetty it was caught and carried onto the nearby shore.
The accident report concluded:
  • RAF staff reported it was extremely unusual for all four of the RAF Valley helicopters to be unserviceable with such substantial technical faults.
  • The MV Carrier's master, one of seven Polish nationals on board, was not sure of the meaning of some of the words used in UK maritime weather forecasts.
  • Jetty staff allowed the ship to continue loading despite the bad weather conditions.
  • None of the staff at the jetty had significant maritime experience.
  • "It is concerning that there may be other harbours like Raynes Jetty around the UK coast whose operators consider themselves outside the normal scope of port operations".
The MAIB said the rescue was delayed primarily because of the technical problems with all four helicopters at RAF Valley, while snowstorms stopped a helicopter from RAF Leconfield launching immediately.
The report added the Leconfield crew was "obliged to make an extremely hazardous flight in very poor conditions across the width of the country".

It said the performance of all the helicopter crews was "extremely commendable".

"However, the risks they faced during the rescue were exacerbated by the lack of more locally-available search and rescue (SAR) helicopters," it said.

"It was extremely fortunate the situation on board Carrier remained stable for long enough to enable all the crew to be rescued without injury."

The Maritime and Coastguard Agency has also been asked to work with the Met Office to ensure the terminology used in weather broadcasts are "clearly understood by mariners and other users of the service".
Shore-based staff also needed a "good understanding of maritime weather forecasting" the report added.

Thursday, May 02, 2013

Size of the matter – offshore ergonomics prepares for an overhaul

Offshore Technology by Heidi Vella 22 April 2013

A new study measuring the size of offshore oil and gas workers' bodies is currently underway, with the aim of improving ergonomic safety on rigs. It is the first study of its kind for more than twenty years.

Industry data reveals the offshore oil and gas work force is on average 19% heavier than it was in the 1980s.
To accurately quantify the current body size of offshore workers, the Robert Gordon University in Aberdeen is conducting a two-year study using 3D scanners to measure the size of the workforce.

The study has provoked an interest in the health and fitness of the workforce, which is known to be an ageing group, as well as concern about the safety implications of a heavier, and therefore presumably larger, workforce operating in a space originally designed for smaller people.

"We want to make the industry aware of the size of the actual people working there. We need to not expect the size that would have suited them [workers] three decades ago to suit them now," project leader at RGU, Dr Arthur Stewart, says.

The team will divide people into weight categories and map their size and variability with up to six concise scans.

"Shoulder width and chest depth are two critical dimensions we are going to be measuring, which might critically affect the ability of two people to pass each other in a narrow corridor," says Dr Stewart.
The data, which will be owned by Oil & Gas UK, will be made freely available to the industry.

Oil & Gas UK and Dr Stewart's team believe designing rigs with current, and not old, data will lead to rigs with better ergonomic safety. But what aspects of offshore safety are most affected by a larger workforce?

"What I see as the biggest impact is on helicopter transportation," says industry ergonomics advisor, Tim Southam, from PTP-Global Ltd.

Helicopters that transport workers to and from rigs, sometimes for an hour and a half at a time, can be dangerous. Last year there were two helicopter ditches in the North Sea involving Super Pumas, with four helicopter ditches in four years.

Not only do larger people take up more room and make for a particularly uncomfortable ride - as many industry insiders have testified to, including Southam - but if a helicopter ditches, workers need to be able to squeeze through small spaces to quickly exit the vehicle.

Health and Safety Policy Manager at Oil & Gas UK, Bob Lauder, says that the industry has already made adjustments to life boat capacity and payloads on helicopters have been adjusted in accordance with a Big Person study that Oil & Gas UK carried out a few years ago, which showed them the body size of the industry workforce is increasing. Also, in 2005, the Civil Aviation Authority increased the weight allocation for each helicopter passenger by 20lbs, from 14 stone to 15 stone 6lb.

Southam also warns that decades' old rig designs servicing people that are now on average bigger can affect special factors, such as crawling under pipes, the size of beds, living space and shower cubicles.
Dr Stewart agrees, he says: "If you can imagine an emergency situation, body size, when you're trying to move quickly and urgently, can become potentially critical, particularly if you are trying to escape through a narrow window for example."

However, not all concur. John Taylor from offshore workers' union Unite says: "The size of your body mass doesn't make a blind bit of difference getting out of a corridor, it doesn't make any difference in the accommodation. The only problem would be if a person became that overweight he couldn't escape out of a window in a helicopter."

Dr Stewart and Lauder stress that the study, which is funded by Oil & Gas UK and major offshore companies, isn't focussing on the weight or health of offshore workers, although weight will be recorded.
However, they both concede that health relates to body size; therefore it is almost impossible to talk about one without considering the other.

Transocean has recognised this problem and are addressing it by offering healthy eating and fitness assistance to workers with a waist of more than 37 inches, which both Lauder and Taylor support.

However, unlike Norway, where 120kg is the largest an offshore worker is allowed to weigh, in the UK there is no automatic cut off figure that prevents people working offshore, though anyone with a BMI of more than 40 is required to satisfy a number of additional conditions before they are passed as fit to work offshore.



Wrexham call centre staff fly to New Zealand to cover night shifts

BBC Website 2 May 2013

Call centre staff from Wrexham are taking turns to live in New Zealand to cover night shifts back home in the UK.

With New Zealand 12 hours ahead, Moneypenny staff normally based in Wrexham are still working day shifts but provide late-night cover when colleagues in Wales clock off.

Before opening the office in Auckland, bosses asked staff if they wanted to work nights or relocate temporarily.

A trial group of four staff are due to return after flying out last November

The staff have been working four days on and four days off so they can take in the sights while living abroad, a pattern which is set to continue in four to six month stints when the next group take over.

Moneypenny provides a phone answering service, handling over 8m calls a year for 6,000 clients from sole traders to multinationals.And bosses said more UK customers had wanted calls handling through the night.
Staff in Wrexham cover the working day before colleagues in Auckland take over

The company is putting up the first group of workers in a rented house.

It is envisaged British employees will spend over four months in New Zealand although the changeover could be altered to suit them.

Rachel Clacher, who set up the company with brother Ed Reeves, had the idea to base staff overseas while on a sabbatical in Australia.

Until opening the office last October she says they had "resisted" expanding the service to deal with out-of-hours calls having seen research about detrimental effects on people working nights, affecting health and attitude, which could also impact on customers.
The issue was compounded when only a handful of the company's 280 staff said they wanted to work nights.
But more than 40 said they were interested in mixing work between home and abroad.

Now, when the Wrexham-based workers leave the office, at the "flick of a switch" at 20:00 GMT their colleagues in Auckland take over until 08:00 GMT and UK customers continue to receive the same service through the night.

Ms Clacher said: "We had looked at hiring staff to work overnight but we weren't confident service levels could be maintained so would have never taken that risk.

"By working on the other side of the world we're now able to offer a truly 24 hour first-rate service, with bright, chirpy and wide-awake people."

Wednesday, April 24, 2013

Uncovering the unknown

The Chemical Engineer, March 2013 by Richard Gowland

The European Process Safety Centre (EPSC) has been looking at events such as BP Texas City, Buncefield and Fukushima in or to determine whether they were so unusual that they "somehow escaped the risk management process of the responsible operators."  They concluded that there is a problem because scenarios are often considered to be impossible or very unlikely when assessing risk, yet after the event we find that there was information available that could have shown the accident was credible.

The work carried out has identified four categories of events as follows:
* Known knowns
* Known unknowns
* Unknown knowns
* Unknown unknowns

We know we have processes that can be effective at capturing the first two of these, including Process Hazard Reviews (PHR) and Hazard and Operability (HAZOP), but unless we can also address the unknown knowns/unknowns we will continue to experience accidents like the ones mentioned at the start.

The paper concludes that actually there are very few unknown unknowns and hence we need to work harder and be more creative when identifying hazards and assessing risks.  As a minimum we need to:

* make sure we address steady state situations comprehensively with a range of 'what if' analysis;
* cover non-steady state situations (particularly start-up and shutdown) with the same rigour, whether that involves using HAZOP or a complementary approach;
* consider worst case scenarios at a very early stage of our analysis.

"There is also much to be gained from critical task analysis and human error analysis in predicting atypical events and managing them better.  They should exploit the 'known knowns,' 'known unknowns,' and 'unknown knowns;' and use a creative approach to imagine the 'unknown unknowns,' which can be studied with 'bow-tie' analysis and perhaps, controversially, a 'reverse HAZOP' where we start with the worst-case consequence and work out what can initiate or fail for the full impact to be realised."

Friday, April 19, 2013

Sat-nav mix up leaves pupils in Towyn not Tywyn

BBC Website 19 April 2013

A sat-nav mix up left a coach load of school pupils almost 80 miles from home after a trip to Paris.
The children from Tywyn, on the west coast of Wales in Gwynedd, ended up a couple of hours away at Towyn, on the north Wales coast near Rhyl.

The coach firm said the driver inputted the wrong place in his sat-nav.

Ysgol Uwchradd Tywyn head teacher Helen Lewis said the mistake was common, with deliveries sometimes wrongly sent to Towyn.

The 37 children, aged 11 to 14, had spent three nights in the French capital and were heading home overnight.
Louise Hughes Parent and governor

Pupils woke up after the 13-hour journey and phoned parents to say they were in the wrong town.
Ms Lewis said: "The driver, when he was told Tywyn, had made the incorrect assumption it was Towyn.
"It is something that happens a lot here although it is the first time we had a group of pupils end up in the wrong place.

"We have had deliveries wrongly sent to Towyn.

"The children were tired because it was a long journey anyway so the extra couple of hours wouldn't have made a difference. They'd had a brilliant time."

It is thought the mistake happened after the coach had changed drivers at Shrewsbury.
Some parents were said to be angry about the incident but others were less concerned.

Gwynedd councillor Louise Hughes, a school governor whose daughter was on the trip, said: "I wouldn't want anyone to lose their job over this - that would be an over-reaction.

"The main thing is they all got back safely.

"Delivery drivers make the same mistake and people ring saying 'we can't find you, we're in Towyn'. It happens all the time."

Monday, April 08, 2013

10 Very Costly Typos

Mental Floss by Jennifer Wood on 8 April 2013


The damage: $80 million
A single dash led to absolute failure for NASA in 1962 in the case of Mariner 1, America’s first interplanetary probe. The mission was simple: get up close and personal with close neighbor Venus. But a single missing hyphen in the coding used to set trajectory and speed caused the craft to explode just minutes after takeoff.


The damage: $502,996
A missing ‘P’ cost one sloppy (and we’d have to surmise ill-informed) eBay seller more than half-a-mill on the 150-year-old beer he was auctioning. Few collectors knew a bottle of Allsopp’s Arctic Ale was up for bid, because it was listed as a bottle of Allsop’s Arctic Ale. One eagle-eyed bidder came across the rare booze, purchased it for $304, then immediately re-sold it for $503,300.


The damage: $4590 (and eternal damnation)
In 1631, London’s Baker Book House rewrote the 10 Commandments when a missing word in the seventh directive declared, “Thou shalt commit adultery.” Parliament declared that all erroneous copies of the Good Book—which came to be known as “The Wicked Bible”—be destroyed and fined the London publisher 3000 pounds.


The damage: $20,000
An unfortunate blunder in The Pasta Bible, published by Penguin Australia in 2010, recommended seasoning of tagliatelle with sardines and prosciutto with “salt and freshly ground black people.” Though no recall was made of the books already in circulation, the printer quickly destroyed all 7000 remaining copies in its inventory.


The damage: $175 million
Online trading was still in its relative infancy in 1994, a fact Juan Pablo Davila will never forget. It all started when the former copper trader—who was employed by Chile’s government-owned company Codelco—mistakenly bought stock he was trying to sell. After realizing the error, he went on a bit of a trading rampage—buying and selling enough stock that, by day’s end, he had cost the company/country $175 million. Davila was, of course, fired. And Codelco ended up filing suit against Merrill Lynch, alleging that the brokerage allowed Davila to make unauthorized trades. Merrill coughed up $25 million to settle the dispute—but not before a new word entered the popular lexicon: davilar, a verb used to indicate a screw-up of epic magnitude.


The damage: $340 million
In December 2005, Japan’s Mizuho Securities introduced a new member to its portfolio of offerings, a recruitment company called J-Com Co., nicely priced at 610,000 yen per share. Less than a year later, one of the company’s traders made more than a simple boo-boo when he sold 610,000 shares at one yen apiece. No amount of pleading to the Tokyo Stock Exchange could reverse the error.


The damage: $50 million (or $250,000 in Walmart dollars)
In 2007, a New Mexico car dealership mailed out 50,000 scratch tickets, one of which would reveal a $1000 cash prize. But Atlanta-based Force Events Direct Marketing Company mistakenly upped the ante when they printed said scratch tickets, making every one of them a grand-prize winner, for a grand payout of $50 million. Unable to honor the debt, the dealership instead offered a $5 Walmart gift certificate for every winning ticket.


The damage: $1.4 million
In 2006, New York City comptroller William Thompson admitted that a typo—an extra letter, to be precise—caused its accounting software to misinterpret a document, leading the city’s Department of Education to double its transportation spending (shelling out $2.8 million instead of $1.4 million).


The damage: $500,000
New York City’s Transportation Authority had to recall 160,000 maps and posters that announced the recent hike for the minimum amount put on pay-per-ride cards from $4.50 to $5.00. The problem? A typographical error that listed the “new” price as $4.50.


The damage: $10 million (plus $230 per month)
Banner Travel Services, California-based travel agency decided, to market its services in the phone book ... only to find that the final printing advertised its specialization in exotic destinations as a forte in “erotic” destinations. The typo certainly piqued the interest of some new customers, just not the kind of clientele the company was hoping to attract. The printer offered to waive its $230 monthly listing fee, but Banner sued for $10 million anyway.

Read the full text here:
--brought to you by mental_floss!

Monday, February 11, 2013

John E Karlin "Father of Human Factors Engineering" dies

Core77 design 11 February 2013

You may not know his name, but you know his work. John E. Karlin, who passed away in late January, essentially invented the touch-tone keypad. We take that ubiquitous input device for granted—it's on everything from cell phones to alarm systems to microwave ovens—but there was a time when that interface didn't exist, and no one knew what the "correct" design for quickly inputting numbers ought to be.

An industrial psychologist, Karlin was working for Bell Labs (AT&T's R&D department) in the 1940s when he convinced them to start a dedicated human factors department. By 1951 he himself was the director of Human Factors Engineering. In the late 1950s they sought a faster alternative to rotary dialing, and Karlin and his group developed the configuration we know so well today.

Forming the department and working on the keypad wasn't the only thing Karlin did, of course. The Times, who refer to Karlin as "widely considered the father of human-factors engineering in American industry," relates an amusing story of an earlier project--one that demonstrates his keen understanding of human behavior:

An early experiment involved the telephone cord. In the postwar years, the copper used inside the cords remained scarce. Telephone company executives wondered whether the standard cord, then about three feet long, might be shortened. Mr. Karlin's staff stole into colleagues' offices every three days and covertly shortened their phone cords, an inch at time. No one noticed, they found, until the cords had lost an entire foot. From then on, phones came with shorter cords.

Friday, February 08, 2013

Super Bowl blackout was caused by electrical relay

San Francisco Chronicle 8 February 2013 by Kevin McGill

The power failure cut lights to about half of the stadium, halting play and interrupting the nation's most-watched sporting event for 34 minutes.

The company that supplied electricity to the Super Bowl says the blackout that halted the big game was caused by a device it installed specially to prevent a power failure.

But the utility stopped short of taking all the blame and said Friday that it was looking into whether the electrical relay at fault had a design flaw or a manufacturing defect.

The relay had been installed as part of a project begun in 2011 to upgrade the electrical system serving the Superdome in anticipation of the championship game. The equipment was supposed to guard against problems in the cable that links the power grid with lines that go into the stadium.

"The purpose of it was to provide a newer, more advanced type of protection for the Superdome," Dennis Dawsey, an executive with Entergy Corp., told members of the City Council. Entergy is the parent company of Entergy New Orleans, the city's main electric utility.

"If higher settings had been applied, the equipment would not have disconnected the power," said Michael J.S. Edmonds, vice president of strategic solutions for S&C.

In a follow-up statement, Entergy said that tests conducted by S&C and Entergy on the two relays at the Superdome showed that one worked as expected, the other did not.

Shabab Mehraeen, an assistant professor of electrical engineering at Louisiana State University, said relays are common electrical fixtures in businesses and massive facilities such as the Superdome.

"They are designed to keep a problem they sense from becoming something bigger, like a fire or catastrophic event," he said.

"It's not unusual for them to have problems," Mehraeen said. "They can be unpredictable, despite national testing standards recommended by manufacturers."

It was reported that that the power being drawn at the time of the failure was only two-thirds of capacity.

Tuesday, January 29, 2013

Man allegedly follows GPS directions to wrong house; shot dead

CNET 29 January 2013 by Chris Matyszczyk

Friends say a man in his early 20s was picking up one more of their group to go skating, when his GPS took him to the wrong house and the home-owner allegedly shot him dead, later saying he feared a home invasion.

 According to Yeson Jimenez, 15, one of the passengers, Diaz pulled into a driveway; then 69-year-old Phillip Sailors peered out of a window of the house.

He allegedly came out, went back inside, then emerged again, firing a gun into the air.
Jimenez says Sailors said nothing to them but "Shut up!"

Jimenez insists they tried to drive away and that as they did, Sailors fired his .22 gun and shot Diaz fatally in the head.

Sailors' lawyer, Michael Puglise, told the Journal-Constitution: "He is very distraught over the loss of life from the defense of his home. This incident happened late in the evening hours when he was home with his wife and he assumed it was a home invasion and he maintains his innocence."

Monday, January 28, 2013

That Daily Shower Can Be a Killer (low risk but frequent activity)

The New York Times 28 January 2013 by Jared Diamond

The other morning, I escaped unscathed from a dangerous situation. No, an armed robber didn’t break into my house, nor did I find myself face to face with a mountain lion during my bird walk. What I survived was my daily shower.

You see, falls are a common cause of death in older people like me. (I’m 75.) Among my wife’s and my circle of close friends over the age of 70, one became crippled for life, one broke a shoulder and one broke a leg in falls on the sidewalk. One fell down the stairs, and another may not survive a recent fall.
“Really!” you may object. “What’s my risk of falling in the shower? One in a thousand?” My answer: Perhaps, but that’s not nearly good enough. 

Life expectancy for a healthy American man of my age is about 90. (That’s not to be confused with American male life expectancy at birth, only about 78.) If I’m to achieve my statistical quota of 15 more years of life, that means about 15 times 365, or 5,475, more showers. But if I were so careless that my risk of slipping in the shower each time were as high as 1 in 1,000, I’d die or become crippled about five times before reaching my life expectancy. I have to reduce my risk of shower accidents to much, much less than 1 in 5,475.

This calculation illustrates the biggest single lesson that I’ve learned from 50 years of field work on the island of New Guinea: the importance of being attentive to hazards that carry a low risk each time but are encountered frequently.

I first became aware of the New Guineans’ attitude toward risk on a trip into a forest when I proposed pitching our tents under a tall and beautiful tree. To my surprise, my New Guinea friends absolutely refused. They explained that the tree was dead and might fall on us.

Yes, I had to agree, it was indeed dead. But I objected that it was so solid that it would be standing for many years. The New Guineans were unswayed, opting instead to sleep in the open without a tent.

I thought that their fears were greatly exaggerated, verging on paranoia. In the following years, though, I came to realize that every night that I camped in a New Guinea forest, I heard a tree falling. And when I did a frequency/risk calculation, I understood their point of view.

Consider: If you’re a New Guinean living in the forest, and if you adopt the bad habit of sleeping under dead trees whose odds of falling on you that particular night are only 1 in 1,000, you’ll be dead within a few years. In fact, my wife was nearly killed by a falling tree last year, and I’ve survived numerous nearly fatal situations in New Guinea.

I now think of New Guineans’ hypervigilant attitude toward repeated low risks as “constructive paranoia”: a seeming paranoia that actually makes good sense. Now that I’ve adopted that attitude, it exasperates many of my American and European friends. But three of them who practice constructive paranoia themselves — a pilot of small planes, a river-raft guide and a London bobby who patrols the streets unarmed — learned the attitude, as I did, by witnessing the deaths of careless people.

Traditional New Guineans have to think clearly about dangers because they have no doctors, police officers or 911 dispatchers to bail them out. In contrast, Americans’ thinking about dangers is confused. We obsess about the wrong things, and we fail to watch for real dangers.

Studies have compared Americans’ perceived ranking of dangers with the rankings of real dangers, measured either by actual accident figures or by estimated numbers of averted accidents. It turns out that we exaggerate the risks of events that are beyond our control, that cause many deaths at once or that kill in spectacular ways — crazy gunmen, terrorists, plane crashes, nuclear radiation, genetically modified crops. At the same time, we underestimate the risks of events that we can control (“That would never happen to me — I’m careful”) and of events that kill just one person in a mundane way.

Having learned both from those studies and from my New Guinea friends, I’ve become as constructively paranoid about showers, stepladders, staircases and wet or uneven sidewalks as my New Guinea friends are about dead trees. As I drive, I remain alert to my own possible mistakes (especially at night), and to what incautious other drivers might do.

My hypervigilance doesn’t paralyze me or limit my life: I don’t skip my daily shower, I keep driving, and I keep going back to New Guinea. I enjoy all those dangerous things. But I try to think constantly like a New Guinean, and to keep the risks of accidents far below 1 in 1,000 each time.

Jared Diamond, a professor of geography at the University of California, Los Angeles, is the author of the new book “The World Until Yesterday: What Can We Learn From Traditional Societies?"

The New York Times 28 January 2013 by Jared Diamond

Wednesday, January 23, 2013

Ergonomics in the workplace

SSI Schafer 23 January 2013 by Dr Max Winkler

Article is actually titled "Why ergonomics makes a difference in warehouse logistics." The interesting part to me is the underlying process described.

There are 3 principles of ergonomics@work!® that are combined here to improve the quality:
  1. removing physical loads from the employee and thus reducing errors caused by fatigue
  2. simple and clearly structured processes to reduce the number of possible errors right from the start
  3. intelligent workplaces that recognize mistakes before the process is completed
 Good ergonomics is self-explanatory and simple. Ergonomics is certainly more than just going easy on joints and muscles. It is also about logic, easy to follow work steps and stress-free processes. In relation to a distribution centre, this means for example optimizing search and orientation tasks. Either there is just one removal position (which means there’s no need for orientation), as in a pick-to-tote workstation, or the error-prone study of picking lists is replaced by light pointers and pick-by-light displays. On top of that, a good workplace is also intelligent. It “knows” which step is possible next or which processes are not permitted at that particular moment. For instance, an order cannot be completed if the article is dropped into the wrong chute.

Thursday, January 10, 2013

Few Savings From Digital Health Records

The New York Times 10 January 2013 by Reed Abelson and Julie Creswsell

The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.

Optimistic predictions by RAND in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place. 

“We’ve not achieved the productivity and quality benefits that are unquestionably there for the taking,” said Dr. Arthur L. Kellermann, one of the authors of a reassessment by RAND that was published in this month’s edition of Health Affairs, an academic journal.

RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.

The report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure RAND now says was overstated. The study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems.

“RAND got a lot of attention and a lot of buzz with the original analysis,” said Dr. Kellermann, who was not involved in the 2005 study. “The industry quickly embraced it.”

But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services.

Health care spending has risen $800 billion since the first report was issued, according to federal figures. The reasons are many, from the aging of the baby boomer population, to the cost of medical advances, to higher usage of medical services over all.

Officials at RAND said their new analysis did not try to put a dollar figure on how much electronic record-keeping had helped or hurt efforts to reduce costs. But the firm’s acknowledgment that its earlier analysis was overly optimistic adds to a chorus of concern about the cost of the new systems and the haste with which they have been adopted.

The recent analysis was sharply critical of the commercial systems now in place, many of which are hard to use and do not allow doctors and patients to share medical information across systems. “We could be getting much more if we could take the time to do a little more planning and to set more standards,” said Marc Probst, chief information officer for Intermountain Healthcare, a large health system in Salt Lake City that developed its own electronic records system and is cited by RAND as an example of how the technology can help improve care and reduce costs.

The RAND researchers pointed to a number of other reasons the expected savings had not materialized. The rate of adoption has been slow, they said, and electronic records do not address the fact that doctors and hospitals reap the benefits of high volumes of care.

Many experts say the available systems seem to be aimed more at increasing billing by providers than at improving care or saving money. Federal regulators are investigating whether electronic records make it easier for hospitals and doctors to bill for services they did not provide and whether Medicare and other federal agencies are adequately monitoring the use of electronic records.

Technology “is only a tool,” said Dr. David Blumenthal, who helped oversee the federal push for the adoption of electronic records under President Obama and is now president of the Commonwealth Fund, a nonprofit health group. “Like any tool, it can be used well or poorly.” While there is strong evidence that electronic records can contribute to better care and more efficiency, Dr. Blumenthal said, the systems in place do not always work in ways that help achieve those benefits.