Article by David Learmount published 10 October 2006 on Flight website
Talks about a course titled 'Safety Stand-down' for experienced pilots run in US. Claims that the course "takes fully trained pilots well above and beyond what an advanced conventional or recurrent flying training programme provides. It challenges preconceptions, stimulates questions, and presents a pilot with a mirror in which his/her latent professional and personal vulnerabilities become fully visible. More than that, it renews a pilot’s respect for the multiple disciplines it takes to be a really good aviator."
Quotes Bob Agostino (Bombardier Business Aircraft director of operations): “Development of the human half of the man-machine equation has not kept pace with the technology developments in either formal training programmes nor in regulatory development.”
Also Dr Tony Kern (senior partner in Convergent Knowledge Solutions): "The challenge of human error will never be remedied by any traditional safety programme. Personal error must be slowly untangled in a private battle within each individual.”
Finally, researcher from University of Manchester: “The study of human error has grown dramatically in the last 20 years. We know why people make errors and how to prevent 90% of them, but no-one seems to care.”
Andy Brazier
Wednesday, October 11, 2006
Friday, October 06, 2006
Indian Air Force
According to article from Reuters on 5 October 2006 available here
"Out of nearly 800 MiG-21s that India's air force has acquired since 1963, 330 have crashed, mostly due to human error, according to official figures."
The Indian Air Force are buying new trainer jets to try and improve then safety record.
Andy Brazier
"Out of nearly 800 MiG-21s that India's air force has acquired since 1963, 330 have crashed, mostly due to human error, according to official figures."
The Indian Air Force are buying new trainer jets to try and improve then safety record.
Andy Brazier
Thursday, October 05, 2006
IT reliability
Article by Borris Sadacca on 3 October 2006 available here
Mostly concerned with datacentres, and the reliance on reliable equipment and reliable power supply including Uninterruptible Power Supply (UPS). "It is clear that to achieve high availability in the datacentre, IT directors need to look not only at the applications and server infrastructure and service level agreements associated with the IT, but also at the non-IT infrastructure - the mechanical, electrical and plumbing systems that keep the datacentre operational."
It points out that systems designed to be highly reliable are often brought down by human error. Examples quoted include:
* Staff may be needed to work after hours and are tired.
* A common problem is when maintenance staff do not follow procedures step by step, which happens especially with well-versed personnel.
* Systems components are replaced even though there are no signs of wear or failure. This creates an opportunity for inserting other failures.
* Invasive checks that require the removal of other components can introduce problems.
"So while technology and multiple levels of redundancy can limit the effect of failure, much of what keeps a datacentre going is down to the people. Many problems can be avoided simply by operating a two-person maintenance team."
Andy Brazier
Mostly concerned with datacentres, and the reliance on reliable equipment and reliable power supply including Uninterruptible Power Supply (UPS). "It is clear that to achieve high availability in the datacentre, IT directors need to look not only at the applications and server infrastructure and service level agreements associated with the IT, but also at the non-IT infrastructure - the mechanical, electrical and plumbing systems that keep the datacentre operational."
It points out that systems designed to be highly reliable are often brought down by human error. Examples quoted include:
* Staff may be needed to work after hours and are tired.
* A common problem is when maintenance staff do not follow procedures step by step, which happens especially with well-versed personnel.
* Systems components are replaced even though there are no signs of wear or failure. This creates an opportunity for inserting other failures.
* Invasive checks that require the removal of other components can introduce problems.
"So while technology and multiple levels of redundancy can limit the effect of failure, much of what keeps a datacentre going is down to the people. Many problems can be avoided simply by operating a two-person maintenance team."
Andy Brazier
Shift work
Article written by George Brogmus and Wayne Maynard 4 October 2006
here
Findings of a recently published Liberty Mutual Research Institute study modeling the impact of the components of long work hours on injuries and accidents:
* Work-related injuries increased 15.2 percent on afternoon shifts and 27.9 percent on the night shift relative to the morning shift.
* Injury risk increases nearly linearly after the eighth hour of a shift, with risk increasing 13 percent on a 10-hour shift and almost 30 percent on a 12-hour shift.
* As consecutive shifts increase, injury risk also increases, but at a higher rate for night shifts than for day shifts.
* Average risk for injury is 36 percent higher on the last night of a four-consecutive-night shift. Risk increases incrementally over each night on the job: 6 percent higher on the second night, 17 percent higher on the third night – culminating at 36 percent on the fourth night.
* Injury risk is 2 percent higher on the second morning/day shift, 7 percent higher on the third day and 17 percent higher on the fourth day than it is on the first shift.
* Injury risk also increases as time between breaks increases. The last 30 minutes of a 2-hour work period has twice the risk of injury as the 30 minutes immediately after the break.
Advice to minimise problems includes:
* Evaluate the combined effect of work scheduling factors rather than to just limit total work hours (i.e. time of day, breaks on shift).
* Establish maximum limits for days and nights worked per week, including overtime. Whenever possible, favor day/morning shifts over afternoon or night shifts.
* Consider adding hours to existing shifts or add an additional day of work to the project, and limit work to five or six consecutive shifts.
* Provide for frequent rest breaks. Hourly breaks generally are appropriate, but consider providing more frequent breaks for highly repetitive or strenuous work.
* Schedule work so every worker has at least two consecutive rest days and at least one of these days is Saturday or Sunday.
* Avoid scheduling several days of work followed by four- to seven-day mini-vacations.
* Keep consecutive nights shifts to a minimum – four nights maximum in a row should be worked before a couple of days off and schedule no more than 48 hours of night shiftwork per worker per week.
* Educate workers on the importance of getting enough good sleep. Suggest they use black-out drapes, turn off phones and pagers and use a fan or white noise to mask daytime noises. Regular exercise, diet and relaxation techniques also are effective strategies for coping with night work.
* Consider alternatives to adopting permanent night shifts. Most workers never fully adapt to night shiftwork, since they go back to a daytime schedule during days off.
* Avoid quick shift changes and adjust shift length to the workload.
* Take into account all aspects of workers' job and home lives when changing work schedules.
* Provide a minimum of 11 hours off between shifts and a minimum of 24 to 48 hours when rotating workers off the night shift.
* Change from the night and morning shifts should happen between 7 a.m and 9 a.m., as starting the morning shift too early often cuts down on evening sleep time.
* Forward shift rotation – going from a day to afternoon or afternoon to night or night to day shift – is more compatible with normal sleep patterns than backward shift rotation.
Andy Brazier
here
Findings of a recently published Liberty Mutual Research Institute study modeling the impact of the components of long work hours on injuries and accidents:
* Work-related injuries increased 15.2 percent on afternoon shifts and 27.9 percent on the night shift relative to the morning shift.
* Injury risk increases nearly linearly after the eighth hour of a shift, with risk increasing 13 percent on a 10-hour shift and almost 30 percent on a 12-hour shift.
* As consecutive shifts increase, injury risk also increases, but at a higher rate for night shifts than for day shifts.
* Average risk for injury is 36 percent higher on the last night of a four-consecutive-night shift. Risk increases incrementally over each night on the job: 6 percent higher on the second night, 17 percent higher on the third night – culminating at 36 percent on the fourth night.
* Injury risk is 2 percent higher on the second morning/day shift, 7 percent higher on the third day and 17 percent higher on the fourth day than it is on the first shift.
* Injury risk also increases as time between breaks increases. The last 30 minutes of a 2-hour work period has twice the risk of injury as the 30 minutes immediately after the break.
Advice to minimise problems includes:
* Evaluate the combined effect of work scheduling factors rather than to just limit total work hours (i.e. time of day, breaks on shift).
* Establish maximum limits for days and nights worked per week, including overtime. Whenever possible, favor day/morning shifts over afternoon or night shifts.
* Consider adding hours to existing shifts or add an additional day of work to the project, and limit work to five or six consecutive shifts.
* Provide for frequent rest breaks. Hourly breaks generally are appropriate, but consider providing more frequent breaks for highly repetitive or strenuous work.
* Schedule work so every worker has at least two consecutive rest days and at least one of these days is Saturday or Sunday.
* Avoid scheduling several days of work followed by four- to seven-day mini-vacations.
* Keep consecutive nights shifts to a minimum – four nights maximum in a row should be worked before a couple of days off and schedule no more than 48 hours of night shiftwork per worker per week.
* Educate workers on the importance of getting enough good sleep. Suggest they use black-out drapes, turn off phones and pagers and use a fan or white noise to mask daytime noises. Regular exercise, diet and relaxation techniques also are effective strategies for coping with night work.
* Consider alternatives to adopting permanent night shifts. Most workers never fully adapt to night shiftwork, since they go back to a daytime schedule during days off.
* Avoid quick shift changes and adjust shift length to the workload.
* Take into account all aspects of workers' job and home lives when changing work schedules.
* Provide a minimum of 11 hours off between shifts and a minimum of 24 to 48 hours when rotating workers off the night shift.
* Change from the night and morning shifts should happen between 7 a.m and 9 a.m., as starting the morning shift too early often cuts down on evening sleep time.
* Forward shift rotation – going from a day to afternoon or afternoon to night or night to day shift – is more compatible with normal sleep patterns than backward shift rotation.
Andy Brazier
Friday, September 29, 2006
Human error not a safety issue???
Quote from an article about the Maglev crash in Germany this month. "The crash has prompted a closer look at safety, even though the cause was probably human error."
What a strange thing to say. This seems to be the classic where people assume high technology and automation remove the opportunity for error and so human factors are no longer relevant. The reality usually is that error likelihood may be reduced but the potential consequences are higher and the errors are more complex in nature. Therefore, human factors is far more important.
Article here from the Economist on 28 September 2006.
Andy Brazier
What a strange thing to say. This seems to be the classic where people assume high technology and automation remove the opportunity for error and so human factors are no longer relevant. The reality usually is that error likelihood may be reduced but the potential consequences are higher and the errors are more complex in nature. Therefore, human factors is far more important.
Article here from the Economist on 28 September 2006.
Andy Brazier
Thursday, September 28, 2006
Fire risk assessment
Attended talk yesterday given by Dai Roberts of North Wales Fire and Rescue service. About new fire regulations coming in on 1 October 2006.
Main point made was for any employer, it is their risk and they must manage it. Fire service will no longer give certificates or specific advice. The minimum requirement is to have completed a suitable and sufficient fire risk assessment and to have plans in place to address any significant findings.
The new regulations apply to nearly every type of building except domestic premises. In early days the priority will be 'high life risk' premises, which include pubs, hotels, community centres, hostels.
Fire services will audit risk assessments and premises. The is a concordat that requires them to act in a fair way. In practice this means they will give 5 weeks notice of an audit, unless they have reason to believe there is a problem (e.g. if there has been a fire or specific complaint).
Fire services will be responsible for fire safety of premises. HSE will maintain responsibility for process (i.e. the activities at the premises).
Andy Brazier
Main point made was for any employer, it is their risk and they must manage it. Fire service will no longer give certificates or specific advice. The minimum requirement is to have completed a suitable and sufficient fire risk assessment and to have plans in place to address any significant findings.
The new regulations apply to nearly every type of building except domestic premises. In early days the priority will be 'high life risk' premises, which include pubs, hotels, community centres, hostels.
Fire services will audit risk assessments and premises. The is a concordat that requires them to act in a fair way. In practice this means they will give 5 weeks notice of an audit, unless they have reason to believe there is a problem (e.g. if there has been a fire or specific complaint).
Fire services will be responsible for fire safety of premises. HSE will maintain responsibility for process (i.e. the activities at the premises).
Andy Brazier
Wednesday, September 27, 2006
Maglev train crash
Several news items regarding the crash in Germany on 22 September 2006. Seems that the train was on a trial run and crashed into a maintenance truck that was on the tracks. The presence of the truck had been noted in a handwritten log by controllers, but automatic detection did not work.
The suggestion that human error was to blame is being made. This seems inevitable, at least a failure of communication between truck, controllers and train. Knowing this on its own won't really help us make it any safer.
Chancellor Angela Merkel is quoted as saying "At this point I don't see any connection with the technology. The technology is a very, very safe technology." People tend to think that technology and automation eliminate the possibility of human error. The reality is they change the opportunities, and often whilst the likelihood may be reduced the potential consequences are often much greater.
Articles from Reuters
and
Yahoo news
Andy Brazier
The suggestion that human error was to blame is being made. This seems inevitable, at least a failure of communication between truck, controllers and train. Knowing this on its own won't really help us make it any safer.
Chancellor Angela Merkel is quoted as saying "At this point I don't see any connection with the technology. The technology is a very, very safe technology." People tend to think that technology and automation eliminate the possibility of human error. The reality is they change the opportunities, and often whilst the likelihood may be reduced the potential consequences are often much greater.
Articles from Reuters
and
Yahoo news
Andy Brazier
Calculated risks
Amanda Platell in Daily Mail on 23 September 2006, writing about the crash TopGear presenter had in a jet powered car.
She quote Hammond saying sometime in the past "I would only take calculated risks." She then goes on to say "well, somehow his calculation went disastrously wrong."
Why does having a crash mean that his calculations were wrong? Unless the risk was zero, there is always a possibility that something will go wrong and that some harm may result. Unfortunately no one seems to acknowledge this nowadays.
What a daft thing to write!
Article is online here.
Andy Brazier
She quote Hammond saying sometime in the past "I would only take calculated risks." She then goes on to say "well, somehow his calculation went disastrously wrong."
Why does having a crash mean that his calculations were wrong? Unless the risk was zero, there is always a possibility that something will go wrong and that some harm may result. Unfortunately no one seems to acknowledge this nowadays.
What a daft thing to write!
Article is online here.
Andy Brazier
Thursday, September 14, 2006
Getting to grips with human error
Some very useful looking resources on the UK P&I clubs website
Link
At the bottom of the page there are links to a couple of PDF's that seem to sum up issues regarding error rather well.
I don't known anything about UK P&I club, but they are clearly in the maritime industry and I think they are something to do with insurance.
Andy Brazier
Link
At the bottom of the page there are links to a couple of PDF's that seem to sum up issues regarding error rather well.
I don't known anything about UK P&I club, but they are clearly in the maritime industry and I think they are something to do with insurance.
Andy Brazier
Wednesday, September 13, 2006
Sensible risk management
From BBC website on 22 August 2006
Link
A campaign has been launched to encourage people to stop worrying about "trivial" concerns over safety and concentrate on real risks. The Health and Safety Commission said unnecessary concerns over paperwork and the fear of being sued were being used to cancel school trips and outings.
Instead it is urging people to focus on risks that cause harm and suffering.
The HSC is concerned that too much concern over paperwork and bureaucracy will stifle learning and innovation.
Quote from Chair of the HSC Bill Callaghan:
"My message is that if you're using health and safety to stop everyday activities - get a life and let others get on with theirs."
Andy Brazier
Link
A campaign has been launched to encourage people to stop worrying about "trivial" concerns over safety and concentrate on real risks. The Health and Safety Commission said unnecessary concerns over paperwork and the fear of being sued were being used to cancel school trips and outings.
Instead it is urging people to focus on risks that cause harm and suffering.
The HSC is concerned that too much concern over paperwork and bureaucracy will stifle learning and innovation.
Quote from Chair of the HSC Bill Callaghan:
"My message is that if you're using health and safety to stop everyday activities - get a life and let others get on with theirs."
Andy Brazier
ISO 14001
From a short talk given by Ollie Shaw of Standard Plus
Achieving ISO 14001 involves the following (year long) project
1. Initial review - current arrangements
2. Define improvement programme
3. Define controls - work instructions
4. Operate the system
5. Audit
6. Assessment
To determine the importance of environmental aspects you need to evaluate
1. The impact - land, sea, air, noisy, ugly, gas guzzler (expensive on resources)
2. Its significance - legislation, cost, interested parties
Whilst a company may measure performance in financial terms, it is important this is not presented to the ISO assessor who is interested in environmental measures. For example, saving electricity may save £X per year, it is better to describe in kW.
Andy Brazier
Achieving ISO 14001 involves the following (year long) project
1. Initial review - current arrangements
2. Define improvement programme
3. Define controls - work instructions
4. Operate the system
5. Audit
6. Assessment
To determine the importance of environmental aspects you need to evaluate
1. The impact - land, sea, air, noisy, ugly, gas guzzler (expensive on resources)
2. Its significance - legislation, cost, interested parties
Whilst a company may measure performance in financial terms, it is important this is not presented to the ISO assessor who is interested in environmental measures. For example, saving electricity may save £X per year, it is better to describe in kW.
Andy Brazier
Drilling rig fatal accident - Morecambe Bay
Texas-based oil and gas multi-national Ensco has been ordered to pay fines and costs totalling £290,000 after the tragic death of a worker (Russell Bell aged 25) died after falling 100ft into the Irish Sea in Morecambe Bay from a gas exploration platform. According to an article published on 12 September 2006 on
Lancashire Evening Post website.
He was involved in derigging some hoses that had been used for cooling lifeboats whilst flaring was taking place. Judge Russel said "Tragically he was unable to hold on to the ladder he had stepped onto and fell to his death some 100ft into the sea". It was accepted that the company did have a "safety culture" in place and there was no question of them, "putting profits before safety".
Mr Bell should not have been on the ladder according to safety instructions but the company, said Judge Russell, should have put measures in place to deal with human error.
Health and Safety for beginners website provides some more information and photos. It seems the dead person was replacing stair treads. He was supposed to only have one missing at any time, but for some reason had removed two. The article implies that, whilst this was fully covered on the permit to work, enough may not have been done to explain the permit and discuss the job before starting.
Andy Brazier
Lancashire Evening Post website.
He was involved in derigging some hoses that had been used for cooling lifeboats whilst flaring was taking place. Judge Russel said "Tragically he was unable to hold on to the ladder he had stepped onto and fell to his death some 100ft into the sea". It was accepted that the company did have a "safety culture" in place and there was no question of them, "putting profits before safety".
Mr Bell should not have been on the ladder according to safety instructions but the company, said Judge Russell, should have put measures in place to deal with human error.
Health and Safety for beginners website provides some more information and photos. It seems the dead person was replacing stair treads. He was supposed to only have one missing at any time, but for some reason had removed two. The article implies that, whilst this was fully covered on the permit to work, enough may not have been done to explain the permit and discuss the job before starting.
Andy Brazier
Monday, September 11, 2006
Working time directive - rest breaks
EUobserver.com article 7 September 2006
The European Court of Justice (ECJ) ruled on Thursday (7 September) that the UK must change guidelines saying that employers "must make sure that workers can take their rest, but are not required to make sure they do take their rest." The requirement is that employers make sure employees take their breaks.
This includes 11 hours away from work in any day (between shifts) and break at work if present for more than 6 hours.
There are complaints from business that this interferes with flexibility. However, my observation is that there are too many people in safety critical roles not taking breaks, and this can only contribute to fatigue which has short and long term effects.
Andy Brazier
The European Court of Justice (ECJ) ruled on Thursday (7 September) that the UK must change guidelines saying that employers "must make sure that workers can take their rest, but are not required to make sure they do take their rest." The requirement is that employers make sure employees take their breaks.
This includes 11 hours away from work in any day (between shifts) and break at work if present for more than 6 hours.
There are complaints from business that this interferes with flexibility. However, my observation is that there are too many people in safety critical roles not taking breaks, and this can only contribute to fatigue which has short and long term effects.
Andy Brazier
Thursday, September 07, 2006
Fire risk assessment
There seems to be a lot of debate about fire risk assessment, which are part of the new fire regulations coming in on 1 October 2006.
There is a particularly good debate going on at the Fire Net Forum
http://www.fire.org.uk/punbb/upload/viewtopic.php?id=1073&p=1
Around page six there is a discussion about whether the man in the street understands descriptive or numerical estimates of risk. Is it better to say that a fire is likely or to say there is a 75% chance of a fire. People may well understand the numbers better but may assume it is based on a more scientific approach, when in most cases it is just someones 'gut feeling.'
There is a rather worrying debate on the IOSH forum
http://www.iosh.co.uk/index.cfm?go=discussion.view&forum=2&thread=20603
Some people on this one don't seem to know what a risk assessment is!
Andy Brazier
There is a particularly good debate going on at the Fire Net Forum
http://www.fire.org.uk/punbb/upload/viewtopic.php?id=1073&p=1
Around page six there is a discussion about whether the man in the street understands descriptive or numerical estimates of risk. Is it better to say that a fire is likely or to say there is a 75% chance of a fire. People may well understand the numbers better but may assume it is based on a more scientific approach, when in most cases it is just someones 'gut feeling.'
There is a rather worrying debate on the IOSH forum
http://www.iosh.co.uk/index.cfm?go=discussion.view&forum=2&thread=20603
Some people on this one don't seem to know what a risk assessment is!
Andy Brazier
Driving coaching
Article titled 'Joined up thinking better for Drivers' on femalefirst.co.uk 6 September 2006.
Research by Brunnel University has shown that the coaching and practical on-road assessment and feedback providing by the Institute of Advanced Motorists improves people's driving ability, whilst others do not improve after passing their test, or even deteriorate.
Improvement is put down to having a greater awareness of other road users, road conditions, and infrastructure. But the greatest impact is the ability join these up so that drivers can achieve an overall understanding of potential hazards and the appropriate driver response.
They break the competence into knowledge of what was going on around them, skills applied to the driving tasks, and attitude towards driving.
Andy Brazier
Research by Brunnel University has shown that the coaching and practical on-road assessment and feedback providing by the Institute of Advanced Motorists improves people's driving ability, whilst others do not improve after passing their test, or even deteriorate.
Improvement is put down to having a greater awareness of other road users, road conditions, and infrastructure. But the greatest impact is the ability join these up so that drivers can achieve an overall understanding of potential hazards and the appropriate driver response.
They break the competence into knowledge of what was going on around them, skills applied to the driving tasks, and attitude towards driving.
Andy Brazier
Wednesday, September 06, 2006
Leading by example
Zoe Thomas writing Sunday Times 'Best Companies' supplement on 3 September 2006
Top tips for leading by example include:
1. Listen to your employees
2. Act on what staff tell you, or explain why you do not agree with their idea
3. Trust your workforce and delegate important jobs to them
4. Trust fellow senior employees
5. Formulate clear company values/principles
6. Live the company values yourself
7. Place the company first, not your own personal ambition
8. Keep meetings with other senior managers to a minimum
9. Communicate decisions arrived at such meetings to all staff
10. Make sure everyone in the company knows who is responsible for what
Top tips for leading by example include:
1. Listen to your employees
2. Act on what staff tell you, or explain why you do not agree with their idea
3. Trust your workforce and delegate important jobs to them
4. Trust fellow senior employees
5. Formulate clear company values/principles
6. Live the company values yourself
7. Place the company first, not your own personal ambition
8. Keep meetings with other senior managers to a minimum
9. Communicate decisions arrived at such meetings to all staff
10. Make sure everyone in the company knows who is responsible for what
Best companies to work for
Article by Zoe Thomas in Sunday Times 'Best Companies' Supplement on 3 September 2006
Eight critical influences on the overall workplace experience are:
1. Leadership: how people feel about the head of the company and the most senior managers
2. Personal growth: to what extent people feel stretched by their job
3. My manager: people's feelings towards their day-to-day managers
4. My company: feelings about the company people work for as opposed to the people they work with
5. My team: people's feelings about their immediate colleagues
6. Wellbeing: how people feel about stress, pressure and the balance between their work and home life
7. Giving something back: how much companies are thought to put back into society and the community
8. Fair deal: how happy employees are with their pay and benefits
Apparently, success in these factors generates "employee engagement" which defines the quality and strength of relationship between the workforce and their organisation.
Andy Brazier
Eight critical influences on the overall workplace experience are:
1. Leadership: how people feel about the head of the company and the most senior managers
2. Personal growth: to what extent people feel stretched by their job
3. My manager: people's feelings towards their day-to-day managers
4. My company: feelings about the company people work for as opposed to the people they work with
5. My team: people's feelings about their immediate colleagues
6. Wellbeing: how people feel about stress, pressure and the balance between their work and home life
7. Giving something back: how much companies are thought to put back into society and the community
8. Fair deal: how happy employees are with their pay and benefits
Apparently, success in these factors generates "employee engagement" which defines the quality and strength of relationship between the workforce and their organisation.
Andy Brazier
Problems with new technology
David Johnson article "Don't wince when the digital revolution behaves like a spoilt brat" in the Sunday Times on 3 September 2006
He describes the newest technology as being "like a wayward child that you want to embrace, even if it will keep spitting you in the eye." This is because companies are more interested in giving us headline-grabbing new features or a new look, without thinking how they will work in practice.
He quotes examples including the new Nokia 6233 mobile phone with a screen you can't read in daylight and the LG chocolate phone with a touch sensitive keypad that performs unwanted actions when your finger hovers over it. Also, rail company Southern introduced an electronic ticket machine that required users to wade through multiple pages and often rejected credit cards late in the sequence, causing huge queues.
Other complaints include website for booking tickets where you are never sure if the transaction has gone through successfully. Items with "known issues" such as a DAB radio that would not turn off or a VCR that could not record when first put on sale.
Also, it doesn't help that different manufacturers use different names for the same basic functions. The name even changes between different models from the same manufacturer.
Andy Brazier
He describes the newest technology as being "like a wayward child that you want to embrace, even if it will keep spitting you in the eye." This is because companies are more interested in giving us headline-grabbing new features or a new look, without thinking how they will work in practice.
He quotes examples including the new Nokia 6233 mobile phone with a screen you can't read in daylight and the LG chocolate phone with a touch sensitive keypad that performs unwanted actions when your finger hovers over it. Also, rail company Southern introduced an electronic ticket machine that required users to wade through multiple pages and often rejected credit cards late in the sequence, causing huge queues.
Other complaints include website for booking tickets where you are never sure if the transaction has gone through successfully. Items with "known issues" such as a DAB radio that would not turn off or a VCR that could not record when first put on sale.
Also, it doesn't help that different manufacturers use different names for the same basic functions. The name even changes between different models from the same manufacturer.
Andy Brazier
Computer Science for Fun
I have been looking around the Computer Science for Fun website. Some really interesting games that introduce useful concepts about error, user interfaces etc. Well worth a look
CS4F Website
Andy Brazier
CS4F Website
Andy Brazier
Everyday errors
Good article on the Computer Science For Fun website about research into pilot error. Includes a space invaders game that can be played on line that induces you to make errors to see if you avoid them.
http://www.dcs.qmul.ac.uk/cs4fn/humanerror/
Web article talks about every day errors that most of us make. The list includes
Forget your change in a shop or from a vending machine?
Forget to take the receipt?
Photocopy something then forget the original.
Forget to switch off the headlights of your car?
Forget to switch off the gas on the cooker.
People are naturally prone to make these errors because they all involve completing the thing you were trying to do: get a drink or chocolate, a photocopy, arrive at the place you were going to, cook the meal, etc. For all of these errors there was an extra thing you had to do after you had completed the main task ... and you forgot to do it. (take the change, take the receipt, switch off the headlights or the gas). Experiments have shown that these errors happen due to working memory overload combined with the structure of the task.
Early cash machines gave back the money first then the card. People regularly forgot their cards. Same error. Now, in Britain at least, the machines always give the card back first. People rarely forget their cards with the redesigned machines. Better design: human error disappears.
Andy Brazier
http://www.dcs.qmul.ac.uk/cs4fn/humanerror/
Web article talks about every day errors that most of us make. The list includes
Forget your change in a shop or from a vending machine?
Forget to take the receipt?
Photocopy something then forget the original.
Forget to switch off the headlights of your car?
Forget to switch off the gas on the cooker.
People are naturally prone to make these errors because they all involve completing the thing you were trying to do: get a drink or chocolate, a photocopy, arrive at the place you were going to, cook the meal, etc. For all of these errors there was an extra thing you had to do after you had completed the main task ... and you forgot to do it. (take the change, take the receipt, switch off the headlights or the gas). Experiments have shown that these errors happen due to working memory overload combined with the structure of the task.
Early cash machines gave back the money first then the card. People regularly forgot their cards. Same error. Now, in Britain at least, the machines always give the card back first. People rarely forget their cards with the redesigned machines. Better design: human error disappears.
Andy Brazier
Friday, September 01, 2006
Back injuries
Very comprehensive article about back injuries, prevention and treatment by Josh Cable
http://www.occupationalhazards.com/articles/15578
"Of the 1.3 million reported lost-time injuries and illnesses in private industry in 2003, sprains and strains – most often involving the back – were far and away the leading type of injury in every major industry sector, accounting for 43 percent of the total lost-time cases, according to the Bureau of Labor Statistics (BLS)"
"While it's not easy to put a nationwide price tag on back injuries, the 2005 Liberty Mutual Workplace Safety Index found injuries caused by overexertion – defined as excessive lifting, pushing, pulling, holding, carrying or throwing an object, all of which are key ingredients of back injuries – cost employers $13.4 billion."
Maintaining the curve is key. It is suggested we unlearn proper use of a out bodies at a young age, around 4 or 5.
http://www.occupationalhazards.com/articles/15578
"Of the 1.3 million reported lost-time injuries and illnesses in private industry in 2003, sprains and strains – most often involving the back – were far and away the leading type of injury in every major industry sector, accounting for 43 percent of the total lost-time cases, according to the Bureau of Labor Statistics (BLS)"
"While it's not easy to put a nationwide price tag on back injuries, the 2005 Liberty Mutual Workplace Safety Index found injuries caused by overexertion – defined as excessive lifting, pushing, pulling, holding, carrying or throwing an object, all of which are key ingredients of back injuries – cost employers $13.4 billion."
Maintaining the curve is key. It is suggested we unlearn proper use of a out bodies at a young age, around 4 or 5.
Motivating ergonomic behaviour
Article by Robert Pater presented June 2006 at ASSE's (American Society of Safety Engineers) annual Professional Development Conference. Summarised here
Many organisation have employed engineering solutions to improve ergonomics. They have been successful, but improvements have plateaued. Behaviours need to really change for further improvement.
Pater states that "leaders incite change by motivating receptivity and trial of new behaviors, transferring critical mental and physical skills and reinforcing improved performance – all with a goal of setting positive, safe default habits." He proposes a seven stage approach
1. Set and assess ergonomic-motivating objectives - realistic expectations
2. Identify barriers to ergonomic receptivity and behavioral change.
3. Energize all - move from just prevention to personal benefits of fitness
4. Spark involvement - simultaneous topdown/bottom-up "scissors" approach
5. Focus on home, as well as work
6. Build critical ergonomic skill sets, both mental and physical
7. Make it (self) reinforcing - publicise plans and success, get everyone talking about it.
To achieve involvement managers can help select the leading ergonomic indicators they deem valuable. Supervisors are involved in setting the timing for and reinforcing action changes. Some employees might be trained to become "peer catalysts," who are agents of ergonomic behavioral change. And all workers can select and monitor personal ergonomic objectives.
Pater lists skills sets that can be taught as
seeing your own level of accepted risk;
directing attention at will;
recalling policies/procedures/techniques;
understanding and applying underlying ergonomic principles;
maximizing leverage to maximize effective strength;
heightening balance;
improving eye-hand coordination;
boosting flexibility/range of motion;
reducing fatigue;
controlling breathing;
effective preparation and recovery methods.
Andy Brazier
Many organisation have employed engineering solutions to improve ergonomics. They have been successful, but improvements have plateaued. Behaviours need to really change for further improvement.
Pater states that "leaders incite change by motivating receptivity and trial of new behaviors, transferring critical mental and physical skills and reinforcing improved performance – all with a goal of setting positive, safe default habits." He proposes a seven stage approach
1. Set and assess ergonomic-motivating objectives - realistic expectations
2. Identify barriers to ergonomic receptivity and behavioral change.
3. Energize all - move from just prevention to personal benefits of fitness
4. Spark involvement - simultaneous topdown/bottom-up "scissors" approach
5. Focus on home, as well as work
6. Build critical ergonomic skill sets, both mental and physical
7. Make it (self) reinforcing - publicise plans and success, get everyone talking about it.
To achieve involvement managers can help select the leading ergonomic indicators they deem valuable. Supervisors are involved in setting the timing for and reinforcing action changes. Some employees might be trained to become "peer catalysts," who are agents of ergonomic behavioral change. And all workers can select and monitor personal ergonomic objectives.
Pater lists skills sets that can be taught as
seeing your own level of accepted risk;
directing attention at will;
recalling policies/procedures/techniques;
understanding and applying underlying ergonomic principles;
maximizing leverage to maximize effective strength;
heightening balance;
improving eye-hand coordination;
boosting flexibility/range of motion;
reducing fatigue;
controlling breathing;
effective preparation and recovery methods.
Andy Brazier
Thursday, August 31, 2006
Allocating blame for cable car crash
Article on BBC site 18 July 2006. Provides more information about the Nevis Range cable car crash that injured 5 people.
http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/5189324.stm
I am interested by the language used by Mr Hinteregger from the operating company. Couple of quotes:
"there must have been human error as the safety systems worked as intended"
"the company was not "in charge" of allocating blame, as that was up to the investigating authorities."
http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/5189324.stm
I am interested by the language used by Mr Hinteregger from the operating company. Couple of quotes:
"there must have been human error as the safety systems worked as intended"
"the company was not "in charge" of allocating blame, as that was up to the investigating authorities."
Red-face spellchecker
Article from Reuters 26 July 2006
here
TextTrust is a company that sells a service checking web sites for spelling errors. Unfortunately they issued a news release with multiple errors. "It said commonly misspelled words included independent, accommodation and definitely, which were spelled independant, accomodation and definately."
Oops
here
TextTrust is a company that sells a service checking web sites for spelling errors. Unfortunately they issued a news release with multiple errors. "It said commonly misspelled words included independent, accommodation and definitely, which were spelled independant, accomodation and definately."
Oops
Pitfalls of nuclear power
Book titled 'Nuclear Power Is Not the Answer' by Dr Helen Caldicott is summarised at this web site
http://www.vheadline.com/readnews.asp?id=65443
Dr. Caldicott is President of the Nuclear Policy Research Institute. She has become "perhaps the world's leading advocate for the abolition of a technology too unsafe to be tolerated any longer."
Human error gets several mentions. See quotes below
"Many experts agree it's only a matter of when and where, not if, a devastating meltdown will occur in one or more of the 438 nuclear power plants located in 33 countries worldwide. It may result from human error, a plant owner's unwise or unsafe attempt to minimize operating costs, the Nuclear Regulatory Commission's (NRC) imprudent accession to industry pressure to allow 20 year operating extensions to plants designed to run only for 40 years, the effects of a tsunami or high enough magnitude earthquake in areas vulnerable to them or from a deliberate attack or internal sabotage."
And
"Every US power plant is moving into the old-age cycle" because no new ones have been built here since the TMI accident in Pennsylvania in 1979. As a result, the number of near-misses and near-meltdowns has increased mostly resulting from human error, aging equipment and inadequate maintenance and regulatory oversight. With the dangers so high and inevitable and the supposed benefits totally without merit, why would the leaders and residents of any community ever be willing to allow the construction or operation of a nuclear power plant near enough to them to destroy their lives should a catastrophic nuclear event happen as it surely will potentially at any of the world's nuclear plants.
http://www.vheadline.com/readnews.asp?id=65443
Dr. Caldicott is President of the Nuclear Policy Research Institute. She has become "perhaps the world's leading advocate for the abolition of a technology too unsafe to be tolerated any longer."
Human error gets several mentions. See quotes below
"Many experts agree it's only a matter of when and where, not if, a devastating meltdown will occur in one or more of the 438 nuclear power plants located in 33 countries worldwide. It may result from human error, a plant owner's unwise or unsafe attempt to minimize operating costs, the Nuclear Regulatory Commission's (NRC) imprudent accession to industry pressure to allow 20 year operating extensions to plants designed to run only for 40 years, the effects of a tsunami or high enough magnitude earthquake in areas vulnerable to them or from a deliberate attack or internal sabotage."
And
"Every US power plant is moving into the old-age cycle" because no new ones have been built here since the TMI accident in Pennsylvania in 1979. As a result, the number of near-misses and near-meltdowns has increased mostly resulting from human error, aging equipment and inadequate maintenance and regulatory oversight. With the dangers so high and inevitable and the supposed benefits totally without merit, why would the leaders and residents of any community ever be willing to allow the construction or operation of a nuclear power plant near enough to them to destroy their lives should a catastrophic nuclear event happen as it surely will potentially at any of the world's nuclear plants.
Repetetive stress injuries (RSI)
Article "Exercise may be the rx for RSI" on LAtimes.com 7 August 2006. Suggests the cost of RSI to US industry may be as much as $100 billion annually if direct and indirect costs of lost productivity and absenteeism are included.
Response to RSI is often to invest in expensive ergonomic equipment. However, there have been very few studies to evaluate their effectiveness. This article suggests ergonomic equipment is good for prevention, but pain killers and exercise are likely to be more effective once someone has got RSI.
As well as being generally fit, it is important to take 3 to 5 minute breaks every 20 to 40 minutes, and frequent 10 to 15 second 'micro breaks.' "You must get out of your chair a couple of times an hour."
Article online at
http://www.latimes.com/features/health/la-he-ergonomics7aug07,0,7236861.story?coll=la-home-health
Similar article at
http://www.insurancejournal.com/news/international/2006/07/25/70711.htm
Response to RSI is often to invest in expensive ergonomic equipment. However, there have been very few studies to evaluate their effectiveness. This article suggests ergonomic equipment is good for prevention, but pain killers and exercise are likely to be more effective once someone has got RSI.
As well as being generally fit, it is important to take 3 to 5 minute breaks every 20 to 40 minutes, and frequent 10 to 15 second 'micro breaks.' "You must get out of your chair a couple of times an hour."
Article online at
http://www.latimes.com/features/health/la-he-ergonomics7aug07,0,7236861.story?coll=la-home-health
Similar article at
http://www.insurancejournal.com/news/international/2006/07/25/70711.htm
Thumb ache from texting
Article in Guardian online on 15 August 2006.
Warns that sending lots of text messages can cause pain and swelling of tendons at the base of the thumb and wrist. It seems mobile phones are not designed with the capabilities of the thumb in mind, which is "not a very dextrous digit."
However, a reader has added comment. "Please tell me this is a joke article. I really hope there hasn't actually been serious research done" on this topic.
http://blogs.guardian.co.uk/mortarboard/2006/08/thumbsoff_thursday.html
Warns that sending lots of text messages can cause pain and swelling of tendons at the base of the thumb and wrist. It seems mobile phones are not designed with the capabilities of the thumb in mind, which is "not a very dextrous digit."
However, a reader has added comment. "Please tell me this is a joke article. I really hope there hasn't actually been serious research done" on this topic.
http://blogs.guardian.co.uk/mortarboard/2006/08/thumbsoff_thursday.html
Blunders by NHS kill thousands of patients a year
Front page of Sunday Telegraph, 27 August 2006.
Quotes data from National Patient Safety Agency (NPSA) - "a total of 2,159 died after serious lapses in care by hospitals, family doctors' surgeries, ambulance trusts and in community and mental health care last year. A further 4,529 patients suffered severe harm because of avoidable mistakes." This is from a total of 500,000 reported patient safety incidents.
Apparently 165,135 people suffered harm while in NHS care. Of these
20,000 vulnerable patients managed to harm themselves whilst in care, with an unknown number committing suicide.
50,000 incidents involved patients being given the wrong medication
49,000 suffered errors during operations or other treatments
19,749 involved medical device failures
6,000 infection control incidents were reported.
We have to accept there will be a significant degree of under-reporting. The trouble is the NPSA do not seem to have any idea of what causes the errors, or make any evaluation of whether the risk is tolerable or not. It is a tragedy that people are harmed whilst in health care, but it will always happen. To evaluate the risk we need to at least have some understanding of what would happen if treatment had not been provided.
Quotes data from National Patient Safety Agency (NPSA) - "a total of 2,159 died after serious lapses in care by hospitals, family doctors' surgeries, ambulance trusts and in community and mental health care last year. A further 4,529 patients suffered severe harm because of avoidable mistakes." This is from a total of 500,000 reported patient safety incidents.
Apparently 165,135 people suffered harm while in NHS care. Of these
20,000 vulnerable patients managed to harm themselves whilst in care, with an unknown number committing suicide.
50,000 incidents involved patients being given the wrong medication
49,000 suffered errors during operations or other treatments
19,749 involved medical device failures
6,000 infection control incidents were reported.
We have to accept there will be a significant degree of under-reporting. The trouble is the NPSA do not seem to have any idea of what causes the errors, or make any evaluation of whether the risk is tolerable or not. It is a tragedy that people are harmed whilst in health care, but it will always happen. To evaluate the risk we need to at least have some understanding of what would happen if treatment had not been provided.
Meeting mixup
Had one of those heart stopping moments yesterday. It is the last week of the school holidays, and I had taken a day out from work to go out with the family. Mobile phone rings. It is one of my clients. He asks "are you nearly here?"
Now I have a meeting scheduled for the next day, which I point out. Reply is "no definitely today. The guy from the Netherlands has arrived to see you."
Anyway, turns out the email I received said the meeting was on Wednesday 31st. Should have said Wednesday 30th. What interests me is why I latched onto the date and the client latched on to the day, so that neither of us realised the error.
Being freelance, I don't tend to work a standard week. Work comes in small bursts, and I had recently been doing some work over the weekend. I don't have any particular reference points related to the day of the week, so probably consider the date more.
In contrast, when you have a 'proper job,' life is much more closely related to the Monday to Friday week. Hence, I can see that the day is of more interest.
Equally, when I got the phone message, I did wonder if I had made a mistake. I remember making a mental note that the meeting was on the last day of August, as a way of remembering. It would have been quite easy for me to have made this note for a meeting on the 30th, as I usually have to give some thought to which months have 30 and which have 31 days.
As it turned out we managed to cover everything important on the phone. I spent the day with the family and avoided a drive across country to go to the meeting.
Now I have a meeting scheduled for the next day, which I point out. Reply is "no definitely today. The guy from the Netherlands has arrived to see you."
Anyway, turns out the email I received said the meeting was on Wednesday 31st. Should have said Wednesday 30th. What interests me is why I latched onto the date and the client latched on to the day, so that neither of us realised the error.
Being freelance, I don't tend to work a standard week. Work comes in small bursts, and I had recently been doing some work over the weekend. I don't have any particular reference points related to the day of the week, so probably consider the date more.
In contrast, when you have a 'proper job,' life is much more closely related to the Monday to Friday week. Hence, I can see that the day is of more interest.
Equally, when I got the phone message, I did wonder if I had made a mistake. I remember making a mental note that the meeting was on the last day of August, as a way of remembering. It would have been quite easy for me to have made this note for a meeting on the 30th, as I usually have to give some thought to which months have 30 and which have 31 days.
As it turned out we managed to cover everything important on the phone. I spent the day with the family and avoided a drive across country to go to the meeting.
Monday, August 28, 2006
Drowsy driving
According to this article
http://www.tnn.co.uk/UKNews/plonearticle.2006-08-21.2124105117
Loughborough university have tested how good sugar and caffeine are at keeping us awake. They conclude that a 'sugar rush' is not effective, and that to have "a drink that contains more useful amounts of caffeine and combine this with a short nap" is best. High sugar in caffeinated drinks seems to counteract the effect of the caffeine.
http://www.tnn.co.uk/UKNews/plonearticle.2006-08-21.2124105117
Loughborough university have tested how good sugar and caffeine are at keeping us awake. They conclude that a 'sugar rush' is not effective, and that to have "a drink that contains more useful amounts of caffeine and combine this with a short nap" is best. High sugar in caffeinated drinks seems to counteract the effect of the caffeine.
Egyptian train crash
Reported to have killed 'dozens' when one train went into the back of another. Human error is being cited as the cause, suggesting a driver passed a signal. Interesting to note that the head of the state railway authority was fired and his deputy suspended before the inquiry had reached any conclusions. It seems that the rail authority has been seen as being generally lenient regarding safety for some time, and there is motivation to maintain standard.
http://today.reuters.co.uk/news/articlenews.aspx?type=worldNews&storyID=2006-08-21T193532Z_01_L21330896_RTRUKOC_0_UK-EGYPT-TRAINS.xml&pageNumber=0&imageid=&cap=&sz=13&WTModLoc=NewsArt-C1-ArticlePage3
http://today.reuters.co.uk/news/articlenews.aspx?type=worldNews&storyID=2006-08-21T193532Z_01_L21330896_RTRUKOC_0_UK-EGYPT-TRAINS.xml&pageNumber=0&imageid=&cap=&sz=13&WTModLoc=NewsArt-C1-ArticlePage3
Sunday, August 13, 2006
Risk management - new guidance from HSE
I noticed this on the HSE home page a few weeks ago. At first it looked good, examples of how to do risk assessments. However, my view is that a fundamental aspect of risk management is that opportunities to remove hazards, followed by reducing hazards are taken before controls are considered. This seems to be completely overlooked in the examples provided.
I have written to HSE about this and received a reply saying they have debated this point internally and concluded that what they provide is a 'good enough' solution. I don't agree, especially with the ever increasing requirements for risk assessment including fire, stress, ATEX.
The new guidance is at http://www.hse.gov.uk/risk/index.htm
I have written to HSE about this and received a reply saying they have debated this point internally and concluded that what they provide is a 'good enough' solution. I don't agree, especially with the ever increasing requirements for risk assessment including fire, stress, ATEX.
The new guidance is at http://www.hse.gov.uk/risk/index.htm
Friday, July 14, 2006
Cable car accident
There has been an accident on the Nevis Range cable car system in Scotland. See article at http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/5178870.stm
We had a great day out on this last summer when we were touring the area. It was our younger son's birthday treat, before going to MacDonalds in Fort William for lunch (his idea, not ours).
It will be interesting to see what the cause comes out to be. More immediately, how to you balance risks with having a good time. Of course there must be risks from cable cars, but people seem to expect that everything can be made risk free. We have a cable car system in Llandudno, but it has not worked for several years (I don't know why). I doubt this accident will help its restart.
We had a great day out on this last summer when we were touring the area. It was our younger son's birthday treat, before going to MacDonalds in Fort William for lunch (his idea, not ours).
It will be interesting to see what the cause comes out to be. More immediately, how to you balance risks with having a good time. Of course there must be risks from cable cars, but people seem to expect that everything can be made risk free. We have a cable car system in Llandudno, but it has not worked for several years (I don't know why). I doubt this accident will help its restart.
Radiation risks
There was a very interesting edition of Horizon on BBC2 last night. See write-up here http://news.bbc.co.uk/1/hi/sci/tech/5173310.stm
Looking at data from Chernobyl, the cases of cancer following the accident are far lower than expected. The suggested reason is that the predictions were based on data from the Hiroshima and Nagasaki nuclear bombs. Whilst these provided plenty of data for high doses of radiation, the effect of low doses was determined on a straight line graph, suggesting all levels of radiation have some risk. The basic premise of the Horizon program was that there is a minimum threshold, below which there is very little risk and in fact some data suggests it may be beneficial.
I had always naively assumed that when it was reported that 2,000 or 20,000 people had died prematurely as the result of Chernobyl, that this was based on medical data (i.e. the actual number of people that have died). It actually turns out that this was probably based on projected figures. A good example of where a projected figure is published, and over time it starts to be quoted as an actual result.
I have often wondered if we can get useful data from animals. They were not evacuated from region after the accident, and even today there are sheep in the UK that are considered too contaminated for human consumption. The program did follow this line of investigation, and claimed that there was no evidence that animalimal populations were suffering from the effects.
ossibly more harmful than the actual exposure.
Looking at data from Chernobyl, the cases of cancer following the accident are far lower than expected. The suggested reason is that the predictions were based on data from the Hiroshima and Nagasaki nuclear bombs. Whilst these provided plenty of data for high doses of radiation, the effect of low doses was determined on a straight line graph, suggesting all levels of radiation have some risk. The basic premise of the Horizon program was that there is a minimum threshold, below which there is very little risk and in fact some data suggests it may be beneficial.
I had always naively assumed that when it was reported that 2,000 or 20,000 people had died prematurely as the result of Chernobyl, that this was based on medical data (i.e. the actual number of people that have died). It actually turns out that this was probably based on projected figures. A good example of where a projected figure is published, and over time it starts to be quoted as an actual result.
I have often wondered if we can get useful data from animals. They were not evacuated from region after the accident, and even today there are sheep in the UK that are considered too contaminated for human consumption. The program did follow this line of investigation, and claimed that there was no evidence that animalimal populations were suffering from the effects.
ossibly more harmful than the actual exposure.
Thursday, July 13, 2006
Emails deleted from server
Apparently PlusNet have wiped a load of emails from their server during a system upgrade. It is estimated 700 GB of data was lost when a a senior engineer mistook the management interface of a live email server for that of a backup server, and erased all the data on the wrong one.
Company representative Ian Wild has assured disgruntled members: "It was a genuine mistake, an accident, and I'm afraid no measure of change control procedures or anything else would have completely prevented this. At the end of the day, all we can do is hold our hands up here and say that although an unfortunate set of events, this should never have happened… you can never remove the risk of a human error entirely."
Interesting how companies start to say human error cannot be totally eliminated when they think it might get them out of paying compensation. Conversely, they choose to blame individuals for making errors (i.e. suggesting errors are preventable) when they think that transfer the heat from the company. Or am I being cynical?
Article is at
http://news.zdnet.co.uk/communications/0,39020336,39278586,00.htm
Company representative Ian Wild has assured disgruntled members: "It was a genuine mistake, an accident, and I'm afraid no measure of change control procedures or anything else would have completely prevented this. At the end of the day, all we can do is hold our hands up here and say that although an unfortunate set of events, this should never have happened… you can never remove the risk of a human error entirely."
Interesting how companies start to say human error cannot be totally eliminated when they think it might get them out of paying compensation. Conversely, they choose to blame individuals for making errors (i.e. suggesting errors are preventable) when they think that transfer the heat from the company. Or am I being cynical?
Article is at
http://news.zdnet.co.uk/communications/0,39020336,39278586,00.htm
Basic ergonomics
Although I am a registered member of the ergonomics society (virtually equivalent to being chartered - but the society does not yet have chartership available) I rarely get involved in what I call 'basic ergonomics.' To me this is the occupational health side, whereas I usually deal with major hazard risks and more interested in human error and system safety.
Found this useful summary of 'eight ergonomic essentials' at http://www.freelancenews.com/lifestyles/contentview.asp?c=189667&siteID=33
1. Move frequently - "the best position is the next position."
2. Rest frequently.
3. Use proper postures - maintain the spine's natural curve
4. Keep an eye on vision - make sure things are at or just below eye level and in front of you at a comfortable viewing distance
5. Organise things into your reach zone
6. Use the right tool for the task
7. Don't be afraid to ask for help
8. Listen to your sensible self - look at what you are doing and ask if things could be arranged better
Found this useful summary of 'eight ergonomic essentials' at http://www.freelancenews.com/lifestyles/contentview.asp?c=189667&siteID=33
1. Move frequently - "the best position is the next position."
2. Rest frequently.
3. Use proper postures - maintain the spine's natural curve
4. Keep an eye on vision - make sure things are at or just below eye level and in front of you at a comfortable viewing distance
5. Organise things into your reach zone
6. Use the right tool for the task
7. Don't be afraid to ask for help
8. Listen to your sensible self - look at what you are doing and ask if things could be arranged better
Tuesday, July 11, 2006
Unable to use the emergency phone
Continuing my theme of problems caused by technology. Talking to some people recently. They have to communicate with an offshore platform. There was a problem with the 'land-line' phone system. Following previous problems, they had been provided with a satellite phone. Unfortunately they had never used it before, and were not sure how to use it. Also, they did not know what number to call to contact the platform.
People seem to assume new technology creates automatic improvement. This is clearly not the case.
People seem to assume new technology creates automatic improvement. This is clearly not the case.
Wednesday, June 28, 2006
Ship sinking - crew unable to use new technology
Article in Risk digest at http://catless.ncl.ac.uk/Risks/24.33.html summarises initial findings of inquiry into sinking of Queen of the North. Ship had a new computer based chart system. Crew did not know how to reduce the illumination level from the screen, which at night caused them problems. Their solution was to switch the display off.
Space probe error
According to an article at www.cnn.com on June 14 2006 and recreated in the risks digest at http://catless.ncl.ac.uk/Risks/24.33.html engineers made a catastrophic error when they put together the Genesis space probe. Apparently they put in gravity switches in backward. These were supposed to deploy a parachute as the probe returned to earth, but instead it crashed to earth and was destroyed. Also, the makers skipped a critical pre-launch test and simply did a paperwork review. It is claimed this was partly due to severe financial constraints caused by competitive tendering process.
Tuesday, June 27, 2006
Handling uncertainty
Interesting article in May 2006 Chemical Engineer by Chris Beale.
includes Donald Rumsfeld's famous quote "There are known knowns. These are things we know we know. There are known unknowns. That is to say, things we know that we don't know. But there also unknown unknowns. These are the things we don't know we don't know."
Chris points out that people often interpret risk assessment as certainties, when this often far from the case. He proposes three levels of uncertainty.
1. Using established technology. Minimal uncertainty.
2. Incremental change. Risks considered to be similar to those already known. Use management of change but recognise there may be incorrect assumptions about impact of change.
3. Step changes to completely new product or process. Need to pilot and then scale up. Expect to uncover many gaps in knowledge.
The suggested yard stick for assessments is to consider if you assessed the risk using worst case data, would it change your recommendations for risk reduction measures? If yes, uncertainty could be critical and a cautious approach is required.
includes Donald Rumsfeld's famous quote "There are known knowns. These are things we know we know. There are known unknowns. That is to say, things we know that we don't know. But there also unknown unknowns. These are the things we don't know we don't know."
Chris points out that people often interpret risk assessment as certainties, when this often far from the case. He proposes three levels of uncertainty.
1. Using established technology. Minimal uncertainty.
2. Incremental change. Risks considered to be similar to those already known. Use management of change but recognise there may be incorrect assumptions about impact of change.
3. Step changes to completely new product or process. Need to pilot and then scale up. Expect to uncover many gaps in knowledge.
The suggested yard stick for assessments is to consider if you assessed the risk using worst case data, would it change your recommendations for risk reduction measures? If yes, uncertainty could be critical and a cautious approach is required.
Perceptions of management commitment to safety
I come across it very often that people at the sharp end perceive that their managers, although saying the right things, are not really that interested in safety.
An article in May 2006 Chemical Engineer by Tom Woollard illustrates this. "Most easy to spot is the company executive who makes sure that 'health and safety is the first agenda item' and is adept with emergency exit briefings and the 'safety first' and 'people are our greatest asset' rhetoric; and yet is often seen speeding out of the car park, sales figures on the passenger seat, clutching their mobiles to their ears. These kinds of safety observations tend to travel quickly through the organisation whether or not they are recorded in the safety log book."
Tom relates this to failures in behavioural safety programs. This occurs either through lack of commitment or perceived sincerity. Often because the company has not got the right culture in place for the program to work effectively.
One solution, apparently, is to make sure people understand the importance of safety at work and at home. This supposedly starts to work at an emotional level.
I guess this can work, but as Tom says it is easy for them to be seen as gimmicks if done badly. I guess my concern is that the message become that risk is not acceptable, and it can quickly result in people not doing what they enjoy doing when out of work.
An article in May 2006 Chemical Engineer by Tom Woollard illustrates this. "Most easy to spot is the company executive who makes sure that 'health and safety is the first agenda item' and is adept with emergency exit briefings and the 'safety first' and 'people are our greatest asset' rhetoric; and yet is often seen speeding out of the car park, sales figures on the passenger seat, clutching their mobiles to their ears. These kinds of safety observations tend to travel quickly through the organisation whether or not they are recorded in the safety log book."
Tom relates this to failures in behavioural safety programs. This occurs either through lack of commitment or perceived sincerity. Often because the company has not got the right culture in place for the program to work effectively.
One solution, apparently, is to make sure people understand the importance of safety at work and at home. This supposedly starts to work at an emotional level.
I guess this can work, but as Tom says it is easy for them to be seen as gimmicks if done badly. I guess my concern is that the message become that risk is not acceptable, and it can quickly result in people not doing what they enjoy doing when out of work.
Speed cameras
I drove past the spot at the weekend where I picked up a speeding ticket a couple of years ago. It is in Caernarfon, North West Wales. The ticket said I was doing 42 mph in a 30 limit
The problem I have with is that at the time I thought I was in a 40 limit. OK, so I was still over that limit, but by a much lesser margin. The road where the camera is located chops and changes limits, and I would argue there are few visual clues (other than the signs at the change points) to inform you what limit you are in.
So I got a ticket, not for speeding to great excess, but for not noticing a change in speed limit. I really wonder how effective it has been at changing my behaviour or attitude, and hence has there been any improvement in the safety of my driving? The only major change I am aware of is that I now know to drive at 30mph on that particular stretch of road. Something I may do a handful of times per year.
I think this has parallels with what we talk about in industrial safety and human factors. If we take actions at face value we may make interventions that either have minimal or counter-productive affects. If we have too many rules and/or enforce them too rigidly the culture will change completely. Equally, if we are too lenient there will be consequences. I guess there is a balance to make, and we have to work continuously to make sure that balance is being achieved.
The problem I have with is that at the time I thought I was in a 40 limit. OK, so I was still over that limit, but by a much lesser margin. The road where the camera is located chops and changes limits, and I would argue there are few visual clues (other than the signs at the change points) to inform you what limit you are in.
So I got a ticket, not for speeding to great excess, but for not noticing a change in speed limit. I really wonder how effective it has been at changing my behaviour or attitude, and hence has there been any improvement in the safety of my driving? The only major change I am aware of is that I now know to drive at 30mph on that particular stretch of road. Something I may do a handful of times per year.
I think this has parallels with what we talk about in industrial safety and human factors. If we take actions at face value we may make interventions that either have minimal or counter-productive affects. If we have too many rules and/or enforce them too rigidly the culture will change completely. Equally, if we are too lenient there will be consequences. I guess there is a balance to make, and we have to work continuously to make sure that balance is being achieved.
Thursday, June 22, 2006
Risk Aversion
Interesting article in RiskTec's quarterly newsletter Spring 06. See www.risktec.co.uk
There is great concern about risk aversion leading to crazy decisions. Reasons for this vary but fear of litigation, dogmatic implementation of policy without considering its suitability, belief that risk should be eliminated and simply using it as a conventient excuse are all noted.
A list of UK examples is provided
A 73 year old pensioner from Cardiff was ordered off a bus for carrying a tin of water-based emulsion paint.
Children at a London primary school have been banned from making daisy chains in case they pick up germs from the flowers.
Barmaids across Europe may be forced to cover up because of an EU directive on sun exposure.
A district council felled a line of conker trees to prevent youngsters from injuring themselves while gathering conkers.
A girl was banned from bringing sun cream into class during a heatwave in case it caused allergies in other pupils.
Two Christmases ago, a secondary school in Chipping Sodbury banned the wearing of tinsel to prevent any danger of strangulation.
Cakes baked by Radwinter WomenÂ’s Institute were banned from a hospital over fears they could present a health risk to elderly patients.
AA publicann from Taunton Deane was prevented from displaying hanging baskets on the front of the Ring of Bells pub by council officials concerned that some of the
flowers might spill onto the pavement, forcing pedestrians into the road.
Also, from www.landroverclub.net/Club/HTML/humour_silly_laws.htm and www.dumblaws.com
Alabama state law prohibits a driver to be blindfolded while operating a vehicle.
In New Britain, Connecticut, it is illegal for fire trucks to exceed 25mph, even when going to a fire.
It is illegal in Singapore to drive within 50 metres of a pedestrian crossing the street.
In Evanston, Illinois, it is unlawful to change clothes in an automobile with the curtains drawn, except in case of fire.
In Luxembourg you must have window wipers but you are not required to have a windscreen.
Danish law stipulates no one may start a car while someone is underneath the vehicle.
A driver in Belgium who needs to turn through oncoming traffic has the right of way unless he slows down or stops.
In Thailand, the law requires you to wear a shirt while driving a car.
And finally, although the underlying reasons are unclear, spare a thought for the Swiss, who are not permitted to wash their car on a Sunday.
There is great concern about risk aversion leading to crazy decisions. Reasons for this vary but fear of litigation, dogmatic implementation of policy without considering its suitability, belief that risk should be eliminated and simply using it as a conventient excuse are all noted.
A list of UK examples is provided
A 73 year old pensioner from Cardiff was ordered off a bus for carrying a tin of water-based emulsion paint.
Children at a London primary school have been banned from making daisy chains in case they pick up germs from the flowers.
Barmaids across Europe may be forced to cover up because of an EU directive on sun exposure.
A district council felled a line of conker trees to prevent youngsters from injuring themselves while gathering conkers.
A girl was banned from bringing sun cream into class during a heatwave in case it caused allergies in other pupils.
Two Christmases ago, a secondary school in Chipping Sodbury banned the wearing of tinsel to prevent any danger of strangulation.
Cakes baked by Radwinter WomenÂ’s Institute were banned from a hospital over fears they could present a health risk to elderly patients.
AA publicann from Taunton Deane was prevented from displaying hanging baskets on the front of the Ring of Bells pub by council officials concerned that some of the
flowers might spill onto the pavement, forcing pedestrians into the road.
Also, from www.landroverclub.net/Club/HTML/humour_silly_laws.htm and www.dumblaws.com
Alabama state law prohibits a driver to be blindfolded while operating a vehicle.
In New Britain, Connecticut, it is illegal for fire trucks to exceed 25mph, even when going to a fire.
It is illegal in Singapore to drive within 50 metres of a pedestrian crossing the street.
In Evanston, Illinois, it is unlawful to change clothes in an automobile with the curtains drawn, except in case of fire.
In Luxembourg you must have window wipers but you are not required to have a windscreen.
Danish law stipulates no one may start a car while someone is underneath the vehicle.
A driver in Belgium who needs to turn through oncoming traffic has the right of way unless he slows down or stops.
In Thailand, the law requires you to wear a shirt while driving a car.
And finally, although the underlying reasons are unclear, spare a thought for the Swiss, who are not permitted to wash their car on a Sunday.
Managing workplace transport risk
HSE have a proposed 'route map' out for consultation. It is important because 70 people were killed in accidents involving workplace transport in 2004/05
The route map is divided into four sections
1. Site layout and design
2. Vehicle selection and maintenance
3. Personnel matters
4. Management responsibilities
As it stands, my feeling is the document is weak and has a number of omissions. I think there is a fundamental problem because the causes of accidents is not made clear, so it not easy to see which of the proposed measures is likely to be most effective.
As with many things, my experience is that management of change is one of the most important elements, and it requires everyone working on a site to be aware of the risks of change. In particular new routes (including temporary and one-off), different vehicles, different activities and change to plant and equipment next to traffic routes can influence the risk.
I have sent some comments to HSE. You can do the same by going to
http://consultations.hse.gov.uk/inovem/consult.ti/wptms
The route map is divided into four sections
1. Site layout and design
2. Vehicle selection and maintenance
3. Personnel matters
4. Management responsibilities
As it stands, my feeling is the document is weak and has a number of omissions. I think there is a fundamental problem because the causes of accidents is not made clear, so it not easy to see which of the proposed measures is likely to be most effective.
As with many things, my experience is that management of change is one of the most important elements, and it requires everyone working on a site to be aware of the risks of change. In particular new routes (including temporary and one-off), different vehicles, different activities and change to plant and equipment next to traffic routes can influence the risk.
I have sent some comments to HSE. You can do the same by going to
http://consultations.hse.gov.uk/inovem/consult.ti/wptms
Thursday, June 08, 2006
Why most training doesn't work
Article in June 2006 Chemical Engineer about project management included a paragraph about why the 'obvious' answer for improving management is training, but that most proves to be ineffective.
It states that for an individual or team to improve they need to improve knowledge, attitudes, skills and habits. The vast majority of training concentrates on knowledge and skills. People may well gain these, but if they do not change their attitudes or habits there will be minimal affect. The problems are even worse if people do not think they need training (i.e. being sent on a mandatory course). Lack of confidence can also be an attitude problem that means people continue to avoid using the skill even after the training.
In my experience, most training is done 'on the job.' This has many benefits, but needs to planned, controlled and verified. Unfortunately planning, control and verification are usually only carried out for formal training events (e.g courses).
It states that for an individual or team to improve they need to improve knowledge, attitudes, skills and habits. The vast majority of training concentrates on knowledge and skills. People may well gain these, but if they do not change their attitudes or habits there will be minimal affect. The problems are even worse if people do not think they need training (i.e. being sent on a mandatory course). Lack of confidence can also be an attitude problem that means people continue to avoid using the skill even after the training.
In my experience, most training is done 'on the job.' This has many benefits, but needs to planned, controlled and verified. Unfortunately planning, control and verification are usually only carried out for formal training events (e.g courses).
Good teams
Article in Appointments section of the Sunday Times on 4 June 2006.
Relating to football, with the World Cup on its way. "A team of champions doesn't make a champion team." From this the prediction is that smaller teams with reasonably well educated people who are highly driven by representing their country will do better (e.g. Croatia and Australia). Compare to bigger countries that often disappoint.
I find that the aging workforce is affecting team work in companies. Whereas there used to be a cross section of age and experience, this is no longer the case. In the past the young guys did the running around whilst the older ones could do the thinking. Now the middle agers are doing everything.
Relating to football, with the World Cup on its way. "A team of champions doesn't make a champion team." From this the prediction is that smaller teams with reasonably well educated people who are highly driven by representing their country will do better (e.g. Croatia and Australia). Compare to bigger countries that often disappoint.
I find that the aging workforce is affecting team work in companies. Whereas there used to be a cross section of age and experience, this is no longer the case. In the past the young guys did the running around whilst the older ones could do the thinking. Now the middle agers are doing everything.
Tuesday, June 06, 2006
7 July 2005 - emergency plans
Final comments from the 7 July bombing response report. See previous posts.
The report suggests there was a lack of consideration of the individuals caught up in major or catastrophic incidents. Procedures tend to focus too much on incidents, rather than on individual and on processes rather than people. Emergency plans tend to cater for the needs of the emergency and other responding services, rather than explicitly addressing the needs and priorities of the people involved.
Part of the problem was that plans were developed in light of September 11th in New York where most people died and relatively few survived. This was opposite in London on July 7 when there were a great number of survivors to deal with. From this it was recommended that plans need to be recast on the needs of individuals involved in major catastrophes rather than the needs of emergency services. This will require a change of mindset from incidents to individuals and from processes to people.
The report suggests there was a lack of consideration of the individuals caught up in major or catastrophic incidents. Procedures tend to focus too much on incidents, rather than on individual and on processes rather than people. Emergency plans tend to cater for the needs of the emergency and other responding services, rather than explicitly addressing the needs and priorities of the people involved.
Part of the problem was that plans were developed in light of September 11th in New York where most people died and relatively few survived. This was opposite in London on July 7 when there were a great number of survivors to deal with. From this it was recommended that plans need to be recast on the needs of individuals involved in major catastrophes rather than the needs of emergency services. This will require a change of mindset from incidents to individuals and from processes to people.
7 July 2005 - technology
More from report of the 7 July bombing response report. See previous post.
Tim O’Toole, the Managing Director of London Underground is quoted in the report as saying a year before the event that “the big lesson for us is to invest in staff, rely on them; invest in technology but do not rely on it.”
I think this is an excellent insight. Equally it is interesting the report, having made this point, then talks at great length about having additional technology in preparation for such an event in the future. In particular, there were major problems with communication because mobile phone systems were overloaded and because emergency services could not communicate underground. I totally agree these were major weaknesses, but it seems likely that we need our emergency plans to work when technology is not available, and to use the technology when it is available to assist.
An interesting point is made about the ambulance service. They are now issuing key staff with pagers again. They had stopped doing this a couple of years ago because it appears that mobile phones do a better job. We are all starting to expect mobile phones to work reliably, but that can never be guaranteed with any technology.
Tim O’Toole, the Managing Director of London Underground is quoted in the report as saying a year before the event that “the big lesson for us is to invest in staff, rely on them; invest in technology but do not rely on it.”
I think this is an excellent insight. Equally it is interesting the report, having made this point, then talks at great length about having additional technology in preparation for such an event in the future. In particular, there were major problems with communication because mobile phone systems were overloaded and because emergency services could not communicate underground. I totally agree these were major weaknesses, but it seems likely that we need our emergency plans to work when technology is not available, and to use the technology when it is available to assist.
An interesting point is made about the ambulance service. They are now issuing key staff with pagers again. They had stopped doing this a couple of years ago because it appears that mobile phones do a better job. We are all starting to expect mobile phones to work reliably, but that can never be guaranteed with any technology.
7 July 2005 - emergency management
The report of the 7 July Review Committee has published it report examining how the multiple bombing in London were handled. It is available at http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/05_06_06_london_bombing.pdf
It states that one of the main problems was establishing exactly what had happened. There was very little communication from underground, where three of the bombs exploded, and much of the initial information was conflicting. Even once it was established what had happened, establishing the scale of the incident was very difficult. This was partly due to a procedural failure where each emergency service declared their own emergencies at each scene, whereas the first declaration of an emergency should have applied to all the services.
This seems fairly typical in my experience of emergency management. There is a general reluctance to declare an emergency. Although people do tend to start following the emergency procedure, the lack of formal declaration often causes delay and confusion.
I also wonder if a single command centre for all the emergency services would have been more effective. There seems to be political problems with the emergency services working together, which are simply beyond me. We want a combined response, and them have seperate control centres does not seem to help in any way.
It states that one of the main problems was establishing exactly what had happened. There was very little communication from underground, where three of the bombs exploded, and much of the initial information was conflicting. Even once it was established what had happened, establishing the scale of the incident was very difficult. This was partly due to a procedural failure where each emergency service declared their own emergencies at each scene, whereas the first declaration of an emergency should have applied to all the services.
This seems fairly typical in my experience of emergency management. There is a general reluctance to declare an emergency. Although people do tend to start following the emergency procedure, the lack of formal declaration often causes delay and confusion.
I also wonder if a single command centre for all the emergency services would have been more effective. There seems to be political problems with the emergency services working together, which are simply beyond me. We want a combined response, and them have seperate control centres does not seem to help in any way.
Monday, June 05, 2006
Isambard Kingdom Brunel
We have just returned from a week's holiday in Bristol. Given that it is 200 years since Brunel was born and his strong links with the city, there was a lot about him in the various museums we visited and at the SS Great Britain (the first large iron hulled steam powered ship).
An interesting point made about Brunel was that he was not always successful. This demonstrated he was willing to take risks and usually learnt from his mistakes. It is suggested that this is how he was able to push technology so far.
I am concerned that we are tending to become more risk averse, but when we finally decide to do something we expect to it to be successful and rarely look back to see if we made mistakes that we can learn from. Some of Brunel's failures cost people's lives and caused companies to go bankrupt, but surely we should know enough about risk management now to take calculated risks and know the warning signs that mean we stop an endeavour before actual harm is experienced.
An interesting point made about Brunel was that he was not always successful. This demonstrated he was willing to take risks and usually learnt from his mistakes. It is suggested that this is how he was able to push technology so far.
I am concerned that we are tending to become more risk averse, but when we finally decide to do something we expect to it to be successful and rarely look back to see if we made mistakes that we can learn from. Some of Brunel's failures cost people's lives and caused companies to go bankrupt, but surely we should know enough about risk management now to take calculated risks and know the warning signs that mean we stop an endeavour before actual harm is experienced.
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