Article at http://www.murfreesboropost.com
'Focus on safety begins to pay off for Nissan' by Erin Edgemon. This is interesting as it sounds like the programme being followed is most concerned with hazardous conditions, rather than behaviors.
Nissan North America decreased its reportable injuries at its manufacturing plants by nearly 72 percent from 2000 to 2005.
2000 Nissan North America had a recordable injury rate of 31.4 meaning that 31.4 out of every 100 people had an injury that required more than first aid treatment during the year. By 2005 that rate dropped to 8.9. Over the same time lost work time rate dropped from 6.3 to 1.6.
Nissan's safety program works because it gets everyone from top-level management to production technicians on the manufacturing floor involved. Nissan benchmarked other companies including receiving consultations from Dupont, which is known for its world-class safety program. It spent millions of dollars to improve safety in its plants from purchasing mats for technicians to stand on to installing lift assists and robots to do more physically demanding jobs.
“The intent of it was to enhance our safety program to become world class,” said Greg Daniels, senior vice president of Nissan’s U.S. manufacturing of the program. “We wanted our employees to come to work and leave the same way. It was critical to us.”
In order to make the program work, Daniels said employee mindset had to be changed to view safety as the first priority. Every employee is trained to spot problems and are expected to tell non-management safety committee members or management to have them corrected.
Workers inspect their work zones at least once a week. It takes a few hours to inspect for potential hazards and to talk to the employees in his area. The employees doing the inspections have the authority to fix problems or write-up work orders to have problems fixed.
Each zone on the manufacturing floor is audited for safety eight times a month due to the constantly changing environment, Dove said.
Now that Nissan has the basics perfected, more of the company’s focus has been placed on ergonomics and making the assembly of vehicles easier for employees.
"Most of our issues now are design issues," Dove said.
Andy Brazier
Tuesday, January 23, 2007
Wednesday, January 17, 2007
BP Baker Panel Report - Human Factors
The report identifies human factors as a key part of process safety. It also raises a number of human factors issues, which are summarised below.
For most of its incident investigations, BP uses a list of causal factors to analyze root causes. BP refers to this method as the Comprehensive List of Causes (CLC).
A list of human factors is also provided for use in conjunction with the CLC. This contains a guide to analyzing human behaviors, beginning with a determination of whether the identified behavior leading to a cause was intentional or unintentional and leading to the identification of external and internal influences and other conditions under which personnel are likely to make mistakes.
In the Panel’s experience, investigations typically use a checklist as a complete list of potential causes instead of a starting point for discussion of the deeper root causes and usually will not identify factors that are not on the list.
The Panel also believes that BP’s list of systemic factors related to engineering problems (e.g., “inadequate technical design”) appears somewhat superficial.
While inadequate technical design is a valid factor, BP should use it to invite more extensive inquiry: What is the design inadequacy? Why was it present? Why was it not discovered prior to the incident under investigation?
Many of the listed systemic factors do not represent systemic issues. Fatigue, for instance, is included as a systemic cause.
BP uses the CLC for both personal safety accidents and process safety accidents. In the Panel’s opinion, the causal factors involved in occupational or personal safety incidents and process safety incidents typically are very different.
The human error analysis, which focuses investigators’ efforts on personal safety aspects of incidents rather than all aspects of an incident, may introduce additional bias in the analysis toward finding behavioral root causes.
At the time of the Carson refinery technical review in May 2006, about half of process hazard analysis, or PHA, action items at Carson from 2001-2004 remained open.
Action items from facility siting and human factors checklists used in PHAs were not consistently tracked and implemented.
Andy Brazier
For most of its incident investigations, BP uses a list of causal factors to analyze root causes. BP refers to this method as the Comprehensive List of Causes (CLC).
A list of human factors is also provided for use in conjunction with the CLC. This contains a guide to analyzing human behaviors, beginning with a determination of whether the identified behavior leading to a cause was intentional or unintentional and leading to the identification of external and internal influences and other conditions under which personnel are likely to make mistakes.
In the Panel’s experience, investigations typically use a checklist as a complete list of potential causes instead of a starting point for discussion of the deeper root causes and usually will not identify factors that are not on the list.
The Panel also believes that BP’s list of systemic factors related to engineering problems (e.g., “inadequate technical design”) appears somewhat superficial.
While inadequate technical design is a valid factor, BP should use it to invite more extensive inquiry: What is the design inadequacy? Why was it present? Why was it not discovered prior to the incident under investigation?
Many of the listed systemic factors do not represent systemic issues. Fatigue, for instance, is included as a systemic cause.
BP uses the CLC for both personal safety accidents and process safety accidents. In the Panel’s opinion, the causal factors involved in occupational or personal safety incidents and process safety incidents typically are very different.
The human error analysis, which focuses investigators’ efforts on personal safety aspects of incidents rather than all aspects of an incident, may introduce additional bias in the analysis toward finding behavioral root causes.
At the time of the Carson refinery technical review in May 2006, about half of process hazard analysis, or PHA, action items at Carson from 2001-2004 remained open.
Action items from facility siting and human factors checklists used in PHAs were not consistently tracked and implemented.
Andy Brazier
Tuesday, January 16, 2007
BP Baker Panel Report - Process Safety
Not all refining hazards are caused by the same factors or involve the same degree of potential damage. Personal or occupational safety hazards give rise to incidents—such as slips, falls, and vehicle accidents—that primarily affect one individual worker or each occurrence.
Process safety hazards can give rise to major accidents involving the release of potentially dangerous materials, the release of energy (such as fires and explosions), or both. Process safety incidents can have catastrophic effects and can result in multiple injuries and fatalities, as well as substantial economic, property, and environmental damage. Process safety refinery incidents can affect workers inside the refinery and members of the public who reside nearby. Process safety in a refinery involves the prevention of leaks, spills, equipment malfunctions, over-pressures, excessive temperatures, corrosion, metal fatigue, and other similar conditions. Process safety programs focus on the design and engineering of facilities, hazard assessments, management of change, inspection, testing, and maintenance of equipment, effective alarms, effective process control, procedures, training of personnel, and human factors. The Texas City tragedy in March 2005 was a process safety accident.
Andy Brazier
Process safety hazards can give rise to major accidents involving the release of potentially dangerous materials, the release of energy (such as fires and explosions), or both. Process safety incidents can have catastrophic effects and can result in multiple injuries and fatalities, as well as substantial economic, property, and environmental damage. Process safety refinery incidents can affect workers inside the refinery and members of the public who reside nearby. Process safety in a refinery involves the prevention of leaks, spills, equipment malfunctions, over-pressures, excessive temperatures, corrosion, metal fatigue, and other similar conditions. Process safety programs focus on the design and engineering of facilities, hazard assessments, management of change, inspection, testing, and maintenance of equipment, effective alarms, effective process control, procedures, training of personnel, and human factors. The Texas City tragedy in March 2005 was a process safety accident.
Andy Brazier
BP Baker Panel Report - Recommendations
RECOMMENDATION # 1 – PROCESS SAFETY LEADERSHIP
BP’s corporate management must provide effective leadership on and establish appropriate goals for process safety.
RECOMMENDATION #2 – INTEGRATED AND COMPREHENSIVE PROCESS SAFETY MANAGEMENT SYSTEM
BP should establish and implement an integrated and comprehensive process safety
management system that systematically and continuously identifies, reduces, and manages process safety risks at its U.S. refineries.
RECOMMENDATION #3 – PROCESS SAFETY KNOWLEDGE AND EXPERTISE
BP should develop and implement a system to ensure that its executive management, its
refining line management above the refinery level, and all U.S. refining personnel, including managers, supervisors, workers, and contractors, possess an appropriate level of process safety knowledge and expertise.
RECOMMENDATION #4 – PROCESS SAFETY CULTURE
BP should involve the relevant stakeholders to develop a positive, trusting, and open
process safety culture within each U.S. refinery.
RECOMMENDATION #5 – CLEARLY DEFINED EXPECTATIONS AND ACCOUNTABILITY FOR PROCESS SAFETY
BP should clearly define expectations and strengthen accountability for process safety performance at all levels in executive management and in the refining managerial and supervisory reporting line.
RECOMMENDATION #6 – SUPPORT FOR LINE MANAGEMENT
BP should provide more effective and better coordinated process safety support for the U.S. refining line organization.
RECOMMENDATION #7 – LEADING AND LAGGING PERFORMANCE INDICATORS FOR PROCESS SAFETY
BP should develop, implement, maintain, and periodically update an integrated set of
leading and lagging performance indicators for more effectively monitoring the process safety performance of the U.S. refineries
RECOMMENDATION #8 – PROCESS SAFETY AUDITING
BP should establish and implement an effective system to audit process safety performance at its U.S. refineries.
RECOMMENDATION #9 – BOARD MONITORING
BP’s Board should monitor the implementation of the recommendations of the Panel and the ongoing process safety performance of BP’s U.S. refineries. The Board should also report publicly on the progress of such implementation and on BP’s ongoing process safety performance.
RECOMMENDATION #10 – INDUSTRY LEADER
BP should use the lessons learned from the Texas City tragedy and from the Panel’s report to transform the company into a recognized industry leader in process safety management.
BP’s corporate management must provide effective leadership on and establish appropriate goals for process safety.
RECOMMENDATION #2 – INTEGRATED AND COMPREHENSIVE PROCESS SAFETY MANAGEMENT SYSTEM
BP should establish and implement an integrated and comprehensive process safety
management system that systematically and continuously identifies, reduces, and manages process safety risks at its U.S. refineries.
RECOMMENDATION #3 – PROCESS SAFETY KNOWLEDGE AND EXPERTISE
BP should develop and implement a system to ensure that its executive management, its
refining line management above the refinery level, and all U.S. refining personnel, including managers, supervisors, workers, and contractors, possess an appropriate level of process safety knowledge and expertise.
RECOMMENDATION #4 – PROCESS SAFETY CULTURE
BP should involve the relevant stakeholders to develop a positive, trusting, and open
process safety culture within each U.S. refinery.
RECOMMENDATION #5 – CLEARLY DEFINED EXPECTATIONS AND ACCOUNTABILITY FOR PROCESS SAFETY
BP should clearly define expectations and strengthen accountability for process safety performance at all levels in executive management and in the refining managerial and supervisory reporting line.
RECOMMENDATION #6 – SUPPORT FOR LINE MANAGEMENT
BP should provide more effective and better coordinated process safety support for the U.S. refining line organization.
RECOMMENDATION #7 – LEADING AND LAGGING PERFORMANCE INDICATORS FOR PROCESS SAFETY
BP should develop, implement, maintain, and periodically update an integrated set of
leading and lagging performance indicators for more effectively monitoring the process safety performance of the U.S. refineries
RECOMMENDATION #8 – PROCESS SAFETY AUDITING
BP should establish and implement an effective system to audit process safety performance at its U.S. refineries.
RECOMMENDATION #9 – BOARD MONITORING
BP’s Board should monitor the implementation of the recommendations of the Panel and the ongoing process safety performance of BP’s U.S. refineries. The Board should also report publicly on the progress of such implementation and on BP’s ongoing process safety performance.
RECOMMENDATION #10 – INDUSTRY LEADER
BP should use the lessons learned from the Texas City tragedy and from the Panel’s report to transform the company into a recognized industry leader in process safety management.
BP Baker Panel Report - Key findings
Released today. Review of BP's corporate safety culture, safety management systems,
and corporate safety oversight at its U.S. refineries following the Texas City Fire. Running to 374 pages, it will be a while before I have had the chance to read it all, but the executive summary is very interesting - almost exclusively regarding process safety - see separate post here for an explanation.
The full report is available here
The Report's Recommendations are summarised here.
KEY POINTS FROM EXECUTIVE SUMMARY
The Panel believes that BP has not provided effective process safety leadership and has not adequately established process safety as a core value across all its five U.S. refineries.
BP has not provided effective leadership in making certain its management and U.S. refining workforce understand what is expected of them regarding process safety performance.
BP has emphasized personal safety in recent years and has achieved significant improvement in personal safety performance, but BP did not emphasize process safety.
BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its U.S. refineries. This created a false sense of confidence.
Process safety leadership appeared to have suffered as a result of high
turnover of refinery plant managers.
At Texas City, Toledo, and Whiting, BP has not established a positive, trusting, and open environment with effective lines of communication between management and the workforce
BP has not always ensured that it identified and provided the resources required
for strong process safety performance at its U.S. refineries.
Despite having numerous staff at different levels of the organization that support
process safety, BP does not have a designated, high-ranking leader for process safety dedicated to its refining business.
The company did not always ensure that adequate resources were effectively allocated to support or sustain a high level of process safety performance.
BP’s corporate management mandated numerous initiatives that applied to the U.S. refineries and that, while well-intentioned, have overloaded personnel at
BP’s U.S. refineries. This “initiative overload” may have undermined process safety performance at the U.S. refineries.
In addition, operations and maintenance personnel in BP’s five U.S. refineries sometimes work high rates of overtime, and this could impact their ability to perform their jobs safely and increases process safety risk.
The Panel also found that BP did not effectively incorporate process safety into management decision-making.
BP tended to have a short-term focus, and its decentralized management system and
entrepreneurial culture have delegated substantial discretion to U.S. refinery plant managers without clearly defining process safety expectations, responsibilities, or accountabilities.
BP has not demonstrated that it has effectively held executive management and refining line managers and supervisors accountable for process safety performance.
Although the five refineries do not share a unified process safety culture, each exhibits some similar weaknesses.
The Panel found instances of a lack of operating discipline, toleration of serious deviations from safe operating practices, and apparent complacency toward serious process safety risks at each refinery.
While all of BP’s U.S. refineries have active programs to analyze process hazards, the system as a whole does not ensure adequate identification and rigorous analysis of those hazards. The
The Panel observed that BP does have internal standards and programs for managing process but found that BP’s corporate safety management system does not ensure timely compliance with internal process safety standards. This included standards applying to rupture disks under relief valves; equipment inspections; critical alarms and
emergency shut-down devices; area electrical classification; and near miss investigations.
BP’s corporate safety management system does not ensure timely implementation of external good engineering practices that support and could improve process safety performance
BP’s system for ensuring an appropriate level of process safety awareness, knowledge, and competence in the organization has not been effective in a number of respects.
BP has not effectively defined the level of process safety knowledge or competency required of executive management, line management above the refinery level, and refinery managers.
BP has not adequately ensured that its U.S. refinery personnel and contractors have sufficient process safety knowledge and competence.
The implementation of and over-reliance on BP’s computerbased training contributes to inadequate process safety training of refinery employees.
BP’s corporate process safety management system does not effectively translate corporate expectations into measurable criteria for management of process risk or define the appropriate role of qualitative and quantitative risk management criteria.
BP has not effectively implemented its corporate-level aspirational guidelines and
expectations relating to process risk. Therefore, the Panel found that BP has not implemented an integrated, comprehensive, and effective process safety management system for its five U.S. refineries.
Significant deficiencies existed in BP’s site and corporate systems for measuring process safety performance, investigating incidents and near misses, auditing system performance, addressing previously identified process safety-related action items, and ensuring sufficient management and board oversight.
Many of the process safety deficiencies are not new but were identifiable to BP based upon lessons from previous process safety incidents, including process incidents that occurred at BP’s facility in Grangemouth, Scotland in 2000.
BP tracked some metrics relevant to process safety at its U.S. refineries. Apparently, however, BP did not understand or accept what this data indicated about the risk of a major accident or the overall performance of its process safety management systems.
BP has not instituted effective root cause analysis procedures to identify
systemic causal factors that may contribute to future accidents. When true root or system causes are not identified, corrective actions may address immediate or superficial causes, but not likely the true root causes.
BP has an incomplete picture of process safety performance at its U.S. refineries because BP’s process safety management system likely results in underreporting of incidents and near misses.
BP has not implemented an effective process safety audit system for its U.S. refineries based
The principal focus of the audits was on compliance and verifying that required management systems were in place to satisfy legal requirements. It does not appear, however, that BP used the audits to ensure that the management systems were
delivering the desired safety performance or to assess a site’s performance against industry best practices.
BP has sometimes failed to address promptly and track to completion process safety deficiencies identified during hazard assessments, audits, inspections, and incident investigations.
The Panel’s review found repeat audit findings at BP’s U.S. refineries, suggesting that true root causes were not being identified and corrected.
BP does not effectively use the results of its operating experiences, process hazard analyses, audits, near misses, or accident investigations to improve process operations and process safety management systems.
The company’s system for assuring process safety performance uses a bottom-up reporting system that originates with each business unit, such as a refinery. As information is reported up, however, data is aggregated. By the time information is formally reported at the Refining and Marketing segment level, for example, refinery-specific performance data is no longer presented separately.
The Panel’s examination indicates that BP’s executive management either did not receive refinery-specific information that suggested process safety deficiencies at some of the U.S. refineries or did not effectively respond to the information that it did receive.
A substantial gulf appears to have existed between the actual performance of BP’s process safety management systems and the company’s perception of that performance.
BP’s Board can and should do more to improve its oversight of process safety at BP’s five U.S. refineries.
The Report's Recommendations are summarised here.
Some comments are made about human factors in the report. They are summarised here
Andy Brazier
and corporate safety oversight at its U.S. refineries following the Texas City Fire. Running to 374 pages, it will be a while before I have had the chance to read it all, but the executive summary is very interesting - almost exclusively regarding process safety - see separate post here for an explanation.
The full report is available here
The Report's Recommendations are summarised here.
KEY POINTS FROM EXECUTIVE SUMMARY
The Panel believes that BP has not provided effective process safety leadership and has not adequately established process safety as a core value across all its five U.S. refineries.
BP has not provided effective leadership in making certain its management and U.S. refining workforce understand what is expected of them regarding process safety performance.
BP has emphasized personal safety in recent years and has achieved significant improvement in personal safety performance, but BP did not emphasize process safety.
BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its U.S. refineries. This created a false sense of confidence.
Process safety leadership appeared to have suffered as a result of high
turnover of refinery plant managers.
At Texas City, Toledo, and Whiting, BP has not established a positive, trusting, and open environment with effective lines of communication between management and the workforce
BP has not always ensured that it identified and provided the resources required
for strong process safety performance at its U.S. refineries.
Despite having numerous staff at different levels of the organization that support
process safety, BP does not have a designated, high-ranking leader for process safety dedicated to its refining business.
The company did not always ensure that adequate resources were effectively allocated to support or sustain a high level of process safety performance.
BP’s corporate management mandated numerous initiatives that applied to the U.S. refineries and that, while well-intentioned, have overloaded personnel at
BP’s U.S. refineries. This “initiative overload” may have undermined process safety performance at the U.S. refineries.
In addition, operations and maintenance personnel in BP’s five U.S. refineries sometimes work high rates of overtime, and this could impact their ability to perform their jobs safely and increases process safety risk.
The Panel also found that BP did not effectively incorporate process safety into management decision-making.
BP tended to have a short-term focus, and its decentralized management system and
entrepreneurial culture have delegated substantial discretion to U.S. refinery plant managers without clearly defining process safety expectations, responsibilities, or accountabilities.
BP has not demonstrated that it has effectively held executive management and refining line managers and supervisors accountable for process safety performance.
Although the five refineries do not share a unified process safety culture, each exhibits some similar weaknesses.
The Panel found instances of a lack of operating discipline, toleration of serious deviations from safe operating practices, and apparent complacency toward serious process safety risks at each refinery.
While all of BP’s U.S. refineries have active programs to analyze process hazards, the system as a whole does not ensure adequate identification and rigorous analysis of those hazards. The
The Panel observed that BP does have internal standards and programs for managing process but found that BP’s corporate safety management system does not ensure timely compliance with internal process safety standards. This included standards applying to rupture disks under relief valves; equipment inspections; critical alarms and
emergency shut-down devices; area electrical classification; and near miss investigations.
BP’s corporate safety management system does not ensure timely implementation of external good engineering practices that support and could improve process safety performance
BP’s system for ensuring an appropriate level of process safety awareness, knowledge, and competence in the organization has not been effective in a number of respects.
BP has not effectively defined the level of process safety knowledge or competency required of executive management, line management above the refinery level, and refinery managers.
BP has not adequately ensured that its U.S. refinery personnel and contractors have sufficient process safety knowledge and competence.
The implementation of and over-reliance on BP’s computerbased training contributes to inadequate process safety training of refinery employees.
BP’s corporate process safety management system does not effectively translate corporate expectations into measurable criteria for management of process risk or define the appropriate role of qualitative and quantitative risk management criteria.
BP has not effectively implemented its corporate-level aspirational guidelines and
expectations relating to process risk. Therefore, the Panel found that BP has not implemented an integrated, comprehensive, and effective process safety management system for its five U.S. refineries.
Significant deficiencies existed in BP’s site and corporate systems for measuring process safety performance, investigating incidents and near misses, auditing system performance, addressing previously identified process safety-related action items, and ensuring sufficient management and board oversight.
Many of the process safety deficiencies are not new but were identifiable to BP based upon lessons from previous process safety incidents, including process incidents that occurred at BP’s facility in Grangemouth, Scotland in 2000.
BP tracked some metrics relevant to process safety at its U.S. refineries. Apparently, however, BP did not understand or accept what this data indicated about the risk of a major accident or the overall performance of its process safety management systems.
BP has not instituted effective root cause analysis procedures to identify
systemic causal factors that may contribute to future accidents. When true root or system causes are not identified, corrective actions may address immediate or superficial causes, but not likely the true root causes.
BP has an incomplete picture of process safety performance at its U.S. refineries because BP’s process safety management system likely results in underreporting of incidents and near misses.
BP has not implemented an effective process safety audit system for its U.S. refineries based
The principal focus of the audits was on compliance and verifying that required management systems were in place to satisfy legal requirements. It does not appear, however, that BP used the audits to ensure that the management systems were
delivering the desired safety performance or to assess a site’s performance against industry best practices.
BP has sometimes failed to address promptly and track to completion process safety deficiencies identified during hazard assessments, audits, inspections, and incident investigations.
The Panel’s review found repeat audit findings at BP’s U.S. refineries, suggesting that true root causes were not being identified and corrected.
BP does not effectively use the results of its operating experiences, process hazard analyses, audits, near misses, or accident investigations to improve process operations and process safety management systems.
The company’s system for assuring process safety performance uses a bottom-up reporting system that originates with each business unit, such as a refinery. As information is reported up, however, data is aggregated. By the time information is formally reported at the Refining and Marketing segment level, for example, refinery-specific performance data is no longer presented separately.
The Panel’s examination indicates that BP’s executive management either did not receive refinery-specific information that suggested process safety deficiencies at some of the U.S. refineries or did not effectively respond to the information that it did receive.
A substantial gulf appears to have existed between the actual performance of BP’s process safety management systems and the company’s perception of that performance.
BP’s Board can and should do more to improve its oversight of process safety at BP’s five U.S. refineries.
The Report's Recommendations are summarised here.
Some comments are made about human factors in the report. They are summarised here
Andy Brazier
IET Health and safety information
A useful looking website from The Institution of Engineering and Technology. Includes briefings, a guide and news. May be a bit too regulatory led for my liking, but some of it looks very useful.
Briefings include
Behaviour-based safety
Blame Free Reporting
Contractor Management
Cost of Safety
Determining the Acceptability of Risk
Do Accidents and Ill-Health Really Cost Me Money?
Hazard Analysis (HAZAN)
Hazard and Operability Studies (HAZOP)
Indicators and Targets
Organisational Change and Safety
Permit to Work Systems
Failure Modes and Effects Analysis - FEMA
Event Tree Analysis - ETA
Fault Tree Analysis - FTA
Reasonably Practicable
Risk Based Inspection
Safety Culture
Andy Brazier
Briefings include
Behaviour-based safety
Blame Free Reporting
Contractor Management
Cost of Safety
Determining the Acceptability of Risk
Do Accidents and Ill-Health Really Cost Me Money?
Hazard Analysis (HAZAN)
Hazard and Operability Studies (HAZOP)
Indicators and Targets
Organisational Change and Safety
Permit to Work Systems
Failure Modes and Effects Analysis - FEMA
Event Tree Analysis - ETA
Fault Tree Analysis - FTA
Reasonably Practicable
Risk Based Inspection
Safety Culture
Andy Brazier
Tuesday, January 09, 2007
Detecting and responding to plant disturbances
Article in October 2006 edition of Ergonomics journal
Title 'Human process of control: tracing the goals and strategies of control room team'
By J Patrick, N. James and A. Ahmed
A study from the nuclear industry. Five shift operations teams were evaluated using a process simulator. Each team was made up of two control room operators and a supervisor.
The simulator was a full-scale mimic of operations.
The teams were set about normal operations and then asked to carry out a routine task of changing over boiler feed pumps. Whilst doing this task a small leak was initiated on one of the pumps. And on top of this a spurious fire alarm in an office was activated that required some action from the supervisor, although not the operators.
The simulated leak was considered to be a plant disturbance that would not create an immediate alarm. However, the leak would cause a drop of level in the dearator, which if undetected would cause a low level alarm and eventually a reactor trip.
The time taken to detect the level drop was recorded. The results were
Team A - 9 min 3 s
Team B - 4 min 6 s
Team C - 1 min 57 s
Team D - 6 min 3 s
Team E - 2 min 30 s
Expert judgement on the site that this scenario should be detected within 2 minutes. Therefore, from the results only Team C was successful.
To explain the long time taken to detect the event the researchers looked at how much attention the operators paid to the routine pump changeover task. Apparently, the normal procedure was that only one operator would be involved in the task, leaving the other to monitor the plant and the supervisor would have minimal involvement. The actual results for proportion of time spent on the task were
Team A - Op1 74% Op2 64% Super 12%
Team B - Op1 81% Op2 53% Super 0%
Team C - Op1 26% Op2 00% Super 16%
Team D - Op1 95% Op2 90% Super 44%
Team E - Op1 98% Op2 93% Super 23%
Clearly, with the exception of Team C, both operators were heavily involved in the routine task, and it is no wonder that they took so long to detect the leak because they would have had little time to monitor the rest of the plant. This is further exacerbated by the fact that in some teams the supervisors got quite involved in the task (which should not have been necessary) taking them away from the main supervisory tasks.
Delving deeper the researchers also found that in most teams, not only did they spend relatively little time monitoring the plant, when they did they were fairly poor at it. In other words the monitoring they did was not good enough to detect the leak quickly.
Overall the finding is that operators easily become fixated on procedural tasks at the expense of the wider, continuous task of monitoring. Also, that supervisors do not tend to intervene to re-orientate the operators (in this case making sure only one is involved in the routine task and the other is concentrating on monitoring) and also have a tendency to get involved where it should not be necessary.
Having detected the leak, the teams had to diagnose its cause and take appropriate action. This was also evaluated. The results for diagnosis and control were
Team A - 6 min 11 s
Team B - 3 min 23 s
Team C - 4 min 46 s
Team D - 1 min 58 s
Team E - 4 min 48 s
In trying to diagnose the problem each team developed a number of hypotheses. Interestingly the operators generated most of these, with relatively little input from the supervisor. It had been assumed that supervisors would lead diagnosis, which clearly did not happen.
Unfortunately none of the hypotheses covered the actual cause of the problem and none of the teams diagnosed the cause of the problem correctly from the control room and needed information from the plant (i.e. someone looking where the water was leaking from).
The researchers identified that the teams took significantly different approaches to dealing with this phase of the scenario in the way they spilt their time between problem solving, mitigating the consequences of the leak and keeping an eye on the rest of the plant. They concluded that none of the teams gave problem hypothesis generation and testing a high enough priority. This suggests a need for more training in diagnosis.
Andy Brazier
Title 'Human process of control: tracing the goals and strategies of control room team'
By J Patrick, N. James and A. Ahmed
A study from the nuclear industry. Five shift operations teams were evaluated using a process simulator. Each team was made up of two control room operators and a supervisor.
The simulator was a full-scale mimic of operations.
The teams were set about normal operations and then asked to carry out a routine task of changing over boiler feed pumps. Whilst doing this task a small leak was initiated on one of the pumps. And on top of this a spurious fire alarm in an office was activated that required some action from the supervisor, although not the operators.
The simulated leak was considered to be a plant disturbance that would not create an immediate alarm. However, the leak would cause a drop of level in the dearator, which if undetected would cause a low level alarm and eventually a reactor trip.
The time taken to detect the level drop was recorded. The results were
Team A - 9 min 3 s
Team B - 4 min 6 s
Team C - 1 min 57 s
Team D - 6 min 3 s
Team E - 2 min 30 s
Expert judgement on the site that this scenario should be detected within 2 minutes. Therefore, from the results only Team C was successful.
To explain the long time taken to detect the event the researchers looked at how much attention the operators paid to the routine pump changeover task. Apparently, the normal procedure was that only one operator would be involved in the task, leaving the other to monitor the plant and the supervisor would have minimal involvement. The actual results for proportion of time spent on the task were
Team A - Op1 74% Op2 64% Super 12%
Team B - Op1 81% Op2 53% Super 0%
Team C - Op1 26% Op2 00% Super 16%
Team D - Op1 95% Op2 90% Super 44%
Team E - Op1 98% Op2 93% Super 23%
Clearly, with the exception of Team C, both operators were heavily involved in the routine task, and it is no wonder that they took so long to detect the leak because they would have had little time to monitor the rest of the plant. This is further exacerbated by the fact that in some teams the supervisors got quite involved in the task (which should not have been necessary) taking them away from the main supervisory tasks.
Delving deeper the researchers also found that in most teams, not only did they spend relatively little time monitoring the plant, when they did they were fairly poor at it. In other words the monitoring they did was not good enough to detect the leak quickly.
Overall the finding is that operators easily become fixated on procedural tasks at the expense of the wider, continuous task of monitoring. Also, that supervisors do not tend to intervene to re-orientate the operators (in this case making sure only one is involved in the routine task and the other is concentrating on monitoring) and also have a tendency to get involved where it should not be necessary.
Having detected the leak, the teams had to diagnose its cause and take appropriate action. This was also evaluated. The results for diagnosis and control were
Team A - 6 min 11 s
Team B - 3 min 23 s
Team C - 4 min 46 s
Team D - 1 min 58 s
Team E - 4 min 48 s
In trying to diagnose the problem each team developed a number of hypotheses. Interestingly the operators generated most of these, with relatively little input from the supervisor. It had been assumed that supervisors would lead diagnosis, which clearly did not happen.
Unfortunately none of the hypotheses covered the actual cause of the problem and none of the teams diagnosed the cause of the problem correctly from the control room and needed information from the plant (i.e. someone looking where the water was leaking from).
The researchers identified that the teams took significantly different approaches to dealing with this phase of the scenario in the way they spilt their time between problem solving, mitigating the consequences of the leak and keeping an eye on the rest of the plant. They concluded that none of the teams gave problem hypothesis generation and testing a high enough priority. This suggests a need for more training in diagnosis.
Andy Brazier
Monday, January 08, 2007
Room temperature and health risks
Article on BBC website explores why the death rate in the UK during winter due to cold is significantly worse than really cold countries. It is interesting because it points out that most UK deaths are not due to 'massive cold' where people are exposed to very cold temperatures, but to 'quite minor degrees of cold that people were getting every day.' The actual cause of death in these cases is stroke and heart attack because the blood is more liable to clot when cold.
Comfort and health issues are quoted from the West Midlands Public Health Observatory
24C - top range of comfort
21C - recommended living room temperature
Less than 20C - death risk begins
18C - recommended bedroom temperature
16C - resistance to respiratory diseases weakened
12C - more than two hours at this temperature raises blood pressure and increases heart attack and stroke risk
5C - Significant risk of hypothermia
People in cold countries keep their houses warmer and take outdoor clothing much more seriously.
Andy Brazier
Comfort and health issues are quoted from the West Midlands Public Health Observatory
24C - top range of comfort
21C - recommended living room temperature
Less than 20C - death risk begins
18C - recommended bedroom temperature
16C - resistance to respiratory diseases weakened
12C - more than two hours at this temperature raises blood pressure and increases heart attack and stroke risk
5C - Significant risk of hypothermia
People in cold countries keep their houses warmer and take outdoor clothing much more seriously.
Andy Brazier
Friday, January 05, 2007
Business continuity
A useful checklist for any business is available from London Prepared website
It covers building facilities, personnel, security, documents, equipment, IT, suppliers, customers and insurance.
Andy Brazier
It covers building facilities, personnel, security, documents, equipment, IT, suppliers, customers and insurance.
Andy Brazier
Perceived risks of hydrogen
Article in November 2006 The Chemical Engineer
Titled "Hydrogen: a matter of perception" by Miriam Ricci, Paul Ballaby, Rob Flynn and Gordon Newsholme.
Hydrogen is being proposed as a fuel of the future for vehicles and other uses. Clearly it is a hazardous material, and there is the danger that this will be viewed in isolation and mean that it is not accepted by society. But this fails to compare the risks associated with hydrogen with those of currently accepted fuels or to consider the benefits of hydrogen. The authors claim that hydrogen should not be viewed according to its physical and chemical properties, but as "an energy carrier in a complex socio-technical system." This is because the risks will depend on how hydrogen is ultimately produced, transported, stored, delivered and used - much of this is currently unknown.
People perceive risks according to perceived benefits and costs (i.e. it is totally contextual). Trust has a lot to do with it, and the public can become uneasy about the motivation of the organisations involved and who is likely to benefit and who is likely to be at risk.
If the public can be persuaded that hydrogen is safe enough, or at least as safe as currently accepted fuels it may well be accepted. But this confidence will take a major hit if there is any sort of large hydrogen-related accident, particularly during transition to a hydrogen economy. This makes a case for not exaggerating the safety of hydrogen. But also, it highlights why industry needs to be very careful when introducing new technology as a loss of confidence due to failure to manage risks can deny society something that in the long term is beneficial.
Reference is made to a more indepth report available online Risk perception of emergency technology
Andy Brazier
Titled "Hydrogen: a matter of perception" by Miriam Ricci, Paul Ballaby, Rob Flynn and Gordon Newsholme.
Hydrogen is being proposed as a fuel of the future for vehicles and other uses. Clearly it is a hazardous material, and there is the danger that this will be viewed in isolation and mean that it is not accepted by society. But this fails to compare the risks associated with hydrogen with those of currently accepted fuels or to consider the benefits of hydrogen. The authors claim that hydrogen should not be viewed according to its physical and chemical properties, but as "an energy carrier in a complex socio-technical system." This is because the risks will depend on how hydrogen is ultimately produced, transported, stored, delivered and used - much of this is currently unknown.
People perceive risks according to perceived benefits and costs (i.e. it is totally contextual). Trust has a lot to do with it, and the public can become uneasy about the motivation of the organisations involved and who is likely to benefit and who is likely to be at risk.
If the public can be persuaded that hydrogen is safe enough, or at least as safe as currently accepted fuels it may well be accepted. But this confidence will take a major hit if there is any sort of large hydrogen-related accident, particularly during transition to a hydrogen economy. This makes a case for not exaggerating the safety of hydrogen. But also, it highlights why industry needs to be very careful when introducing new technology as a loss of confidence due to failure to manage risks can deny society something that in the long term is beneficial.
Reference is made to a more indepth report available online Risk perception of emergency technology
Andy Brazier
The purpose of maintenance - creating change
Article in December 06/January 07 The Chemical Engineer
Article titles "Make the most of your assets" by Sandy Dunn
One of the major barriers to overcome if maintenance is to be improved is that its purpose is not just to repair equipment after it has broken. It is not even abut prediction and prevention - rather it is a holistic process that ensures equipment fulfills its intended business purpose. A key element of this is identification and elimination of the things that cause failures, and this goes far beyond the maintenance department. As a minimum they need to be working with operations and purchasing, and all need to have a shared common goal.
To achieve step-change improvements, the organisation needs to be ready to change to this holistic view. Many will not be, and will need a compelling reason for change.
The necessary change will be multi-dimensional. To achieve it you need to
* make sure people have access to the right tools and information, the authority to make decisions
* change the way performance is measured and rewarded
* rethink lines of reporting
* redesign jobs and procedures; and train people.
To get people on board you need to have a good answer to the question "what is in it for me?" This can be financial, self-esteem, recognition, job satisfaction, career growth, pride and many others. When these have been identified they should be emphasised frequently, although care is required to avoid creating unreasonable expectations.
A rule of thumb says that if there are no tangible benefits following a change within six months support will halve and barriers will double. Therefore the program of change needs to ensure benefits will be achieved throughout as people may not be prepared to wait until the end to see them.
Quoting Dunn. "Newton's Third Law was never so true: an object at rest tends to stay at rest until acted upon by external forces. In change projects, inertia is to be avoided. It is too easy for stakeholders to remain exactly where they are, especially if they are anxious about the change project. Stakeholders need continuous invitations to become involved, constant reassurance that they will get their wins."
Andy Brazier
Article titles "Make the most of your assets" by Sandy Dunn
One of the major barriers to overcome if maintenance is to be improved is that its purpose is not just to repair equipment after it has broken. It is not even abut prediction and prevention - rather it is a holistic process that ensures equipment fulfills its intended business purpose. A key element of this is identification and elimination of the things that cause failures, and this goes far beyond the maintenance department. As a minimum they need to be working with operations and purchasing, and all need to have a shared common goal.
To achieve step-change improvements, the organisation needs to be ready to change to this holistic view. Many will not be, and will need a compelling reason for change.
The necessary change will be multi-dimensional. To achieve it you need to
* make sure people have access to the right tools and information, the authority to make decisions
* change the way performance is measured and rewarded
* rethink lines of reporting
* redesign jobs and procedures; and train people.
To get people on board you need to have a good answer to the question "what is in it for me?" This can be financial, self-esteem, recognition, job satisfaction, career growth, pride and many others. When these have been identified they should be emphasised frequently, although care is required to avoid creating unreasonable expectations.
A rule of thumb says that if there are no tangible benefits following a change within six months support will halve and barriers will double. Therefore the program of change needs to ensure benefits will be achieved throughout as people may not be prepared to wait until the end to see them.
Quoting Dunn. "Newton's Third Law was never so true: an object at rest tends to stay at rest until acted upon by external forces. In change projects, inertia is to be avoided. It is too easy for stakeholders to remain exactly where they are, especially if they are anxious about the change project. Stakeholders need continuous invitations to become involved, constant reassurance that they will get their wins."
Andy Brazier
Change management when introducing new IT
Article in December 06/January 07 The Chemical Engineer.
Titled 'All aboard' and written by Christopher Abiodun of IBM Global Business Services.
Concerned development of the Enterprise Asset Management system for BP's Greater Plutonio oil field operations in Angola. The system was intended to manage maintenance, but was also integrated with materials management, purchasing and supply chain management.
As well as teams dealing with the system's main functions, a change management team was put in place to assist with the people issues such as stakeholder management, project awareness, communications, and training - to ensure engagement with end users. It was felt that this was invaluable in keeping stakeholders engaged, raising awareness of the project, and assessing and communicating to the end users how the system would change current ways of working.
A key functions of the change management team was to analyse training needs and ensure that users got the training they needed. The team found that training was required in using the new system, but also in the underlying business processes. This was to help users understand why the system was designed in the way it was and how to get the most out of it. Also, it reduced intertia and resitance to change.
Abiodun writes "The importance of using change management from the early days of the project through to its conclusion to ensure engagement by stakeholders cannot be overemphasised. It was a key factor in engaging over 200 geographically-dispersed users across two continents to adopt the new system.... The effort this takes should not be underestimates; assessing the impact of change brought about by the new system, developing change strategies and executing them took hard work and dedication."
There is an element of risk in everything. By assessing this early on the risks can be managed. For this project the number 1 risk was reliance on network communications to a deepwater offshore facility. The project had enough time to identify, evaluate and assess a number of potential solutions.
Final quote from Abiodun. "A well-equipped and motivated team of seemingly ordinary people can achieve extraordinary results - although it helps to have the odd one or two extraordinary players in the team."
Andy Brazier
Titled 'All aboard' and written by Christopher Abiodun of IBM Global Business Services.
Concerned development of the Enterprise Asset Management system for BP's Greater Plutonio oil field operations in Angola. The system was intended to manage maintenance, but was also integrated with materials management, purchasing and supply chain management.
As well as teams dealing with the system's main functions, a change management team was put in place to assist with the people issues such as stakeholder management, project awareness, communications, and training - to ensure engagement with end users. It was felt that this was invaluable in keeping stakeholders engaged, raising awareness of the project, and assessing and communicating to the end users how the system would change current ways of working.
A key functions of the change management team was to analyse training needs and ensure that users got the training they needed. The team found that training was required in using the new system, but also in the underlying business processes. This was to help users understand why the system was designed in the way it was and how to get the most out of it. Also, it reduced intertia and resitance to change.
Abiodun writes "The importance of using change management from the early days of the project through to its conclusion to ensure engagement by stakeholders cannot be overemphasised. It was a key factor in engaging over 200 geographically-dispersed users across two continents to adopt the new system.... The effort this takes should not be underestimates; assessing the impact of change brought about by the new system, developing change strategies and executing them took hard work and dedication."
There is an element of risk in everything. By assessing this early on the risks can be managed. For this project the number 1 risk was reliance on network communications to a deepwater offshore facility. The project had enough time to identify, evaluate and assess a number of potential solutions.
Final quote from Abiodun. "A well-equipped and motivated team of seemingly ordinary people can achieve extraordinary results - although it helps to have the odd one or two extraordinary players in the team."
Andy Brazier
Tuesday, December 19, 2006
Cheap office ergonomics
Good article at Psychology today about how to avoid back pain at minimal cost:
1. Maximize your space - make sure that the things you use frequently, such as the stapler or message pad, are within reach. Grabbing for objects can cause back contortions resulting in injury.
2. Level the field - one of the leading causes of back pain is craning your neck to look at a computer screen below your field of vision. "Prop up your monitor with a telephone book," says Kirschner. "They're free and widely available."
3. Lumbarize your chair - if your office chair doesn't offer you enough lumbar support roll up a small towel and placing it in the curve of your lower back. Make sure it is not too large, the towel should just fill the gap between your back and the chair.
4. Get up and stretch periodically - just raise your hands above your head or do a slight back bend every 20 to 40 minutes.
5. Don't cradle the phone - "The single most important preventive measure: don't cradle your phone between your ear and shoulder." Invest in a hands-free headset or use the speakerphone.
Andy Brazier
1. Maximize your space - make sure that the things you use frequently, such as the stapler or message pad, are within reach. Grabbing for objects can cause back contortions resulting in injury.
2. Level the field - one of the leading causes of back pain is craning your neck to look at a computer screen below your field of vision. "Prop up your monitor with a telephone book," says Kirschner. "They're free and widely available."
3. Lumbarize your chair - if your office chair doesn't offer you enough lumbar support roll up a small towel and placing it in the curve of your lower back. Make sure it is not too large, the towel should just fill the gap between your back and the chair.
4. Get up and stretch periodically - just raise your hands above your head or do a slight back bend every 20 to 40 minutes.
5. Don't cradle the phone - "The single most important preventive measure: don't cradle your phone between your ear and shoulder." Invest in a hands-free headset or use the speakerphone.
Andy Brazier
OHSAS 18001 to become BS
BSi recently held a 'webinar' regarding the planned issued of British Standard BS18001. This is intended to superseded the current occupational health 'specification' OHSAS 18001. It seems an international standard is not yet forthcoming because global requirements are not stringent enough for UK legislation.
The BS will be more closely related to ISO 9001 and 14001 and use of terminology will change a bit. Hazard identification and risk assessment will be required to take into account:
* Human factors such as behaviour and capabilities
* Infrastructure, equipment and materials
* Changes or proposed changes in the organisation or its activity
* Modifications to the OH&S MS…and their impacts on operations, processes and activities
* Any legal obligations relating to risk assessment and implementation of necessary control measures
Risk controls will need to be selected to the fairly well accepted hierarchy of control (elimination, substitution, engineering controls, signs/warnings/procedural, PPE).
A commitment must be made to prevent OH&S incidents. The active role of top management will be emphasised, including how they will demonstrate commitment. Also, all employees will have to take responsibility for aspects of OH&S over which they have control.
There will be a requirement to identify training needs, for those need to be met, to evaluate the effectiveness of training and to keep records of training, education and experience.
Organisations will have to periodically evaluate compliance with applicable legal and other requirements and to keep records of the results. Accidents will need to be investigated and analysed with results being documented.
Benefits of achieving OHSAS 18001 are quoted as
* 52% - large/significant improvement in regulatory compliance
* 32% - decrease in overall costs of accidents
* 17% - decrease in insurance premiums
* 4% - decrease of over 10% in insurance premiums
I guess the implication is that BS18001 will have even more benefits.
From this a couple of things strike me because they are things I have felt to have been very important for sometime:
* Taking human factors into account in hazard identification and risk assessment;
* Training needs analysis and evaluation after training
* Identifying accident investigation and analysis as two processes
Andy Brazier
The BS will be more closely related to ISO 9001 and 14001 and use of terminology will change a bit. Hazard identification and risk assessment will be required to take into account:
* Human factors such as behaviour and capabilities
* Infrastructure, equipment and materials
* Changes or proposed changes in the organisation or its activity
* Modifications to the OH&S MS…and their impacts on operations, processes and activities
* Any legal obligations relating to risk assessment and implementation of necessary control measures
Risk controls will need to be selected to the fairly well accepted hierarchy of control (elimination, substitution, engineering controls, signs/warnings/procedural, PPE).
A commitment must be made to prevent OH&S incidents. The active role of top management will be emphasised, including how they will demonstrate commitment. Also, all employees will have to take responsibility for aspects of OH&S over which they have control.
There will be a requirement to identify training needs, for those need to be met, to evaluate the effectiveness of training and to keep records of training, education and experience.
Organisations will have to periodically evaluate compliance with applicable legal and other requirements and to keep records of the results. Accidents will need to be investigated and analysed with results being documented.
Benefits of achieving OHSAS 18001 are quoted as
* 52% - large/significant improvement in regulatory compliance
* 32% - decrease in overall costs of accidents
* 17% - decrease in insurance premiums
* 4% - decrease of over 10% in insurance premiums
I guess the implication is that BS18001 will have even more benefits.
From this a couple of things strike me because they are things I have felt to have been very important for sometime:
* Taking human factors into account in hazard identification and risk assessment;
* Training needs analysis and evaluation after training
* Identifying accident investigation and analysis as two processes
Andy Brazier
Autopilot
According to this article whilst autopilots and pilots individually seldom make mistakes, errors sometimes occur because of "inefficient collaboration" between them and this has been known to have caused accidents.
To avoid this new software is being developed that gives the autopilot more calculation work to do. The result is that the human pilot is presented with explicit statements of the current situation, action to be taken and objectives. This gives them a better understanding of what is going on and hence what their part is in it all. Also, it reduces the workload on the pilot, leaving them to spend more time monitoring situations.
It is interesting to read about how errors occur between automated systems and humans, and this could be entirely relevant in other industries such as process control, where I know optimisers can cause confusion. Whether this new software is the solution, I am not so sure. It sounds like the pilot's role is being further eroded, becoming more passive and boring, which may not help their alertness and may even lead to a degradation in skill over time.
Andy Brazier
To avoid this new software is being developed that gives the autopilot more calculation work to do. The result is that the human pilot is presented with explicit statements of the current situation, action to be taken and objectives. This gives them a better understanding of what is going on and hence what their part is in it all. Also, it reduces the workload on the pilot, leaving them to spend more time monitoring situations.
It is interesting to read about how errors occur between automated systems and humans, and this could be entirely relevant in other industries such as process control, where I know optimisers can cause confusion. Whether this new software is the solution, I am not so sure. It sounds like the pilot's role is being further eroded, becoming more passive and boring, which may not help their alertness and may even lead to a degradation in skill over time.
Andy Brazier
Wednesday, November 08, 2006
Genuine errors that kill
Good post on NHS Blog Doctor. Discusses how we should deal with errors that have catastrophic consequences when someone does something quite normal. In this case the example is loosing control because of sneezing when either driving a car or a surgeon operating. The trouble is if someone dies because of someone else's error, the general public expect someone to be punished. Where someone is negligent or reckless (i.e. driving or operating drunk) this is quite clear-cut. But punishing someone for sneezing does not seem right.
A news article on a similar theme was on BBC website 7 November 2006 nurse gives baby morphine overdose.
In this case the nurse gave morphine meant for another baby when she thought she was giving human albumin solution. She was an experienced nurse and there seems to be no explanation for why she made the error. However, she was sacked and has now been found guilty of misconduct.
A news article on a similar theme was on BBC website 7 November 2006 nurse gives baby morphine overdose.
In this case the nurse gave morphine meant for another baby when she thought she was giving human albumin solution. She was an experienced nurse and there seems to be no explanation for why she made the error. However, she was sacked and has now been found guilty of misconduct.
Tuesday, November 07, 2006
European power outage
Parts of Germany, France, Belgium, Spain, Portugal, Croatia and Italy were blacked out on 5 November 2006 when German power controllers switched off a cable that left some areas lacking power and others overloaded.
Good article about it on BBC website
It is interesting that inter-connecting national grids intends to secure supply. However, it adds complexity which can contribute to failures. This seems to be the result of new technology. The likelihood of failures are reduced but there consequences when they happen are often much greater.
Andy Brazier
Good article about it on BBC website
It is interesting that inter-connecting national grids intends to secure supply. However, it adds complexity which can contribute to failures. This seems to be the result of new technology. The likelihood of failures are reduced but there consequences when they happen are often much greater.
Andy Brazier
Fire risks
There is a phenomenal amount of information available regarding fire at the following website.
I think it refers to the old regulations (i.e. before 1 October 2006) hence is in archive, but most will still be useful guidance.
Andy Brazier
I think it refers to the old regulations (i.e. before 1 October 2006) hence is in archive, but most will still be useful guidance.
Andy Brazier
Fatigue & alertness testing
A company in US (Bowles Langley Technology) has developed online tools that people can use to test their alertness. Aim is to allow people to test themselves to check if they are safe to work or drive home. You can try a demo on their website
Andy Brazier
Andy Brazier
Monday, November 06, 2006
Chronic fatigue after long working hours
October 2002 Mark Fiebig was killed when he fell asleep at the wheel of his car driving home from work. His employer has recently been found guilty of breaching health and safety laws and fined £30k + £24k costs as it was felt they had failed to monitor work hours closely enough.
This is interesting because the accident happened outside work hours. Admittedly the hours being worked were way in excess of what most would do, with it being reported that he had worked 17 hour shifts for four consecutive days. But it is a point I have raised with clients in the past, especially following night shifts. I have tried to encourage them to consider what they would do if someone said they felt really tired. Would they drive the employee home to make sure he got there safely?
The case is reported in a number of places including
Norwich Union
Cambridge evening news
TUC
This is interesting because the accident happened outside work hours. Admittedly the hours being worked were way in excess of what most would do, with it being reported that he had worked 17 hour shifts for four consecutive days. But it is a point I have raised with clients in the past, especially following night shifts. I have tried to encourage them to consider what they would do if someone said they felt really tired. Would they drive the employee home to make sure he got there safely?
The case is reported in a number of places including
Norwich Union
Cambridge evening news
TUC
Wednesday, October 25, 2006
The problems with behavioural safety
I have just found this article by Nancy Lessin published at hazards.org
Problems identified in this paper include:
* Focusing on worker behaviour tends to mean root causes of problems are not looked at closely enough. Production pressure is quoted as a common reason why employees do not behave as safely as they should;
* There is a tendency to place the burden of prevention on the worker, rather than developing technical solutions;
* Everyone makes mistakes, is at some time careless, complacent, overconfident, and stubborn. At times each of us becomes distracted, inattentive, bored and fatigued. BS seems to suggest this should not be the case, and that if people are more careful mistakes will not happen.
* BS tends to mean that any individual acting unsafely is subject to 'inquisitions.' This is not pleasant, so the result is incidents don't get reported.
* BS programmes can be used by management to justify actions that unions have identified in the past, and thus undermining the union.
* A 'systems approach' that emphasizes the identification and elimination of root causes of workplace injuries and illnesses: workplace health and safety hazards would be far more effective.
The paper quotes some examples of where unions and workers have fought back against BS. They include:
* Engaging in a campaign that includes educating and involving the membership, identifying allies, identifying leverage and employing escalating tactics.
* Workers all wearing anti-behavioural safety buttons (badges);
* Placing fluorescent stickers on hazards in the workplace to bring a focus back to hazards rather than workers' "unsafe behaviours";
* Making a sign for the union bulletin board that reads "It has been x days since we asked management to correct [a particular hazard] and they have still not fixed it" (and keeping the count going each day);
* Threatening to call OSHA in to inspect the workplace.
* The United Steelworkers of America developed buttons (badges) for locals going through such campaigns that have a large BS in the center, with a line drawn through it, and the words "Eliminate Hazards - Don't Blame Workers" around the outside.
I certainly don't agree with everything in this paper or the way the message is put over. However, I do also share some of the concerns and am convinced that a systems approach to improved health and safety would be more effective and likely to address process as well as personal safety, as well as health.
Andy Brazier
Problems identified in this paper include:
* Focusing on worker behaviour tends to mean root causes of problems are not looked at closely enough. Production pressure is quoted as a common reason why employees do not behave as safely as they should;
* There is a tendency to place the burden of prevention on the worker, rather than developing technical solutions;
* Everyone makes mistakes, is at some time careless, complacent, overconfident, and stubborn. At times each of us becomes distracted, inattentive, bored and fatigued. BS seems to suggest this should not be the case, and that if people are more careful mistakes will not happen.
* BS tends to mean that any individual acting unsafely is subject to 'inquisitions.' This is not pleasant, so the result is incidents don't get reported.
* BS programmes can be used by management to justify actions that unions have identified in the past, and thus undermining the union.
* A 'systems approach' that emphasizes the identification and elimination of root causes of workplace injuries and illnesses: workplace health and safety hazards would be far more effective.
The paper quotes some examples of where unions and workers have fought back against BS. They include:
* Engaging in a campaign that includes educating and involving the membership, identifying allies, identifying leverage and employing escalating tactics.
* Workers all wearing anti-behavioural safety buttons (badges);
* Placing fluorescent stickers on hazards in the workplace to bring a focus back to hazards rather than workers' "unsafe behaviours";
* Making a sign for the union bulletin board that reads "It has been x days since we asked management to correct [a particular hazard] and they have still not fixed it" (and keeping the count going each day);
* Threatening to call OSHA in to inspect the workplace.
* The United Steelworkers of America developed buttons (badges) for locals going through such campaigns that have a large BS in the center, with a line drawn through it, and the words "Eliminate Hazards - Don't Blame Workers" around the outside.
I certainly don't agree with everything in this paper or the way the message is put over. However, I do also share some of the concerns and am convinced that a systems approach to improved health and safety would be more effective and likely to address process as well as personal safety, as well as health.
Andy Brazier
Thursday, October 19, 2006
Safety last
Article in the Guardian by David Brindle and Paul Lewis on 18 October 2006 link
Provide a summary of the recent debate about society becoming more risk averse. Includes some examples. The problem is, what is the solution?
Andy Brazier
Provide a summary of the recent debate about society becoming more risk averse. Includes some examples. The problem is, what is the solution?
Andy Brazier
Controlling risk associated with violence
An excellent set of responses to a question posted on an IOSH forum to a question related to protecting doctors from violent patients. Not much for me to say. I just want to record the link here for future reference.
Link
Link
Wednesday, October 18, 2006
Driver warning system
Article at CBC published 17 October 2006.
Ford Motor Co. testing a number of different systems that warn drivers when they stray off the lane on a road. Researchers studied drivers who had not slept for 23 hours and had each of the participants drive for three hours in a simulator.
Found that all systems were effective at improving reaction time, implying they would reduce likelihood of accidents. However, I wonder how much such devices will affect driver behaviour. Will people pay less attention when driving because they know there is a device that will warn them that they are straying. Will people drive for longer without a break or be less concerned about driving when they haven't slept?
Andy Brazier
Ford Motor Co. testing a number of different systems that warn drivers when they stray off the lane on a road. Researchers studied drivers who had not slept for 23 hours and had each of the participants drive for three hours in a simulator.
Found that all systems were effective at improving reaction time, implying they would reduce likelihood of accidents. However, I wonder how much such devices will affect driver behaviour. Will people pay less attention when driving because they know there is a device that will warn them that they are straying. Will people drive for longer without a break or be less concerned about driving when they haven't slept?
Andy Brazier
Working under fire
Report by Robert Jaques 17 October 2006 published here
Military student medic were required to perform a thoracostomy (insertion of a tube into the chest cavity to permit fluid to drain) under virtual reality battle conditions.
Interesting findings
* The students' completion times showed that they could perform the surgery efficiently, but that the quality of their work suffered.
* Those who performed the procedure faster were more susceptible to the virtual sniper fire.
* The stress created by the simulated environment may have caused some students to engage in inappropriate and dangerous behaviour that would be likely to result in their being killed in a real combat situation.
Not sure how this would translate into a business setting, but I can imagine that during a major incident people are likely to act differently. We rarely get the chance to give our staff the opportunity to see what it will be like, and have no real idea of how they will react.
Andy Brazier
Military student medic were required to perform a thoracostomy (insertion of a tube into the chest cavity to permit fluid to drain) under virtual reality battle conditions.
Interesting findings
* The students' completion times showed that they could perform the surgery efficiently, but that the quality of their work suffered.
* Those who performed the procedure faster were more susceptible to the virtual sniper fire.
* The stress created by the simulated environment may have caused some students to engage in inappropriate and dangerous behaviour that would be likely to result in their being killed in a real combat situation.
Not sure how this would translate into a business setting, but I can imagine that during a major incident people are likely to act differently. We rarely get the chance to give our staff the opportunity to see what it will be like, and have no real idea of how they will react.
Andy Brazier
Friday, October 13, 2006
Employers not liable for unforseeable events
The HSE has recently lost a case at the court of appeal regarding a case where two employees of Hatton Traffic Management (HTM) died when taking part in road improvements on the A66 near Scotch Corner.
According to this website "HTM were providing traffic management services for contractors (L) who were resurfacing the A66. There were contraflow works, lit at each end by HTM’s mobile telescopic towers which were 9.1 metres tall. 20,000 volt electricity cables passed overhead, dipping to 7.5 metres above the ground. HTM had two employees on site, C and D, who took their day to day instructions from L. C and D were told to move one of the towers. They did not lower the tower under the cables (contrary, said HTM, to their training and to instructions on the tower) and the inevitable happened, with fatal consequences for both employees."
HTM were charged with failing to discharge their duty under s.2(1) of the Health and Safety at Work Act 1974, namely failing to ensure, so far as was reasonably practicable, the health, safety and welfare at work of all its employees. At a preparatory hearing, the judge ruled in favour of HTM on both points. The prosecution’s appeal was unsuccessful.
The HSE took it to appeal and lost. According to this website The implication is that this ruling demonstrates that "Employers cannot be found negligent on health and safety grounds when employees are acting outside their remit."
According to another website HTM's lawyer said after the case "If this argument had been upheld by the COA, Groch believes, it would have effectively removed of any real defence available to employers in the area of risk management. Insurance premiums would have also beeen affected as insurance companies would take action to protect themselves against substantial claims. Another disturbing implication would be that some employers may question the need to invest heavily in health and safety provisions if, in reality, they have no effective defence against criminal prosecution."
But this is unlikely to be the end of the case. HSE will probably take it to the House of Lords, and it does seem there is plenty to debate. I personally find it hard to say that with high voltage cable nearby that it was not foreseeable that workers may forget to lower the lights before moving them. Also, we all know people take shortcuts and we should consider this in our risk assessments.
A spokesman from Norwich Union made the following comments at this website. "In this case it seems that HTM argued they had taken all reasonably practicable steps to ensure the safety of the employees and had provided training and instruction, as required by law. But, they argued the sequence of events that occurred was not foreseeable.
"Some might consider this somewhat disingenuous, despite the ruling. If there is a shortcut - that will save a bit of time and perhaps enable an early tea break, a chance to have a few minutes in the cab out of the rain - then is it not the case that employees will find it?"
Andy Brazier
According to this website "HTM were providing traffic management services for contractors (L) who were resurfacing the A66. There were contraflow works, lit at each end by HTM’s mobile telescopic towers which were 9.1 metres tall. 20,000 volt electricity cables passed overhead, dipping to 7.5 metres above the ground. HTM had two employees on site, C and D, who took their day to day instructions from L. C and D were told to move one of the towers. They did not lower the tower under the cables (contrary, said HTM, to their training and to instructions on the tower) and the inevitable happened, with fatal consequences for both employees."
HTM were charged with failing to discharge their duty under s.2(1) of the Health and Safety at Work Act 1974, namely failing to ensure, so far as was reasonably practicable, the health, safety and welfare at work of all its employees. At a preparatory hearing, the judge ruled in favour of HTM on both points. The prosecution’s appeal was unsuccessful.
The HSE took it to appeal and lost. According to this website The implication is that this ruling demonstrates that "Employers cannot be found negligent on health and safety grounds when employees are acting outside their remit."
According to another website HTM's lawyer said after the case "If this argument had been upheld by the COA, Groch believes, it would have effectively removed of any real defence available to employers in the area of risk management. Insurance premiums would have also beeen affected as insurance companies would take action to protect themselves against substantial claims. Another disturbing implication would be that some employers may question the need to invest heavily in health and safety provisions if, in reality, they have no effective defence against criminal prosecution."
But this is unlikely to be the end of the case. HSE will probably take it to the House of Lords, and it does seem there is plenty to debate. I personally find it hard to say that with high voltage cable nearby that it was not foreseeable that workers may forget to lower the lights before moving them. Also, we all know people take shortcuts and we should consider this in our risk assessments.
A spokesman from Norwich Union made the following comments at this website. "In this case it seems that HTM argued they had taken all reasonably practicable steps to ensure the safety of the employees and had provided training and instruction, as required by law. But, they argued the sequence of events that occurred was not foreseeable.
"Some might consider this somewhat disingenuous, despite the ruling. If there is a shortcut - that will save a bit of time and perhaps enable an early tea break, a chance to have a few minutes in the cab out of the rain - then is it not the case that employees will find it?"
Andy Brazier
Wednesday, October 11, 2006
Human error caused Cyprus air crash
Reuters website 10 October 2006.
Crash in August 2005. The plane on a Larnaca-Prague flight flew on autopilot for two hours, its pilots slumped over the controls, before running out of fuel and ramming into a Greek hillside killing all 121 people on board.
The report blamed deficient technical checks on the ground, failure by the pilots to pick up on compression warnings and a series of other mistakes for the Cypriot Helios Airways Boeing 737-300 crash.
The compression system regulates the oxygen supply, which decreased as the aircraft gained altitude and rendered the pilots and passengers unconscious.
BBC webstite added more. Including:
* Pilots misread instruments regulating cabin pressure and misinterpreted a warning signal.
* Maintenance officials on the ground left pressure controls on an incorrect setting.
* Plane's manufacturers Boeing took "ineffective" measures in response to previous pressurisation incidents in the particular type of aircraft.
* Airline came in for criticism for "deficiencies" in its organisation
* The Cypriot regulatory authority was accused of "inadequate execution of its safety oversight responsibilities"
Andy Brazier
Crash in August 2005. The plane on a Larnaca-Prague flight flew on autopilot for two hours, its pilots slumped over the controls, before running out of fuel and ramming into a Greek hillside killing all 121 people on board.
The report blamed deficient technical checks on the ground, failure by the pilots to pick up on compression warnings and a series of other mistakes for the Cypriot Helios Airways Boeing 737-300 crash.
The compression system regulates the oxygen supply, which decreased as the aircraft gained altitude and rendered the pilots and passengers unconscious.
BBC webstite added more. Including:
* Pilots misread instruments regulating cabin pressure and misinterpreted a warning signal.
* Maintenance officials on the ground left pressure controls on an incorrect setting.
* Plane's manufacturers Boeing took "ineffective" measures in response to previous pressurisation incidents in the particular type of aircraft.
* Airline came in for criticism for "deficiencies" in its organisation
* The Cypriot regulatory authority was accused of "inadequate execution of its safety oversight responsibilities"
Andy Brazier
Eye strain from computer use
Article by Darryl E. Owens published 10 October 2006 on the Orlando Sentinal
Studies haven't found that long-term computer use produces permanent damage But some people do suffer from burning, watery, or dry eyes, or blurred or double vision during or after use.
There is no evidence that this is caused by radiation from the screen. However, the main causes appear to be decreased blinking during computer use and wearing improper or outdated eyeglass prescriptions.
Coloured tints and filters are not the solution. Instead properly adjust your office chair or positioning your computer monitor so that it is 20 to 25 inches from your eyes and slightly below eye level (a screen that is too high or too low will be hard for your eyes to work together). Also, adjust brightness and contrast.
Andy Brazier
Studies haven't found that long-term computer use produces permanent damage But some people do suffer from burning, watery, or dry eyes, or blurred or double vision during or after use.
There is no evidence that this is caused by radiation from the screen. However, the main causes appear to be decreased blinking during computer use and wearing improper or outdated eyeglass prescriptions.
Coloured tints and filters are not the solution. Instead properly adjust your office chair or positioning your computer monitor so that it is 20 to 25 inches from your eyes and slightly below eye level (a screen that is too high or too low will be hard for your eyes to work together). Also, adjust brightness and contrast.
Andy Brazier
The war on error
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
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
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
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