Approaching Safety and Ergonomics Strategically

Article on the Occupational Hazards website 20 December 2005 by Robert Pater

Strategy entails both vision and action. Part of this is looking at what are already doing and what works and what does not. Which interventions are working and which are in the domain of diminishing returns? Which organizational forces currently block improvements and which are supporters? What are the current leadership strengths and limitations? But you need to go beyond what's been previously done if you want to see different results.

Keep in mind that how you initially look at a problem can funnel you into a limited set of solutions. For example, defining ergonomics as making work fit the worker limits intervention to engineering the environment to fix selected problems. But taking ergonomics literally means the science (-nomics) of work (from the Greek word 'ergon"), giving a more "strategic" definition as: improving the fit between people and their work (to improve safety, productivity and morale). This paradigm opens up three different approaches:

* Bringing work "closer" to people (through design, redesign, positioning, etc.);
* Bringing people "closer" to their work (through improving mental skills of attention control, risk assessment, judgment, team focus, etc., and physical skills of improved coordination, leverage, balance, flexibility, range of motion and more); and
* Bringing work closer to people as well as people closer to their work.

This last approach is most preferred. For example, it is more efficient, whenever possible, to take the stuck lid off a jar by twisting the bottom clockwise and the lid counterclockwise (rather than just holding the bottom stationery while working on the top).

There are limitations beyond initial costs. Ergonomics improvement can deteriorate into safety hazards (think of worn-down nonskid mats with curling-up edges); and might require workers to change. (in one place introducing recoilless rivet guns actually exacerbated those hand and arm injuries they was purchased to prevent - until riveters were trained how to gauge the different kinesthetic feel of setting the rivet with the new tool).


A strategic human factors approach relies on effective communication and training to motivate use of and to transfer new skills; requires a work force able to receive communication (are there language or other blockages?); necessitates time away from job tasks for training and reinforcement; can be logistically challenging for multiple sites (especially where facilities have few employees); and is not automatically in place for new hires. But it has the advantages of

* Improving situations where engineering solutions have been exhausted in difficult-to-control environments;
* Is portable to wherever people are - in multiple locations and environments, at work and at home; and
* Can boost involvement and morale while heightening worker abilities that transfer to other needed arenas.

Andy Brazier

The crash-proof car is coming

Article in The Times 11 May 2008 by Emma Smith

"Imagine a world in which parents could nonchalantly hand over their car keys to their teenage son, safe in the knowledge that the car would look after him. A future in which human error is eliminated by electronic systems capable of foreseeing smashes and taking preventative action; a world in which car crashes almost never happen."

I am always concerned when people say human error will be eliminated by some form of automation. Yes, the opportunity for some operator errors may be reduced, but what about maintenance errors and how does it affect operator behaviour?

In this case the proposal from Volvo is for a system that monitors what is going on around the car and applies the brakes to avoid collisions.

In fact the article goes on to quote Peter Rodger, chief examiner for the Institute of Advanced Motorists. "We have to be very careful not to ‘underload’ the driver. There is an issue in the airline industry that if the pilot is inadequately involved and something goes wrong, it takes them a long time to actively take over.

“There needs to be adequate involvement so the driver isn’t allowed to switch off in this way, so that they are ready to react if something goes wrong. We also need to be confident that these systems have the power to work in myriad real-life situations.”

Volvo refer to some interesting research they have made. They claim "about 50% of drivers don’t brake at all before a crash – perhaps because they are paralysed by fear or simply distracted. The other 50% may brake, but probably not as effectively as they could do."

Andy Brazier

Cargo flight near catastophe

Article from BBC website 29 April 2008. Summary of the air accident investigation report of a crash landing of Belgian Boeing 737 cargo plane operated by TNT airways (full report here. The plane tried to land at East Midlands airport, damaged its undercarriage and then made an emergency landing at Birmingham. None of the crew were injured.

The report says that at a critical moment in its approach to East Midlands airport, air traffic control passed a message to the pilot from his company instructing a change of destination. This should not have been done at this time, it confused the pilot who inadvertently turned off the autopilots. The plane lost height but, instead of aborting the landing he continued whilst trying to re-engage the autopilots. The plane came down on grass alongside the runway but then became airborne again. By the time of the landing in Birmingham the plane had no right hand landing gear and its flaps were jammed.

Failures identified by the report include
* Weather forecast did not warn of mist or fog that caused an unexpected diversion from Standsted;
* Air traffic control passed on a message at an inappropriate time;
* Captain lost situational awareness when he inadvertently disconnected the autopilots
* Neither the captain or co-pilot called a "go around" even though they knew they had problems during the approach.

The report recommends that TNT Airways review its standard operating procedures. They actually sacked the pilot a month after the accident saying the incident was down to human error.

It seems pretty poor to me that the pilot got sacked. Even the company said he showed skill in handling the situation. Whilst errors were made, there are a number of contributory factors. TNT claim to have a "zero accident tolerance level" but clearly no understanding of human factors.

Andy Brazier

Awareness training is not enough

Article on Secure Computing website by Paul Fisher 11 April 2008. An interview with Brat Hartman, Chief Technical Officer at RSA.

Hartman is asked about preventing human error where data security is concerned. "Less and less information is actually under the control of central IT these days. Information is created everywhere, it's out on everybody's laptops, it's outsourced, it's developed all over the world" He believes that having the right technologies in place to maintain that control is only the solution and that training, whilst crucial, is of limited value.

Everybody goes for training is told about the company security policy, read it and then ignore it, happily sending out data on USB sticks and web-based email, because they are under pressure to get things done and achieve results.

"The world is too complicated and, frankly, it's too difficult to be able to follow those policies under strain. I'm a believer that the right technologies have to be in place to be able to control and enforce that."

To him then, no matter how much training people have or how often you remind them of the importance of security, they will go on making mistakes. Security is typically down the list in terms of priorities. Most people view barriers as an impediment.

A nice turn of phrase: clever people doing stupid things - it could be the title of a self-help book for information security professionals. Hartman believes that all the technology needed already exists, but that the real problem is a failure of application.

I can see Hartman's point of view, but I am not sure how it works in practice. There is the danger that you put all the technical controls in place but they then make the job too difficult. Rather than making errors, people then have to implement far more sophisticated work arounds that ultimately can be more risky. Equally I agree most training in all domains often fails to achieve its objectives.

Andy Brazier

Oldies but goodies

Article from the April 2008 edition of DC Velocity by Tobey Gooley.

Populations in the US (and I guess the UK) are getting older. In many cases this is currently being counteracted by an influx of younger immigrants, but this may not continue. Whilst it is easy to focus on the negatives of the ageing population, there are many positives with some studies showing employing older people can result in improved productivity and safety.

The article lists 16 steps to a safer workplace with older people in mind (although they probably help for all ages).

1. Improve illumination and add colour contrast.
2. Eliminate heavy lifts, elevated work from ladders and long reaches.
3. Design work floors and platforms with smooth and solid decking while still allowing some cushioning.
4. Reduce static standing time.
5. Remove clutter from control panels and computer screens, and use large video displays.
6. Reduce noise levels.
7. Install chain actuators for valve hand wheels, damper levers, or other similar control devices. This brings the control manipulation to ground level, which helps to reduce falls.
8. Install skid-resistant material for flooring and especially for stair treads.
9. Install shallow-angle stairways in place of ladders when space permits and where any daily, elevated access is needed to complete a task.
10. Utilize hands-free, volume-adjustable telephone equipment.
11. Increase task rotation, which will reduce the strain of repetitive motion.
12. Lower sound-system pitches, such as on alarm systems, as they tend to be easier to hear.
13. Lengthen time requirements between steps in a task.
14. Increase the time allowed for making decisions.
15. Consider necessary reaction time when assigning older workers to tasks.
16. Provide opportunities for practice and time to develop task familiarity.

Andy Brazier

Report on the loss of the "Bourbon Dolphin"

Article in The Norway Post by Rolleiv Solholm 29 March 2008.

"It is not possible to show that an individual error, whether technical or human, led to the loss of the anchor-handling vessel “Bourbon Dolphin” on 12 April 2007." 8 people died and 7 survived the accident.

The Commission's report concludes that a series of circumstances acted together to cause the loss of the vessel. The proximate causes were the vessel’s change of course to port (west) so as to get away from mooring line no. 3, at the same time as the inner starboard towing pin was depressed, causing the chain to rest against the outer port towing pin. The chains altered point and angle of attack on the vessel combined with its load condition and the fact that the roll reduction tank was probably in use caused the vessel to capsize.

A combination of weaknesses in the design of the vessel, and failures in the handling of safety systems by the company, by the operator and on the rig, are major contributory factors. System failures on the part of many players caused necessary safety barriers to be lacking, were ignored or were breached.

Recommendations include in the future requirements are made for the preparation of stability calculations subject to approval by the authorities, formal training of winch operators, a review of requirements for survival suits, plus placement and installation of rescue floats. Safety management systems and risk assessments must be improved, there must be routines for overlap of new personnel and identification of the necessary crew qualifications, plus the preparation of vessel-specific anchor-handling procedures.

Operators’ rig move procedures must be made specific for every operation and be simple to understand for those operating under them. Operator and rig must prepare risk assessments for the entire operation before it is commenced. When the operation is executed, safety and coordination must be continuously evaluated. The Commission also proposes that an attention zone be introduced along the anchor line, indicating a maximum distance within which the vessel shall remain when running out anchors.

Andy Brazier

Lets' dehumanise management

Article on HRZone.co.uk by John Pope 8 April 2008

It starts "we all know that managers can make mistakes in selecting, managing and promoting staff. " HR often have the role of baling them out, which is "an enormous waste of time." Adverts suggest that the science of management allied to the power of IT can solve these problems. The author goes on to examine the reality.

* Recruitment - selection can be done online, and an interview is not necessary. This may well avoid employing mavericks or those who do not fit in. It may be safe, but a bit boring.
* Induction - Initial induction can be at the gate, watching a video and completing an online questionnaire. If they pass they can move on to their department where something similar will happen. They can then learn about their new co-workers online.
* Problems with pay and allowances - again online or via a call centre
* Attitude and retention surveys, 360o appraisals - all online.

So everything can be done without any personal contact between employee and supervisor/manager. But this means opportunities to find out what is really happening and to form relationships are missed. Machines don't make mistakes, although the people who instruct them do, but they have not imagination or ability to take a chance on someone who may be a bit of a maverick but may be innovative or have the ability to create new business.

All too often we focus on the negatives of having people in the system by talking about the errors they make. We somehow overlook the positives. This even applies to accidents investigations where we are always quick to identify who did something wrong, but the vast majority would have had far worse consequences if people had not intervened when they did.

Andy Brazier

Human factors integration: cost and performance benefits on army systems

Paper from the US Army Research Laboratory by Harold R Booher published July 1997. Examines cost savings from human factors integration in design of army systems. The basic premise is that the solider is an integral part of the system and not an add on. Primary objectives are to assure that:

1. Adequate number of personnel with the right skills with the proper training are accounted for in the design
2. The system being designed will adequately perform the missions it is being design to do
3. The system will perform safely with a minimum potential for health hazards or soldier casualties.

Cost savings or avoidance are expected, but as a secondary objective.

Case studies

Comanche lightweight helicopter:
* Workload study showed that a one-person crew would be overloaded in critical events. Design for a two-person crew was adopted, but was justifiable.
* Task analysis was used to prioritise information to crew at specific points during missions. As an example, procedural steps required during target reporting were reduced from 34 to only 5.
* Standard rotor design met government specifications. But a new design taking into account human factors resulted in a rotor that could be maintained by less people requiring lower skill level, was less prone to maintenance error and damage during transport. Design changes required 395 man-hours (estimated cost $50,000) but lifecycle changes estimated as $150 million.
* Engine maintenance simplified. Torque wrenches not required. Connectors unique to prevent improper installations. Training burden reduced by 40%.
* Use of graphite-epoxy composite materials allows 50% of exterior skin to have access doors and panels. Identifying tasks to be performed in field allowed these to be conveniently located for access to required parts. Also, some act as work platforms eliminating the need for ladders etc.
* Projected 12,200% return on cost of human factors on the project
* Predicted that 91 soldier fatalities and 116 disabling injuries will be avoided over 20 years of use of the helicopter due to improved outside visibility, improved situational awareness, better warning of engine problems, avoidance of ground accidents during maneuvers and maintenance.

Apache Helicopter
* Original design of a control panel meant it interfered with seats during a crash and reduced how they absorbed energy and hence crew injury. Human factors analysis allowed the panel to be redesigned so that it was smaller and hence did not interfere with the seat.
* A review of maintenance practices showed that personnel habitually stood on engines, supports and hinges to gain access, which can all cause damage and injury. Support structures were redesigned to incorporate a work platform that avoided the problems.
* Analysis of maintenance task showed that unrelated components had to be removed by additional personnel to gain access. Redesign removed this problem.
* $600,000 costs for human factors give a predicted lifecycle saving of $16.8 million, which equates to a 2,8000% return.

Fox reconnaissance vehicle for nuclear, biological and chemical sample pick up and analysis
* Workload assessment showed predicted four person crew would be overloaded. Redesign of workstations allowed crew to be reduced to three
* Improved interface with sample probe reduced mission time by 12%

Overall, the case studies showed that human factors allows new technology to be used so that more benefits are achieved. Using an iterative "design," "test" and "evaluate" model allows systems to be evaluated before they are built. In one case (Fox vehicle) human factors turned the failing project from being cancelled to a success.

Andy Brazier

Manchester Patient Safety Framework

A number of resources are available on the National Patient Safety Agency website to allow NHS organisations to assess their progress in developing a safety culture.

The principles are based on Westrum's typography of organisational communication (1992) that was expanded by Parker and Hudson (2001) to describe five levels of increasing organisational safety culture as follows

A. Pathological - prevailing attitude is "why waste our time on safety" so that there is little or no investment in improving
B. Reactive - only think about safety after an incident
C. Bureaucratic - paper-based approaches involving ticking boxes to show to auditors and assessors
D. Proactive - place a high value on improving, actively invest in continuous improvement and reward staff who raise safety-related issues
E. Generative - the nirvana where safety is an integral part of the organisation

Andy Brazier

Medical device use-safety: Incoporating human factors engineering into risk management

Guidance for industry from the US Food and Drug Administration (FDA). Written by Ron Kaye and Jay Crowley and issued 18 July 2000

Hazards related to medical device use should be addressed during device development as part of the risk management process. Human factors engineering is a key element in achieving the goal of ensuring users are able to use medical devices safely and effectively throughout the product lifecycle. This requires an understanding of the interaction between users, devices and the use environment.

Evidence suggests that the frequency and consequence of hazards resulting from medical device use might far exceed those arising from device failures. Some of these errors will result in fatality. Whilst direct hazards associated with devices (i.e. chemical, mechanical, electrical etc.) are often well understood, use errors can cause medical problems through misdiagnosis (i.e. assigning the wrong cause to a condition and hence providing inappropriate treatment), failure to recognise and act on information (e.g. information from a monitoring device) or provision of improper treatment (i.e. device set up incorrectly when implementing a therapy).

Use-related hazards occur for one or more of the following reasons:
* Devices used in ways that were not anticipated in design;
* Devices used in ways that were anticipated but inadequately controlled for;
* Device use requires personal abilities (e.g. physical, perceptual, cognitive) that exceed those of the user;
* Device use is inconsistent with users' expectation or intuition about device operation;
* The use environment effects device operation and this effect is not understood by the user;
* The users capacities are exceeded when using the device in a particular environment.

Whilst user trials of devices are an important part of development, it is important to be aware of their limitations. For example, unusual circumstances often represent the greatest threat to safe and effective use of a medical device because users are less able to react appropriately to situations that occur infrequently, but these are difficult to predict during early development or to test during user trials. Also, users will often have a preference for ease of use and aesthetics, whereas the safest arrangement may require some design features that can slow down use of effect aesthetics (e.g. shields over critical controls, mechanical or software-based interlocks).

Human factors engineering shows us the following apply:
* Use environment - light, noise, distraction, motion/vibration, workload;
* User - knowledge, abilities, expectations, limitations;
* Device - operation requirements, procedures, device complexity, specific user interface characteristics

User characteristics include
* General health and mental state (stressed, relaxed, rested, tired, affected by medication or disease) when using the device,
* Physical size and strength,
* Sensory capabilities (vision, hearing, touch),
* Coordination (manual dexterity),
* Cognitive ability and memory,
* Knowledge about device operation and the associated medical condition,
* Previous experience with devices (particularly similar devices or user interfaces),
* Expectations about how a device will operate,
* Motivation, and
* Ability to adapt to adverse circumstances.

A good example for the user is diabetics. They are required to monitor their blood sugar levels on a regular basis, and electronic devices are available to do this. However, diabetics often suffer from retinopathy which affects eye sight. Blood monitoring devices have in the past been provided with small displays which many of the intended users cannot use reliably.

The following list can help identify potential scenarios that could result in hazard
1. Why have problems occurred with the use of other similar products?
2. What are the critical steps in setting-up and operating the device? Can they be performed adequately by the expected users? How might the user set the device up incorrectly and what effects would this have?
3. Is the user likely to operate the device differently than the instructions indicate?
4. Is the user or use environment likely to be different than that originally intended?
5. How might the physical and mental capabilities of users affect their use of the device?
6. Are users likely to be affected by clinical or age-related conditions that impact their physical or mental abilities and could affect their ability to use the device?
7. How might safety-critical tasks be performed incorrectly and what effects would this have?
8. How important is user training, and will users be able to operate the device safely and effectively if they don’t have it?
9. How important are storage and maintenance recommendations for proper device function, and what might happen if they are not followed?
10. Do any aspects of device use seem complex, and how can the operator become "confused" when using the device?
11. Are the auditory and visual warnings effective for all users and use environments?
12. To what extent will the user depend on device output or displayed instructions for adjusting medication or taking other health-related actions?
13. What will happen if necessary device accessories are expired, damaged, missing, or otherwise different than recommended?
14. Is device operation reasonably resistant to everyday handling?
15. Can touching or handling the device harm the user or patient?
16. If the device fails, does it "fail safe" or give the user sufficient indication of the failure?
17. Could device use be affected if power is lost or disconnected (inadvertently or purposefully), or if its battery is damaged, missing or discharged?

Having identified potential hazards, it is then necessary to implement a combination of mitigation and control strategies. The following should be considered in the stated order
1. Modify device design to remove hazard or reduce its consequence;
2. Make user interface, including operating logic, error tolerant
3. Alert users to the hazard
4. Develop written procedures and training for safe operation.

Andy Brazier

Developing an effective safety culture

James Roughton has been in touch with me having seen my blog. He runs a couple of blogs himself, including GotSafety which provides an ever expanding set of articles about accidents and safety news, mostly US based.

Having looked around James' sites I can see he has some really useful content. I particularly like his presentation on Developing an Effective Safety Culture. Some key points include
* Safety should not be a priority because priorities change. Instead it needs to be a core value installed in all parts of the organisation
* We are still using traditional approaches relying on signs and rules, lagging indicators and holding individuals responsible. A more proactive, integrated approach is required.
* A culture is about building relationships with employees.
* If you do what you've always done your get what you always got (Demming).
* To improve your culture you need to know where you want to get to. "If you don't know where you are going, the chances are you will get somewhere else" (Yogi Berra)
* Good leaders are accessible, available, believable, creative, reliable, and trustworthy.
* Sometimes we make things look so easy, we tend to forget the risk and their related hazards.
* Sometimes it’s the trivial things that results in a major “event.”
* Sometimes we do things wrong so often they become right….
* Accident statistics are basically a measure of luck.

James' page here is well worth a look

Andy Brazier

Video refs embrace technology but some caution is needed

Article in the Marlborough Express website on 3 April 2008.

It talks about the role of the video referee in sports such as Rugby and tennis. The concern is that they are becoming too involved and this may not be in the interests of the game because it slows it down and can undermine the referees on the ground. The article concludes "We have to accept that sometimes it is better for the game to include some human error, rather than letting technology run rampant."

I can see parallels here with industry. If we going to have people involved in our processes we need to let them get on with their job. We have to accept there will be errors, but also recognise the ability of people to detect problems, adapt to situations and improvise solutions is highly beneficial. We can't have one without the other.

Andy Brazier

Ergonomic tools: Science or fiction?

John Hedbor, the marketing manager at L.S. Starrett. posted the following checklist on ReliablePlant.com in March 2008. I thought it was a very good summary of issues related to hand tools

A good tool should reduce the risk of direct injury. It should:
* not have any sharp edges on the handle
* minimize wear and tear on the skin
* reduce the risk of users' hands getting caught in tight spots
* reduce the risk of users' hands coming into contact with sharp edges and shoulders
* be slip-resistant

A good tool should reduce the risk of long-term injury. It should:
* have the optimal weight for its purpose
* have a grip that protects the user from hot/cold temperatures
* minimize the build-up of muscular tension during lengthy jobs
* have a large gripping surface that exerts low, even pressure across the hand
* deliver the greatest power with the least possible effort
* vibrate as little as possible
* be perfectly balanced

A good tool should make the tool user's job easier. It should:
* be the correct size and design for its purpose
* be able to be used in different positions
* not require the user to change grip, if possible
* be adjustable in many different positions
* be adjustable even when wearing gloves
* be designed for use with both hands, if required
* be easy to hold, with the right degree of friction against skin
* be available in different sizes, suitable for different tasks
* tolerate oil and grease

Andy Brazier

Constructing Excellence

Article on the Contract Journal website on 12 March 2008 by

It starts "Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime, or so the saying goes. The same may well be true of health and safety. While it's great to have the latest safety equipment, it's irrelevant if nobody shows you how to use it properly."

The article is actually about an organisation called 'Constructing Excellence' that aims to improve safety in the industry. "Through this initiative, companies put forward current projects that in one way or another are demonstrating innovation or best practice in their development." Constructing Excellence then "work alongside these leading-edge projects to capture the knowledge, benchmark their performance and use the resulting case studies to demonstrate the business case."

I know nothing about the scheme or whether it is being successful. But it very much fits with my view of the world. Too often I hear about centralised initiatives where everyone is expected to follow what is considered to be best practice. However, I never understand how a single approach can really be best for everyone. In fact, the best things are done at a local level, where people are prepared to take a risk to be innovative. Hence, rather than running things centrally I feel it is better to give local groups some scope to be innovative and take some risks, but in a context where learning (about success and failure) is shared.

The article is a bit strange because it does not provide a link to the organisations website. It also gets the name wrong on several occassions, calling is 'Construction Excellence' rather than 'Consulting Excellence.'

Andy Brazier

Q&A: UK forces equipment failures

Interesting article on BBC website 15 February 2008 by Paul Adams.

Inquests into service men deaths in Afganistan have highlighted shortages of equipment have put people in danger. But this article also references board inquiries that also referenced "poor tactical decision-making" and a "lack of SOPs" (Standard Operating Procedures) on the ground.

The value of some of the missions (high risk for minimal benefit) and whether commanding officers could have taken more time to organise and prepare their men before sending them out is questioned. With the unpredictable nature of 21st century counter insurgency operations is another factor.

I often hear "we don't have enough equipment" or "we don't have enough people" in the industries I work in. It always strikes me that, with the exception of very small cash strapped companies, this is an unhelpful comment. It is not the absolute number but whether it is enough for what you want to do. The option is always to scale back activity. The trouble is companies seem to aim to still do everything, instead of focussing on what is important. The consequence is everything gets done rather poorly and this introduces risk.

Andy Brazier

Process Safety Leading and Lagging Metrics

Published by Center for Chemical Process Safety December 2007.
Available at AIChemE website

Seems to provide a good insight into the types of indicators companies can use.

Andy Brazier

Tube driver in strain injury claim

Ariticle in the Scotsman on 14 February 2008.

Latona Allison, a train driver on the London underground, developed tenosynovitis in her right-hand wrist because she was not given adequate training in the use of the "dead man's handle" safety brake.

Although the claim was initially dismissed, it was upheld in the court of appeal hearing on 13 February. It came about because the design of the deadmans handle was changed, but no assessment was made or any training given to drivers on how to use it safely.

Lord Justice Smith said in a judgment that London Underground should not have introduced a new design for the safety device without taking advice from an expert. Had it done so, it would have identified the need for the drivers to be trained in the way in which they held the handle in order to minimise the risk of strain injury." Because no advice was taken, the company was in breach of health and safety laws as the training was not adequate.

I believe this could have wide implications. We seem to be particularly bad a managing change in the workplace, and this gives a great example of what can go wrong as a result.


Andy Brazier

Corporate manslaughter - homicide

I attended a very interesting talk today given by John Dyne from Dyne Solicitors

The Corporate Manslaughter and Corporate Homicide Act 2007 is due to come into force on 6 April 2008. It will mean that companies and organisations can be found guilty of corporate manslaughter if its activities are managed or organised by its senior managers in such a way that
1. causes a person’s death, and
2. amounts to a gross breach of a relevant duty of care owed by the organisation to the deceased.

The offence will be Corporate Manslaughter in England, Wales and Northern Ireland and Corporate Homicide in Scotland.

It will lead to prosecutions of companies where gross deficiencies in management lead to fatalities. The penalties will include

1. Unlimited fines
2. Remedial orders - the court can tell the company how to improve systems etc. (this seems to overlap with HSE's remit to a certain extent)
3. Publicity orders - not entirely clear but it could require companies to advertise the fact they have been prosecuted. This may be in the paper or even posters at company sites.

John suggests that to avoid prosecution companies need to:
1. Determine where health and safety management responsibilities lie
2. Determine how responsibilities are delegated and monitored
3. Ensure all senior managers are in a position to control risks
4. Increase health and safety training for senior management
5. Review policies
6. Maintain constant review
7. Consult with employees and give them the opportunity to raise issues
8. Ensure they can demonstrate correct attitudes, policies and systems.

John made the point that an investigation would involved interviewing employees. They may say a lot of things about the company that management may not know themselves before the event. Management can no longer afford to keep their head in the sand as the defence of ignorance will not apply.

The introduction of the act will make organisations liable for Corporate Manslaughter if a fatality results from the way in which its activities are managed or organised. This approach is not confined to a particular level of management within an organisation. The test considers how an activity was managed within the organisation as a whole. However, it will not be possible to convict an organisation unless a substantial part of the organisation’s failure lay at a senior management level.
Corporate manslaughter will continue to be an extremely serious offence, reserved for the very worst cases of corporate mismanagement leading to death. The offence is concerned with the way in which an organisation’s activities were managed or organised. Under this test, courts will look at management systems and practices across the organisation, and whether an adequate standard of care was applied to the fatal activity. Juries will be required to consider the extent to which an organisation was in breach of health and safety requirements, and how serious those failings were. They will also be able to consider wider cultural issues within the organisation, such as attitudes or practices that tolerated health and safety breaches.

The threshold for the offence is gross negligence. The way in which activities were managed or organised must have fallen far below what could reasonably have been expected.


More information is available at the Ministry of Justice website

Andy Brazier

Using consultants

Just discovered "HSE statement to the external providers of health and safety assistance" on HSE website

It explains, very briefly, the duties of consultants and other people who provide advice to companies regarding health and safety. It say "You can help employers to manage risk sensibly, ie, focussing on reducing real risks, both those which arise more often and those with serious consequences. As the provider you must be competent, give a good quality service and deliver help that is fit for purpose."

In general terms advice needs to be

1. Correct
2. Tailored
3. Sensible

I think this is really useful. It appears that some consultants concentrate on number 1, which results in masses of generic paperwork. This rarely, in my opinion, helps the client.

Andy Brazier

Medical negligence due to lack of NHS funds

Negligence worries - Article by Ken Thomas (specialist medical negligence lawyer with South Wales solicitors Harding Evans) writing in the Western Mail on 7 January 2008

Ken says that in the course of his work as a medical negligence lawyer he routinely speaks to medical experts. Over the years, many have hinted strongly, or have said – sometimes quite bluntly and expressly – that medical errors can in part be attributed to lack of money in the NHS. Some of those errors can be gross and even fatal.

But is lack of financial resources a root cause of clinical negligence? Ken thinks it is fair to say that it may well be a factor in some medical mistakes. However, lack of resources is rarely, if ever put forward as an outright excuse or explanation for a failure of care. Put simply, lack of money would not be an attractive defence in court.

Ken makes the point that even in a well-funded healthcare system, mistakes will occur. But over-stretched resources and under-staffed teams cannot help in this regard.

My opinion is that an organisation the size of the NHS can not say they don't have resources. They may not have enough to do everything they want to, but that is different. It is not a lack of resources that cause errors, but it may well be poor prioritisation or organisation.

It is probably quite correct for the NHS to say they would like more money, but that will always be the case. I am pretty sure there is a lot of waste in the system at present, and reducing this should be a priority. I think the NHS can learn a lot from other industries, but they seem unable or unwilling to do this to any great extent.

Andy Brazier

Human factor investigations

Presentation by John Chappelow from his website

John describes a taxonomy that he uses in training non-human factors specialists on accident investigation courses. Once a narrative description of an incident has been
broken down into discrete events, each event is examined to determine the type of error involved according to a simple classification based on the cognitive elements of any task cycle. They are:

1. Perception,
2. Intention,
3. Action.

This is achieved by asking questions as follows.

1. Did you perceive the situation correctly? If no, was it
a. Detection failure
I didn’t see it
I didn’t hear it
I’m sure it was green when I looked
It appeared to be locked when I checked
b. Misjudgement
The gap looked big enough
It didn’t seem to be going that fast
c. Communication failure
I thought he said…

2. Were your intentions appropriate?
a. Inappropriate model
I hadn’t appreciated that…
I obviously misunderstood what was required
In retrospect, the briefing could have been clearer
Suddenly, the plan went pear-shaped
b. Inappropriate evaluation of risk
I saw a simple way to solve the problem
We thought it would work
To save time, I used a different tool/method
We always do it this way on this unit
The laid down procedure takes too long
c. Responsibility management
I thought someone else would…
d. Malicious intent

3. Did you do what you intended to do?
a. Lapse
I forgot to…
b. Slip
I intended to do A but did B instead
c. Skill
I applied too much force
d. Response time
I was too slow/too quick


According to John "this approach has proved robust and easy to use, and, importantly, it can facilitate investigation of possible causal factors by identifying the more likely candidates."

Andy Brazier

Nitrogen in plane emergency air supply

'Fatal' gas pumped into Qantas jet - article in The Age Australia on 16 December 2007 by Matthew Benns.

POTENTIALLY fatal gas being pumped into a passenger jet's emergency oxygen tanks in Australia has sparked a worldwide safety investigation. The Australian Safety Transport Bureau confirmed yesterday that Qantas engineers accidentally put nitrogen into the oxygen tanks of a Boeing 747 at Melbourne Airport.

Non-flammable nitrogen is commonly used to fill aircraft tyres.

The aviation source said: "Qantas took delivery of the new nitrogen cart 10 months ago.

"It looked exactly like the old oxygen cart. When the attachments did not fit they went and took them off the old oxygen cart and started using it."

The mistake was spotted by an aircraft engineer and reported to the Civil Aviation Safety Authority, which declared it a one-off incident. But the aviation source said: "This could have affected at least 175 planes."

An Australian Transport Safety Bureau spokeswoman said Qantas identified 21 aircraft at risk and another 30 at minor risk because of oxygen top-ups.

The planes were inspected and no positive results found.

People often think that having unique connections on gas bottles, tankers etc. prevents errors. As this shows it does not as it is always possible to convert the connections. In fact unique connections can form a false sense of security if you are not careful.

Andy Brazier

Aircraft Maintenance Incident Analysis

CAA PAPER 2007/04 Aircraft Maintenance Incident Analysis - Published by the Civil Aviation Authority, December 2007

Paper is an analysis of a selection of maintenance related events on jet aircraft above 5,700kg MTOW, captured and stored under the requirements of the CAA’s Mandatory Occurrence Reporting (MOR) scheme to identify trends, themes and common causes or * factors.

It presents a taxonomy that looks useful. It has three main categories:

1. Maintenance Control – An event attributed to an ineffective maintenance control
system.

2. Incomplete Maintenance – An event where the prescribed maintenance activity
is prematurely terminated. In these circumstances the correct maintenance procedures appear to have been followed but something was not removed, not fitted or not set correctly towards the end of the process.

3. Incorrect Maintenance Action – An event where the maintenance procedure was completed but did not achieve its aim through the actions or omissions of the maintainer. In these circumstances it appears that an incorrect maintenance procedure or practice was being used. This has resulted in a larger number of second level descriptors than Incomplete Maintenance, but includes the actions of not removing, not fitting or not setting something correctly by virtue of not performing the task correctly, rather than as an error of omission.

Each category is broken down further as follows, showing the results of the analysis.

1. Maintenance Control (Total 733):
* Scheduled task - 223 30·4%
* Inadequate tool control - 84 - 11·5%
* Deferred defect - 81 - 11%
* Airworthiness data - 78 - 10·7%
* Tech log - 67 - 9·2%
* Airworthiness Directive - 66 - 9%
* Modification control - 55 - 7·5%
* MEL interpretation - 37 - 5%
* Configuration control - 23 - 3·1%
* Certification - 13 - 1·8%
* Component robbery - 6 - 0·8%

2. Incomplete Maintenance (Total 602):
* Not fitted - 268 - 44·5%
* Not set correctly - 229 - 38%
* Not removed - 105 - 17·5%

3. Incorrect Maintenance (Total 1589)
* Incorrect fit - 619 - 39%
* Not set correctly - 447 - 28·1%
* Incorrect part - 160 - 10·1%
* Poor maintenance practice - 94 - 5·9%
* Procedure not adhered to - 83 - 5·2%
* Not fitted - 78 - 4·9%
* Incorrect repair - 62 - 3·9%
* Incorrect procedure - 24 - 1·5%
* Not removed - 22 - 1·4%

Unfortunatly the analysis found that information regarding underlying causes is rarely reported. This significantly limits the value of the analysis, and is something the industry needs to address.

Andy Brazier

Introducing new technology

Abbey targets cost and service gains from IT overhaul - article on computerweekly.com on 4 December 2007 by Karl Flinders.

Abbey have developed 'The Partenon' banking platform to replace 30-year-old legacy computer systems and provide the bank with a single view of its customers for the first time. It is hoped to reduce costs to the business by £300m. Abbey has consolidated all of its customer records on to a single database. Eliminating duplication has allowed the bank to reduce the number of customer records it stores from 52 million to 20 million.

The article goes on to say "Training and getting users to buy into projects is an important competency which is often overlooked in the banking sector, according to Ralph Silva, analyst at TowerGroup."

He said human error is responsible for 40% of the failures of major IT projects in the European banking sector. Only 5% are caused by problems with the technology.

"Almost every major failure of any significant IT project in the European financial services sector can be attributed to human error," said Silva. "The human element is always the last one to be considered, and yet it is the highest cause of failure."

Abbey's training programme

* Face-to-face tuition and e-learning on tools and ways of working delivered to 25,000 staff
* Support for staff in branches and contact centres
* Dedicated single point of contact helpline
* Comprehensive pilots before full roll-out
* Post implementation consolidation training
* Training includes "contingency" processes to minimise service disruption
* Training is piloted with focus groups
* Senior Abbey management sent to Santander to meet colleagues and see Partenon working.

Andy Brazier

Adverse drug reactions

Allergy to medicines 'is killing thousands' - Article in the Time Online on 27 December 2007 by David Rose.

Nearly 3,000 patients have died in the past three years as a result of taking medicines intended to help them, official figures show. Thousands more have been hospitalised after suffering harmful side-effects or serious allergic reactions to prescription drugs and other medications.

Drugs most commonly implicated in adverse reactions include low-dose aspirin, diuretics, the anticoagulant drug warfarin and other nonsteroidal antiinflammatory drugs. The most common problem associated with these medications is gastrointestinal bleeding, which can be fatal. But many of the reactions were likely to be because of incorrect dosages or known interactions of the drugs and as such were avoidable, research suggests.

Teresa Innes, 38, lapsed into a coma in September 2001 after a surgeon at Bradford Royal Infirmary prescribed a drug containing penicillin as she was about to undergo a routine procedure to drain fluid from an abscess on her thigh. Despite wearing a red allergy band on her wrist and medical notes giving warning about her acute aversion to the antibiotic, Mrs Innes was given the drug Magnapen, which staff did not realise contained penicillin.

The former care worker suffered an-aphylactic shock, which stopped her heart for 35 minutes, resulting in permanent brain damage. She was left in a persistent vegetative state from which she never recovered. She died two years later.

This is a good example of how complex it is for someone to become competent in a task. In this case it seems likely that everyone knew about Teresa's allergy, but did not have deep enough knowledge of the drug. Given the number of drugs used in health care this is hardly surprising. Some form of job aid could probably help, if people would use it in practice.

Andy Brazier

Ergonomics society oil and gas conference - part 5

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

Andrew Hopkins gave a presentation entitled "Thinking about process safety indicators." Andrew is very well known for his book "Lessons from Longford" which gives a fascinating account of organisational failures related to Esso's fire and explosion in Australia.

Andrew made a number of very good points in his presentation. He talked about the 'Heinrich triangles' which suggest that for every fatal accident there will be 10 major injures, 100 minor injuries, 1000 near misses etc. He said this gives the impression that reducing the rate of minor incidents can influence the likelihood of a major accident. However, this is not the case and that a separate triangle is required that only covers process safety incidents so that for every major accident there is 10 major process disturbances, 100 minor process disturbances and 1000 near misses. There may be a very small overlap on the bottom level of the personal and process safety triangles.

Andrew's main point was that we have become overly concerned with the difference between leading and lagging indicators of safety performance. This distinction is quite artificial and not as clear cut as it may appear. Instead what we need is more process safety indicators. It does not really matter if they are leading or lagging, as they only need to occur with sufficient frequency to give statistically relevant data. To do be effective the indicators need to show how well barriers or defences are working and performing.

An interesting suggestion from Andrew was that manager bonuses should be linked to process safety, although it must be done in a way that does not cause 'perverse outcomes' whereby the act of measuring leads to data being hidden. Any personal incentives should be symbolic and public (e.g. cinema pass).

Andy Brazier

Ergonomics society oil and gas conference - part 4

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

Ian James of HSE presented the 7 step approach to managing human factors:

1. Consider main site hazards
2. Identify human activities for these (e.g. bulk transfers, maintenance, startup, reactor charging)
3. Outline key steps in these activities (remember to talk to operators)
4. Identify potential human failures for key steps (slips, mistakes and violations)
5. Identify performance influencing factors that make failure more likely (job, person, organisation)
6. Use the hierarchy of control (don't reply on human as the last line of defense, but automation introduces new issues)
7. Manager error recovery (makes it more likely that errors will be detected by others or the system)

HSE expect companies to take a structured approach, focused on human role in initiating and mitigating major hazards that considers all error types (unintentional and decision failures, as well as intentional and action failures). They expect operators to be involved, and that management failures are considered. HSE prefer a qualitative approach, and do not expect quantification of risks related to human factors.

Andy Brazier

Ergonomics society oil and gas conference - part 3

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

Isadore (Irv) Rosenthal gave a presentation titles 'BP's Texas City accident - are the lessons taught likely to be learned and implemented?' Irv had been a member of the Baker Panel that investigated the management and organisational failures that contributed to this accident. I have blogged findings from the report previously, and Irv covered many of these points. However, his presentation provided further insight, which is summarised below.

It is easy to see BP as a large, highly profitable company that makes you wonder why money was not being spent to improve safety. Whilst this is true, the fact that the refinery arm of the business made a relatively small contribution to the overall profit, well below that of exploration and production. It is estimated that the accident has cost BP over $2.5 billion in fines, settling claims and most significantly lost opportunity. It also had a very negative impact on stock/share prices for up to 18 months.

The findings from the Baker Panel report should not have been a surprise to the company, because many similar issues had been raised by reports of the accidents at BP Grangemouth Refinery in 2000. For example, quoting from reports:

1. Grangemouth - "Insufficient management attention and resources were given to maintaining and improving technical standards for process operations and enforcing adherence to standards, codes of practice, company procedures and HSE guidance"
1. Texas City - "Process safety, operations performance, and systematic risk reduction priorities had not been set and consistently reinforced by management."

2. Grangemouth - There was a need to build awareness and competencies in process safety and integrity management within senior leadership and the organisation in order to develop a meaningful value conversation around cost versus safety. "There was a lack of experience in some areas, and limited refresher training plans."
2. Texas City - The Texas City Refinery suffers from an "inability to see risks and, hence, tolerance of a high level of risk. This is largely due to poor hazard/risk identification skills throughout management and the workforce, exacerbated by a poor understanding of process safety...There was no ongoing training program in process hazards risk awareness and identification for either operators, supervisors or managers."

3. Grangemouth - "With no formal structure or specific focus on process safety, many of the components of process safety management (PSM) were not formalised at Grangemoth. There was no site governance structure to provide overview and assurance that process safety issues were being handled appropriately. Process safety needed to be elevated to the same level as person safety."
3. Texas City - "The investigation team was not able to identify a clear view of the key process safety priorities for the site or a sense of a vision or future for the long term. Focus (was) on environment and personal safety, not process safety. There was little ownership of PSM through the line organisation."

4. Grangemouth - "BP group and Complex Management did not detect and intervene early enough on deteriorating performance....Inadequate performance measurement and audit systems, poor root cause analysis of incidents, and incorrect assumption about performance based on lost time accident frequencies and a lack of key performance indicators.. meant the company did not adequately measure the major accident hazard potential."
4. Texas City - "The safety measures focused primarily on occupational safety measures, such as recordable and lost time injuries. This focus on personal safety had led to the sense that safety was improving at the site. There was not clear focus or visibility on measures around process safety, such as lagging indicators on loss of containment, hydrocarbon fires, and process upsets."

5. Grangemouth - "Over the years, a number of maintenance and reliability reviews, task forces, and studies had been conducted, but many recommendations had not been implemented. There was a maintenance backlog and mechanical integrity testing was not prioritised to ensure that safety critical equipment received timely preventative maintenance."
5. Texas City - Risk awareness "repeated failures to complete recommended actions from audits, peer reviews and past incident investigations." "There is currently a backlog of unclosed action items in the tracking database related to various aspects of process safety management, including those stemming from incident investigation. Some of the the latter extend back over a period of more than twelve months."

In conclusion Irv felt BP will learn from Texas City because:

1. Everyone at the company felt very bad about the accident and it had had a major financial and public relations impact.
2. The board had recognised that good process safety also improves product quality, yields, profits and the public image need to keep its license to operate and win oil leases.
3. Unions, neighbours, regulatory agencies and political concerns will motivate more action
4. BP are implementing process safety that should lead to better process safety practices.

I hope he is right in his conclusions!!

Andy Brazier

Ergonomics society oil and gas conference - part 2

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

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

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

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

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

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

Andy Brazier

Ergonomics society oil and gas conference - part 1

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

Martin Anderson opened the conference by giving an idea of where industry should be heading. Of particular note was his negativity towards behavioural safety. Not because there is anything particularly wrong with it, but because too many companies think using such a programme means they have 'done' human factors.

Martin showed a poster add from the airforce. It read "It takes about 80,000 rivets, 30,000 washers, 10,000 screws and bolts to help make this aircraft fly...... and only one nut to destroy it." Martin made it clear that this was NOT a useful message. Individuals rarely have much influence over the factors that make it more or less likely they will make an error, and so telling people to 'be careful' makes very little difference.

We all know that culture is an important part of human factors, but Matrin made the point that we can think this refers to 'operator culture' when in fact it is the 'organisational culture' that we need to be looking at. He quoted the following examples from the major accidents

* Poor competency assurance - Esso Longford
* Poor user interfaces - Texaco Pembroke
* Failure to learn from the past - Mexico City
* Poor maintenance management - Bhopal
* Inadequate management of change - Flixborough
* Poor communications - Piper Alpha
* Poor implementation of safety policy - Kings Cross fire

Martin made the point very forcibly that behavioural safety does not equal huaman factors. Behavioural approaches:

* Focus on observable behaviours only
* Draw attention away from process safety issues
* Don't address the significant impacts of management behaviour
* Can make a contribution to safety, but have limited benefits for the control of major hazards.

In particular it is not appropriate to focus on employee behaviour or culture when the organisation has insufficient resources, inapparopriate priorities, does not plan work effecitvely, has not assessed risks, has poor control over contractors, does not invest capital, has inadeqaute procedures and competency assurance etc.

Martin finished with a quote from Winston Churchill

"To look is one thing, to see what you look at is another
To understand what you see is another
To learn from what you understand is something else.
But to act on what you learn is all that really matters"

Andy Brazier

Humorous Communication Errors - QI

Last week's episode of the BBC comedy QI included a couple of classic stories from the panel.

Alan Davies explained how he had the opportunity to go behind the scenes at London Zoo, and took his young nieces along. At the lion enclosure the keeper gave very clear instructions that standing near the smaller mesh was safe but near the bigger mesh was not (of vice verse). When asked if they understood, the young girls said yes. On entering proceeding, one of the girls asked Alan "what is mesh?"

On a similar note, Bill Bailey recounted an opportunity he had to go into a big cat enclosure in a Brazilian zoo. The keeper said "always approach the cat from the front." As Bill made his way into the enclosure the keeper said "sorry, I meant to say never approach from the front."

They made me laugh

Andy Brazier

Missing disks

It is very big news in the UK this week that HM Revenue and Customs have lost two cds containing benefit details of 25 million people when posting them to the National Audit Office. There are lots of news articles, but this one from the BBC is a good place to start.

I think there are a number of worrying things about this case. Not particularly that the disks got lost, as that is entirely predictable. I would expect arrangements are made to minimise the likelihood of it happening, but it can never be zero.

Instead I am concerned that little effort seems to have been made to have protected the data. As I understand it was not encrypted, so could be quite easy to extract by someone who knew what they were doing. Also, some of the data was not necessary but it was considered too expensive to remove it. I would have thought the need to send this type of information to the National Audit Office would be known, and hence that databases etc. would have been set up to allow it to happen safely and easily. It seems that is not the case.

I am also dismayed that the government are so quick to deny systemic failures and blame junior members of staff for not following procedures. What a terrible attitude towards organisational responsibility.

Andy Brazier

LEAN - 5s

LEAN manufacturing has cropped up a few times in various conversations I have had. I must find out more about it sometime. However, one related technique is known as 5s, and I think it has some safety and human factors application.

The 5s's are Japanese words, but it translates quite well:

Seiri - Sort/Tidiness - Throw away all rubbish and unrelated materials in the workplace

Seiton - Simplify/Orderliness - Set everything in proper place for quick retrieval and storage

Seiso - Systematically clean/Cleanliness - Clean the workplace; everyone should be a janitor

Seiketsu - Standardisation - Standardize the way of maintaining cleanliness

Shitsuke - Sustain/Discipline - Practice 'Five S' daily - make it a way of life; this also means 'commitment'

I am sure there are many references to this. Here is one.

Andy Brazier

Stress

Article called "Relax? Don't do it" by Catherine Quin published in the Guardian Office Hours supplement on 15 October 2007

The debate about whether some amount of stress is good for you. Research from the universities of Kentucky and British Columbia has shown that moderate amounts of stress can strengthen the immune system, thought to relate to the primeval fight or flight response to protect primeval humans from injury sustained in a stressful encounter. However, any more than controlled bursts of stress have a negative impact.

Stress can be "acute," which is bouts interspersed with periods of calm. However, "chronic" stress means you don't get the periods of calm. For example, you can't switch off when you get home from work or lie awake at night worrying.

Stress can cause over stimulation of the adrenal gland which interferes with cortical levels, which in turn disrupts waking and sleep patterns. The result can be migraines, hypertension, lowered immunity and depression.

The consequences of stress are closely related to the individuals perception. Even top performs get stressed, but they have identified strategies to control the symptoms and harness the stress to help them perform better. To do this you need to first recognise you have a choice in how you respond to stress. You then need to be able to recognise the effects stress has on you and then learn how to control these effects.

Andy Brazier

The role of consultants

An article in The Times2 on 15 October 2007 by Joe Joseph titles 'Modern morels.'

It asks if you are sitting on a bus or train next to someone doing their homework and you can see them answering a question wrong, should you correct them?

Alexander Pope is quoted as saying "to err is human, to forgive is divine." He did not say "to err is human, but to correct is divine" because no one likes an interfering know-it-all stranger.

There are certain groups of people we pay to criticise others. They include teachers, judges and management consultants. For the latter, bosses pay consultants break uncomfortable news (e.g. restructuring). This leaves the boss free to implement the changes they planned all along and the consultants get the blame. The consultant is not being payed for their corporate insights, but to keep quiet about the Machiavellian subterfuge.

The article finishes by asking whose job is it to criticise outside of work, school etc.? The answer being "spouses."

Andy Brazier

Aviation industry humour

These appear in many places on the internet. They make me laugh and I have blogged them as I am sure I will have a use for them one day when providing human factors training. I don't know the original source, but I copied them from this website

Qantas Maintenance Humor
After every flight, pilots fill out a form called a gripe sheet, which conveys to the mechanics problems encountered with the aircraft during the flight that need repair or correction. The mechanics read and correct the problem, and then respond in writing on the lower half of the form what remedial action was taken, and the pilot reviews the gripe sheets before the next flight. Never let it be said that ground crews and engineers lack a sense of humor. Here are some actual logged maintenance complaints and problems as submitted by Qantas pilots and the solution recorded by maintenance engineers. By the way, Qantas is the only major airline that has never had an accident.

(P = the problem logged by the pilot.)
(S = the solution and action taken by the engineers.)

P: Left inside main tire almost needs replacement.
S: Almost replaced left inside main tire.

P: Test flight OK, except auto-land very rough.
S: Auto-land not installed on this aircraft.

P: Something loose in cockpit.
S: Something tightened in cockpit.

P: Dead bugs on windshield.
S: Live bugs on back-order.

P: Autopilot in altitude-hold mode produces a 200 feet per minute descent.
S: Cannot reproduce problem on ground.

P: Evidence of leak on right main landing gear.
S: Evidence removed.

P: DME volume unbelievably loud.
S: DME volume set to more believable level.

P: Friction locks cause throttle levers to stick.
S: That's what they're there for.

P: IFF inoperative.
S: IFF always inoperative in OFF mode.

P: Suspected crack in windshield.
S: Suspect you're right.

P: Number 3 engine missing.
S: Engine found on right wing after brief search.

P: Aircraft handles funny.
S: Aircraft warned to straighten up, fly right, and be serious.

P: Target radar hums.
S: Reprogrammed target radar with lyrics.

P: Mouse in cockpit.
S: Cat installed.

P: Noise coming from under instrument panel. Sounds like a midget pounding on something with a hammer.
S: Took hammer away from midget.

All too rarely, airline attendants and pilots make an effort to make the in flight safety lecture and other announcements a bit more entertaining. Here are some real examples of intentional and unintentional humor that have been heard or reported:

1. On a Southwest flight (SW has no assigned seating, you just sit where you want) passengers were apparently having a hard time choosing, when a flight attendant announced, "People, people we're not picking out furniture here, find a seat and get in it!"

2. On a Continental Flight with a very "senior" flight attendant crew, the pilot said, "Ladies and gentlemen, we've reached cruising altitude and will be turning down the cabin lights. This is for your comfort and to enhance the appearance of your flight attendants."

3. On landing, the stewardess said, "Please be sure to take all of your belongings. If you're going to leave anything, please make sure it's something we'd like to have.

4. "There may be 50 ways to leave your lover, but there are only 4 ways out of this airplane"

5. "Thank you for flying Delta Business Express. We hope you enjoyed giving us the business as much as we enjoyed taking you for a ride."

6. As the plane landed and was coming to a stop at Ronald Reagan, a lone voice came over the loudspeaker: "Whoa, big fella. WHOA!"

7. After a particularly rough landing during thunderstorms in Memphis, a flight attendant on a Northwest flight announced, "Please take care when opening the overhead compartments because, after a landing like that, sure as hell everything has shifted."

8. From a Southwest Airlines employee: "Welcome aboard Southwest Flight 245 to Tampa . To operate your seat belt, insert the metal tab into the buckle, and pull tight. It works just like every other seat belt; and, if you don't know how to operate one, you probably shouldn't be out in public unsupervised."

9. "In the event of a sudden loss of cabin pressure, masks will descend from the ceiling. Stop screaming, grab the mask, and pull it over your face. If you have a small child traveling with you, secure your mask before assisting with theirs. If you are traveling with more than one small child, pick your favorite."

10. "Weather at our destination is 50 degrees with some broken clouds, but we'll try to have them fixed before we arrive. Thank you, and remember, nobody loves you, or your money, more than Southwest Airlines."

11. "Your seat cushions can be used for flotation; and, in the event of an emergency water landing, please paddle to shore and take them with our compliments."

12. "As you exit the plane, make sure to gather all of your belongings. Anything left behind will be distributed evenly among the flight attendants. Please do not leave children or spouses."

13. And from the pilot during his welcome message: "Delta Airlines is pleased to have some of the best flight attendants in the industry. Unfortunately, none of them are on this flight!"

14. Heard on Southwest Airlines just after a very hard landing in Salt Lake City the flight attendant came on the intercom and said, "That was quite a bump, and I know what y'all are thinking. I'm here to tell you it wasn't the airline's fault, it wasn't the pilot's fault, it wasn't the flight attendant's fault, it was the asphalt."

15. Overheard on an American Airlines flight into Amarillo, Texas, on a particularly windy and bumpy day: During the final approach, the Captain was really having to fight it. After an extremely hard landing, the Flight Attendant said, "Ladies and Gentlemen, welcome to Amarillo . Please remain in your seats with your seat belts fastened while the Captain taxis what's left of our airplane to the gate!"

16. Another flight attendant's comment on a less than perfect landing: "We ask you to please remain seated as Captain Kangaroo bounces us to the terminal."

17. An airline pilot wrote that on this particular flight he had hammered his ship into the runway really hard. The airline had a policy which required the first officer to stand at the door while the passengers exited, smile, and give them a "Thanks for flying our airline." He said that, in light of his bad landing, he had a hard time looking the passengers in the eye, thinking that someone would have a smart comment. Finally everyone had gotten off except for a little old lady walking with a cane. She said, "Sir, do you mind if I ask you a questi on?" "Why, no, Ma'am," said the pilot. "What is it?" The little old lady said, "Did we land, or were we shot down?"

18. After a real crusher of a landing in Phoenix, the attendant came on with, "Ladies and Gentlemen, please remain in your seats until Capt. Crash and the Crew have brought the aircraft to a screeching halt against the gate. And, once the tire smoke has cleared and the warning bells are silenced, we'll open the door and you can pick your way through the wreckage to the terminal."

19. Part of a flight attendant's arrival announcement: "We'd like to thank you folks for flying with us today. And, the next time you get the insane urge to go blasting through the skies in a pressurized metal tube, we hope you'll think of US Airways."

20. Heard on a Southwest Airline flight. "Ladies and gentlemen, if you wish to smoke, the smoking section on this airplane is on the wing and if you can light 'em, you can smoke 'em."

21. A plane was taking off from Kennedy Airport . After it reached a comfortable cruising altitude, the captain made an announcement over the intercom, "Ladies and gentlemen, this is your captain speaking. Welcome to Flight Number 293, nonstop from New York to Los Angeles . The weather ahead is good and, therefore, we should have a smooth and uneventful flight. Now sit back and relax... OH, MY GOD!" Silence followed, and after a few minutes , the captain came back on the intercom and said, "Ladies and Gentlemen, I am so sorry if I scared you earlier. While I was talking to you, the flight attendant accidentally spilled a cup of hot coffee in my lap. You should see the front of my pants!" A passenger in Coach yelled, "That's nothing. You should see the back of mine."

Ergonomics checklist

A very useful information sheet is available from Bosch Rexroth at their website.

Andy Brazier

Six sigma applied to safety improvement

Article "A Safer Way to Manufacture" by Walt Rostykus. Published on the Industry Week website September 2007

Goodyear wanted to improve safety in their tyre manufacturing process. They mapped out a strategy that was linked to Goodyear's continuous improvement process and applied Six Sigma's five steps to safety:

* Define: Establish a common goal for improvement and metrics to track process. Establish needed resources including a support infrastructure.
* Measure: Identify and assess tasks for ergonomic risk. Determine the level of exposure to risk.
* Analyze: Evaluate and identify hazards. Evaluate new tools and processes for risk.
* Improve: Control risks and hazards in the workplace. Validate reduction of risk.
* Control: Monitor, review and maintain controls.

Given the number and diversity of Goodyear operations, officials decided the long-term plan would focus on select locations each year, and be initiated in four phases:

* Establish common tools and approach. In addition to the Ergonomics Process Standard, officials selected common assessment and tracking tools to ensure consistent measurement and tracking. Consultant engineers conducted workshops to engage both plant leadership and leaders of the ergonomics process. Together, they developed implementation plans for their respective sites.
* Engage associates and make quick improvements. Consultant engineers led rapid improvement activities to make quick, simple changes in the workplace. This approach engaged associates, improved the workplace quickly, and started the momentum for the ergonomics process.
* Establish a sustainable improvement process. Key associates took special training to develop the skills to conduct ergonomic risk assessments and design/implement solutions in the workplace. This phase established a sustainable improvement process that could continue long after the consultants left the plant.
* Follow up and audit the process. Finally, officials audited each ergonomic process against the criteria to ensure the plant met company expectations.

To improve the chances of success, Goodyear started with five pilot plants. They were selected for different reasons including; high incidence of work-related musculoskeletal disorders (need to do it), interest of plant management (want to do it), type of operations/products (opportunities for improvement), and agreement with labor (commitment to do it).

A Systems Approach

Based on the pilot implementations, Goodyear designed an Ergonomics Center of Excellence (ECOE) model, which allows for a systematic rollout that includes:

* Site visits by an ergonomics consultant. The purpose is to align expectations with the project charter.
* Conduct RAPID events. RAPID events are a form of Kaizen tactical activity that makes swift, measurable and relevant improvements to the workplace, eliminating non-value-added work elements.
* Follow-up audits to ensure that the process aligns with Goodyear's internal process document.
* Training for all team members, which includes plant manufacturing, functional leadership and floor employees.

Andy Brazier

Simulator training alone not enough, experts warn

Excerpts from an article by Jennifer Harrington September 24, 2007. Available from AINonline

Human error is a contributing factor in 60 to 80 percent of all air incidents and accidents, according to FAA statistics. Advisory Circular 120-51E states that many “problems encountered by flight crews have very little to do with the technical aspects of operating in a multi-person cockpit. Instead, problems are associated with poor group decision-making, ineffective communication, inadequate leadership and poor task or resource management.” The facts also show that relatively few corporate flight departments routinely address issues such as human factors and crew resource management (CRM).

Steve Hopkins, chief instructor and senior partner at Century CRM (Booth No. 1217), a pilot-oriented resource management training provider, said part of the problem stems from the fact that most training programs have been developed using outdated data. “Historically, back in the 1950s, ’60s and ’70s, aircraft weren’t as reliable as they are today,” he said. “If the engine or equipment failed, you needed to know what to do.” As technology advanced, however, hardware failures declined. Unfortunately, “the human factors have stayed pretty constant. People still make the same stupid mistakes,” he said.

“For most operators, 100 percent of their training budget is focused on the simulator, which addresses 20 percent of the accidents,” said Gary Rower, founder of Century CRM. “The human factors, which cause 80 percent of the accidents, go unaddressed.”

Andy Brazier

The tragic human cost of NHS baby blunders

Article in the Observer by Denis Campbell on Sunday September 23, 2007. Available from their website

Quote - "Errors and negligence that result in stillbirths or disabled babies are costing Britain's hospitals billions in compensation. In this investigation, The Observer reveals how staff shortages are wrecking the lives of countless parents "

This article lists a number of tragic cases where errors by medical staff have led to death or severe handicap to babies during birth. However, I can't see how the conclusion that these errors are caused by staff shortages has been made.

I am concerned that the NHS fails to learn from the mistakes that take place. It almost seems that they are expected to say that they need more staff, and are using these errors as a justification. This seems pretty bogus to me. Until the NHS starts to understand the root causes of error they will not be able to learn.

Another quote from the article - "The Department of Health insist that England has a good record on births. Gwyneth Lewis, the Department of Health's chief adviser on childbirth, says: 'Due to the skill and expertise of our midwives and doctors, England is one of the safest places to have a baby.'"

Perhaps it is a case that the principles of risk management do not apply in the medical profession.

Andy Brazier

Ergonomics and the bottom line

"Ergonomics And Economics Why ergonomics makes a lot of sense from a dollars-and-cents standpoint and why it may be inevitable because of legislation.
By M. Franz Schneider published in Office Ergonomics May/June 1985 and available at this web address

A group of 123 office workers were selected to investigate the impact of ergonomic furniture on productivity. For eight months before any design changes, workers kept diaries of time spent on various tasks. The absenteeism rate, and number of errors per document and time to complete tasks was monitored. The workers were given checklists which they completed every half hour, describing their postural comfort and perceived well-being.

Workers participated in the selection of furniture through user evaluations, development of layouts, and determination of finishes and accessories. The performance measures were continued for six months after the design changes.

Results were impressive: Monday morning absenteeism dropped from 7 per cent to less than 1 per cent. Over-all absenteeism fell from 4 per cent to less than 1 per cent. Error rates in document preparation fell from 25 per cent to 11 per cent. The percent of the day computer equipment was in use increased from 60 to 86. These results signified an increase in active work time of more than 40 per cent. Reports of postural discomfort showed a marked drop in frequency, severity and duration.

The subjective ratings that managers made of their own performance indicated that more than 70 per cent felt that their effectiveness had improved "very much." Ninety per cent subjectively rated the productivity of their employees as "much improved."

It is suggested that the fact that the study started 8 months prior to the design changes should mean the "observer effect" was minimised because performance only improved after the design changes were made. Also, the productivity improvements endured after the study team was no longer on-site.

Other studies have demonstrated similar benefits:

The performance of State Farm Insurance clerical workers improved as much as 15 per cent with ergonomically acceptable work stations and seating (Dr. T.J.Springer).

Laboratory work showed that the keystroke rate for data-entry tasks increased five per cent when workers were moved from an ergonomically unacceptable environment to one that was ergonomically correct (Dr. Marvin Dainoff).

The performance of office workers at Blue Cross-Blue Shield was shown to improve with the move to an ergonomically enhanced environment, resulting in an overall productivity improvement of 4.4 per cent.

The Norwegian State Institute showed improvements to work station layout and seating, halved back-related absenteeism and reduced turnover from 40 per cent to 5 per cent.

At a major automobile company, management workers used their computer equipment less than 12 per cent of the day. After the introduction of ergonomic computer tables and an improved chair, the VDT-use rate went up four times. Time taken to complete reports and memos was reduced, and the quality of correspondence was rated as being higher. More significantly, the average management worker had at least three more hours per week of time for work. Time that had initially been eaten up by the tedious clerical/management interface was freed by the use of "user-friendly" computer equipment. A telemarketing group reported an increase from ten per cent to 80 per cent on final closings of sales after the change to ergonomically enhanced office furnishings and improvements to the acoustics and lighting of the environment.

Conclusion

People generally work only 60 per cent of the working day, or about 288 minutes. A 5 per cent improvement would provide 14 minutes of productive work per day, 14 fewer minutes of back discomfort and getting up to wander around the office, and 14 more minutes to review reports. There would be 14 fewer minutes of re-doing memos that have been processed incorrectly and 14 minutes for new work, 14 fewer minutes of frustration with screen glare and 14 more minutes of effective programming.

Andy Brazier

Classifying causes

I have had a comment on my last post regarding the Virgin train crash. It questions whether there are problems with accident investigation because we have not properly defined the terminology used to describe different types of cause (e.g. "immediate" and "underlying").

My view is that these classifications of cause do not give us the full range needed to fully explain an accident. The reality is that there are many different types of failure that can contribute to an accident, and each of these failures may have multiple causes. Most accidents will start with a combination of technical, human and organisational failures that create a hazardous situation. This already highlights the complexity. For example, a human error can be an "immediate" cause of an accident, but it can also cause a technical failure, in which case the human error would be an "underlying" cause.

This is further complicated by the fact that a hazardous situation does not necessarily result in an accident. If the situation has been predicted defences can be put in place. Only if these fail do you have a developing incident. Even then there are opportunities to recover the situation. Failure to recover results in an accident, whilst successful recovery means it is a near miss.

If I look at an accident I tend to start by thinking "what failures resulted in a hazardous situation developing, were there potential defences and did they fail, and could the situation have been recovered?" This gives me a set of failures (you may call them "immediate" causes) that require analysis. These can then be broken down, for example using "why trees" until the root causes are found. In this case the root causes are where the "why tree" cannot be broken down any further.

My view of failure types comes from a model I first saw in the PhD thesis of Tjerk van Der Schaaf, who is now a professor at Eidhoven University. You can see the model reproduced in another thesis (see figure 1.1 on page 6).

Andy Brazier

Virgin Rail crash, February 2007

A summary of Network Rail's investigation into the Virgin rail crash that killed one person was released 4 September 2007. It is available from here

The report uses a lot of railway jargon that I am not familiar with.

The conclusions identify the immediate cause as the deterioration of components in the stretcher bar system on the points. Underlying cause was a failure to carry out an inspection that would have identified the fault.
* Deficiencies in the asset inspection and maintenance regime employed on Lancs & Cumbria maintenance area resulted in the deterioration of 2B points not being identified. These deficiencies included:
* A breakdown in the local management/supervisory structure that leads, monitors and regulates asset inspection and maintenance activities;
* A systematic failure in the track patrolling regime employed on the local area;
* The issue and subsequent briefing of mandated standards not being carried out in a robust and auditable manner;
* A lack of sample verification to test the quality and arrangements for inspections undertaken.

I find this quite bizarre. Failure to inspect something does not cause it to fail. Yes, it may allow a hazard to be discovered before an accident occurs, but that is not the same thing. It sounds to me like Network rail are trying to distract us from more fundamental problems with the design of points. Especially given the fact we still do not know what caused the Potter's Bar train crash, which also involved a failure of points.

In fact, reading more of the report into this crash it seems design issues were raised, and most of the action items are focussed on these types of issue. This makes it even more strange in my opinion that the conclusions in the report (which are probably all that most people will read) are so focussed on inspection.

Drug recall

According to news reports on 6 June 2007, including this one from the BBC, Roche have had to recall all batches of the anti-HIV drug Viracept (generic name nelfinavir) because it was contaminated with potentially cancer causing chemicals. The contamination is being blamed on human error.

According to the Roche website the company are to establish Viracept Patient Registries in order to register and closely follow patients who may have been exposed to a chemical impurity in their Viracept HIV formulations.

Andy Brazier

Inexplicable errors

This is something I have come across a couple of times recently. Someone makes a completely bizarre error and no one can explain exactly why it occurred. I guess this is one of the things with humans, we are not logical creatures and instead more emotional. Sometimes things can't be explained.

This article called "What next for crane safety?" by Phil Bishop, 27 June 2007 describes an incident at Canary Wharf in May 2000 where the top of a tower crane fell whilst being raised into position. In this task it is important to attach the top of the crane to the 'climbing frame.' Because this was forgotten the crane was simply balancing and able to fall. According to the article this is such an obvious and well known issue that it seems incredible that it was forgotten.

Advice in the article is given in the article to reduce the likelihood of errors, but it does not actually address the accident in question. I think the reality is that some bizarre things will happen and we should not spend lots of effort preventing them in the future because we can be fairly sure they are one off incidents. However, we can use these incidents to delve into systems as a whole and find weaknesses and hence opportunities to improve.

Andy Brazier

Quantified human reliability analysis

Available here. Academic paper by Marzio Marseguerra, Enrico Zio, and Massimo Librizzi1 entitled Human Reliability Analysis by Fuzzy “CREAM”

The work uses the the Cognitive Reliability and Error Analysis Method (CREAM) model, which assumes that the human failure probability depends on the level of control a person has over the contextual scenario in which requested to perform. Four modes of control are identified
* Scrambled,
* Opportunistic,
* Tactical,
* Strategic.

The fuzzy approach allows for ambiguity and uncertainty in the calculations.

I must take a closer look at the paper some time.

Andy Brazier