Workplace safety: A cultural change

Financial News and Daily Record by Karen Brune Mathis 28 March 2012

Organizational consultant Hal Resnick contends that workplace safety is a culture and creating it can require major organizational change.

The root causes of major accidents — and most others — lies in the lack of a fundamental safety culture.  In virtually every one the post-disaster analysis revealed a set of underlying conditions that made these disasters both predictable and avoidable.

Resnick says that “Management’s excuse is that excessive attention to safety will hamper productivity and break the bank.  The reality is that creating a safety culture drives the same values and actions that also create increased productivity; enhanced product quality and reliability; increased innovation; continuous improvement; enhanced employee engagement; and an improved bottom line." 

“It’s both the right thing to do and it makes good business sense."

According to Resnick, a safety culture has three dimensions: organizational or structural, group norms, and individual responsibility and accountability.

Structural attributes of a safety culture

• Are roles and responsibilities clearly defined and followed?

• Are employees empowered to act to address safety concerns, or are they expected to follow the chain of command?

• Does the organization recognize and reward employees who raise issues, or is the general response to shoot the messenger?

• Are work processes and procedures clearly defined and followed?

• Is attention to safety everywhere or confined to an employee’s own work area?

• Does the company expect everyone to do work safely or is the message that the organization can’t afford the time to do everything “by the book”?

• Are safety reports reviewed with action and follow-up or do they generate a defensive response?

 

Group norms and values

• Are employees at all levels across the organization encouraged to speak up to raise concerns without fear of retaliation or reproach?

• Are audits welcomed or seen as an intrusion?

• Is safety perceived as a real commitment or an act of compliance?

• Does peer pressure encourage individuals to speak up or keep their mouth shut?

• Are safety and production intertwined or is safety seen as a cost that interferes with production?

• Are accidents seen as preventable or to some extent unavoidable?

• Are employees encouraged to have a questioning attitude?

• Do employees believe they are treated with trust and respect?

 

Individual responsibility and accountability

• Do employees at all levels accept personal responsibility and accountability for safety or is it seen primarily as the job of the safety department?

• Are potential safety issues identified and addressed before an incident happens?

• Does senior management lead safety by personal example?

• Do all employees have the authority to stop work or is that authority reserved only for management?

Google shares suspended after accidental email wipes $22bn off value

The Guardian by Charles Arthur 18 October 2012

Search engine's unfinished financial release inadvertently sent, revealing quarterly results well below Wall Street expectations

It was the printer's error that wiped about $20bn from the value of the world's biggest search engine. Shares in Google were suspended after an accidental email to the US stock market authorities revealed that the company's latest quarterly results were far below Wall Street's demanding expectations.

The inadvertent – and clearly unfinished – financial release began with the words "PENDING LARRY QUOTE" – referring to the company's chief executive, Larry Page, whose job, normally, would be to put the best gloss on the financial figures. But he was likely to be offering different sentiments after the stock tumbled 9% before trading was halted. After trading resumed the shares recovered slightly to close down 8%.

Five Changing Trends in Managing Workplace Ergonomics

Occupational Health and Safety by Walt Rostykus 1 October 2012

Traditionally, safety professionals have driven ergonomic improvements in an effort to reduce injuries, but all along they have been the wrong people to do this.

Occupational ergonomics continues to emerge as one of the priority workplace issues addressed by employers today. This is driven primarily by the need to reduce musculoskeletal disorders (MSDs). In our recent benchmarking study, we found that participants attributed between 24 and 75 percent of injuries to poor ergonomic conditions. This rate has remained relatively consistent over the past several studies. Most companies attribute the high incidence of MSDs to:

• Reduction of other types of injuries. As a result of programs focused on reducing and eliminating mechanical, electrical, and chemical hazards, MSDs are emerging as a priority issue.
• Increased work demand on individual employees. This is typically attributed to workforce downsizing, production rate changes, cost constraints, and "doing more with less."
• Aging workforce. Some companies attribute their MSDs to the capabilities, conditioning, and condition of both older and younger workers.

The five trends are as follows

1. Getting Proactive - using quantitative tools to measure exposure to MSD risk factors and then focus their efforts on changing the job conditions to reduce the level of exposure—before an injury occurs.
2. Integrating the Process - managing ergonomics as a process that is aligned with, or integrated into, existing improvement processes (e.g. Lean Manufacturing, Six Sigma, Continuous Improvement, and Safety Management Systems). This engages people across an organization, ensures that the processes are sustainable as time, leaders, and business needs change, integrates the processes into the business and ensures that they are not dependent upon a few people, and provides a logical system for determining and driving improvement.
3. Engaging Others and Shifting Ownership -Successful organizations expand ownership, involvement, and accountability for ergonomics to people outside the EHS staff.4. Moving Upstream - Consistently addressing ergonomics in the design phase of new processes, equipment, layouts, and products is a common practice of advanced organizations. About 5 percent of all organizations are at this level. The greatest value of good upstream design is the reduced cost of making changes. The cost of changing equipment and layout once it is in place is more than 1,000 times the cost of making the change in the design phase.
5. Addressing the Office - The biggest trend in managing office ergonomics has been the movement toward employee-driven assessments and workplace changes. By providing online training and self-assessments, employers are enabling and empowering individuals to take the first steps in adjusting their workstations to fit them.

In addition to these common trends, we’ve identified two common challenges with managing ergonomics that companies at all levels of program maturity have experienced.
1. Funding for training and engineering solutions
2. Failure to use or meet established ergonomic design standards.

Wrong medical procedure a result of 'human error'

Irish Times by Fiona Gartland 19 September 2012

A CONSULTANT paediatrician who incorrectly recorded a procedure to be carried out on a 2½-year-old girl – who was later given the wrong operation – told a Medical Council fitness-to-practise committee yesterday the mistake was “human error”.

Prof Martin Corbally, who was a paediatric surgeon at Our Lady’s Children’s Hospital in Crumlin when the incident happened in 2010, said he was “probably quite tired” when he filled out the letter in question and accepted he made a mistake. But he said he had correctly recorded the procedure on the admissions card as “tongue tie upper frenulum” and administration had not completed the hospital booking system correctly because they omitted the words “upper frenulum”. “That is where the error really lay,” he said.

“I would see 80 to 100 patients a week between my three clinics and I was not really remembering their names,” he said. He also said he had “no way of knowing” the procedure that should have been carried out on Baby X when she attended for surgery weeks after he had seen her in outpatients.

If the procedure had been transcribed properly by administration he would have remembered, he said. He also said on the morning of the surgery he had been very busy and had three patients in intensive care.
He denied his instruction to his junior “to release the tongue tie” amounted to poor professional performance. There had been a series of errors in the case, he said.

“To err is human,” he said. “Everybody can make a mistake.” Prof Corbally said after the incident, procedures at the hospital had been improved. He also said he was “deeply concerned” about risk in surgery and had taken a course in risk management after the case involving the patient who had the wrong kidney removed. He had also carried out a study about parental involvement in medical staff meetings ahead of surgery on children.

In earlier evidence, an expert witness for the Medical Council, UK consultant paediatric surgeon Hugh Grant, from John Radcliffe Hospital, Oxford, said he believed the transcript error made by Prof Corbally amounted to poor professional performance and “started the chain of events” that led to the incident.
Under cross-examination from Eileen Barrington SC, for Prof Corbally, who queried whether a transcript error could be poor professional performance, Mr Grant said if you call a lump on the arm a lump on the leg you are applying your knowledge incorrectly which amounted to poor professional performance.

A Strategy for Human Factors/Ergonomics as a Discipline and Profession

ergoweb 19 September 2012. 

Peter Budnick refers to a paper from the Institute of Ergonomics and Human Factors (IEHF).  "In essence, the topic boils down to a few key questions, at least in my mind:

• is there such thing as an ergonomics discipline or profession?
• if so, what and who does it encompass?"

It is suggested their are four main reasons why Human Factors/Ergonomics (HFE) is under-utilized:

1. many potential beneficiaries are not aware of the value HFE can bring;
2. sometimes when there is a demand for HFE, there isn't enough "high-quality HFE," or that the available HFE resources are too limited in scope to be recognized as applicable;
3. the HFE field is small in comparison to established design disciplines such as engineering and psychology, and though HFE principles may be applied within these disciplines, there may be no explicit reference to the HFE discipline.
4. "... the very strength of HFE, its multi-disciplinary base, is also a potential weakness; a diversity of topics, views and practices exist within the HFE community, resulting in unclear communication to the external world."

 Key characteristics of HFE are identified as

1. HFE takes a systems approach.
2. HFE is design driven.
3. HFE focuses on two related outcomes: performance and well-being.

The value of HFE for stakeholders

The committee recognizes that the demand for HFE is directly related to the perceived value of HFE among stakeholders of system design. They identify those stakeholders as (interested readers are directed to the full paper, cited below, for additional details):

• System actors (employees in work-systems, and end-users for products and services) who can benefit from HFE through:
  • Improved physical, psychological and social well-being
  • Higher motivation, growth and job satisfaction 
  • Improved performance 
  • Better experience
  • Shorter time of familiarization
  • Better fitting of products/services to individual characteristics/needs
  • Fewer mistakes
  • Greater efficiency

• System experts (any of a variety of professionals that can be involved in a design effort) who can benefit from HFE through:
  • Better users’ acceptance of designed systems
  • Better performance
  • Better fit with (legal) standards 
  • Improved development process 
• System decision makers (e.g., managers, purchasers) who can benefit from HFE through:
  • Better productivity
  • Better quality and reliability of production processes and produced goods and services
  • Lower operating costs due to lower levels of health problems, motivational deficits, accidents, absenteeism, and related productivity loss
  • More innovation by increased employee creativity 
  • Better reputation for hiring and retention of talented employees
  • Better decision-making
  • Better market performance 
  • Greater profitability
  • Less re-design
• System influencers who can benefit from HFE through:
  • Social wealth
  • Economic wealth

Can’t Sleep? It Could Be Your iPad

CBC Phily by Denise Mann 31 August 2012

New research shows that all of those nighttime hours spent with your tablet can wreak havoc on your sleep.
The bright light emitted from these tablets can suppress melatonin. That’s a hormone that helps control sleep and wake cycles, called circadian rhythms. 

“If they are bright and they are big and are close to your eyes, they have more potential to disrupt your melatonin than the TV, which is usually farther way,” says researcher Mariana Figueroa. She is an associate professor at Rensselaer Polytechnic Institute in Troy, N.Y.
iPhones and other small gadgets may not affect circadian rhythms. “Smaller devices emit less light,” she says. But even if these devices aren’t zapping the body’s melatonin supply, they may still be disrupting sleep by delaying your bedtime, she says.

Possible solutions include:

* Invest in a filter
* Dim the lights
* Hold the tablet further from your face
* Don't use late in the evening

Human Error Leaves Zookeeper, Tiger Dead in Germany Read more: http://www.care2.com/causes/human-error-leaves-zookeeper-tiger-dead.html#ixzz29fnsBvZ4

http://www.care2.com/causes/human-error-leaves-zookeeper-tiger-dead.html 25 August 2012

After someone apparently did not close a security gate properly, a tiger named Altai was able to escape from its enclosure in the Cologne Zoo in western Germany,

The tiger wandered to an adjacent storage building where he attacked and killed a 43-year-old zookeeper.

The director of a zoo, Theo Pagel, shot the tiger from the roof a nearby building with a rifle, killing the animal.
The tiger was killed before he could enter public areas and armed officers and a helicopter were at the scene. Visitors at the zoo were evacuated and the zoo closed briefly. A special “Summer Night” event, at which people can visit the zoo after-hours, has been cancelled.

Too Many Screens: Why Drones Are So Hard To Fly, So Easy To Crash

AOL Defense 7 August 2012 by Sydney J Freedberg Jr

The US military depends on drones. But amidst the justifiable excitement over the rise of the robots, it's easy to overlook that today's unmanned systems are not truly autonomous but rather require a lot of human guidance by remote control -- and bad design often makes the human's job needlessly awkward, to the point of causing crashes. Fixing that is the next big challenge for the unmanned industry.

"Too many screens with too much information, folks" -- that's the bottom line, said Col. John Dougherty, a Predator operations commander with the North Dakota National Guard, speaking at a workshop on the first day of 2012 conference of the Association for Unmanned Unmanned Vehicle Systems International (AUVSI) here in Vegas. "I am tired of all these black panels all over the place," Dougherty went on, urging designers to "de-clutter for sanity." But instead, he lamented, "they keep strapping the stuff on," adding more and more sub-systems each with its own unique and user-unfriendly display.

"Human factors was not integrated into the original design of the Predator," Dougherty said. "They were never given the time," because what was originally a technology demonstration project proved so valuable it was rushed into widespread use. As a result, he said, the percentage of major mishaps caused by "human factors" is, ironically, higher for Predators than for manned aircraft.

It's even harder to design a control system for troops operating unmanned systems in the field, instead of from a relatively pristine command center. Something as simple as having to look down at a handheld display can distract a foot soldier from the threats around him, and the light from the screen can give away his position at night, said Army Staff Sergeant Stanley Sweet, an unmanned ground vehicle trainer at Fort Benning and veteran of two tours in Iraq.

Often, Sweet went on, when engineers develop control systems, "they want to use a touchscreen, which looks neat -- [but] the sand, the dirt, the mud, how is it going to affect the screen?" he asked. "How is it going to hold up? My experience is they don't." Controls meant for foot troops have to be physically rugged and conceptually uncomplicated, more like game controllers than like militarized iPads. Infantrymen have no time to navigate complex menus while wondering, "Oh, by the way am I going to get shot at," said Sweet. "If the technology is slow, it will not be used."

......

 More autonomy isn't always the solution, however. When operators do have to take more direct control of unmanned systems, they are badly hampered simply by not being in the vehicle. "In a prior life I was in the airplane, I was there, so a whole bunch of information was being fed to me simply because I was in it," like whether the aircraft was accelerating or not, said Col. Dougherty, a former F-16 pilot. When the operator is in a command post on the ground, however, his screens may tell him the vehicle is moving ahead or swiveling its sensor array, but his inner ear and his peripheral vision are both telling him he's standing still.

Some of the solutions on offer at the workshop included stereo images to improve depth perception, audio cues in three dimensions to alert operators to what's happening behind them, and virtual-reality "telepresence" goggles that let the operator turn his head to see to the side, instead of sitting still and watching images slide past on a screen.

What's essential, said Dougherty, is to break down the cultural preconceptions in the Air Force and elsewhere about what a proper control interface looks like. What works for manned aircraft may not translate to unmanned. "I don't need a cockpit to feel good about myself," he said. "What you need is an appropriate interface, [whether] it's a dome that I'm immersed in or it's a series of flat panels or something that comes down over my eyes with gloves." Our thinking about how best to control the new unmanned technology is still catching up to the possibilities.

Decreased Productivity due to Presenteeism

Ergoweb 16 May 2012

A study involving Sweedish employees has found that presenteeism (attending work when ill) was associated with the psychosocial risk factors of work demands, work control, social climate, employee commitment to the organization, and role compatibility.  When these issues were addressed, the odds of future presenteeism were reduced for all risk factors except work demands.

Whilst the impacts of absenteeism are quite well understood, this is not the case for presenteeism.  In this study particpants were asked “How many times the past 12 months have you been at work even though you according to your health state should have stayed at home?” At the time of the first evaluation, 45.4% reported as performing presenteeism two or more days over the prior year while at the second evaluation, this changed to 44.8% - not statistically significant.

In presenting background information, the authors note that studies have found:

1. An average of $2.30 productivity loss occurs for every $1.00 spent on medical and pharmacy costs
2. Presenteeism costs an estimated $255 per employee per year among US companies
3. For some specific disorders, financial losses due to presenteeism far exceed those due to absenteeism
4. Higher levels of presenteeism are related to high stress, lack of emotional fulfillment, physical inactivity, unhealthy body mass index, and poor diet
5. Higher levels of absenteeism are associated with physical inactivity, high stress, and diabetes/high blood glucose
6. Employees who perceived their jobs to be more stressful than satisfying had greater levels of presenteeism, poor health, greater levels of depression, and riskier lifestyle behavior.

Risk Focus: Slips, trips and falls

UK P&I Club Loss Prevention Booklet

Slips, trips and falls represent nearly one in three of the large personal injury claims submitted to the Club and which aggregate to a staggering $155 m over the past ten years. They are constant too, with very little variation in numbers of claims from year to year.

It is easy to dismiss these unpleasant accidents as ‘human error’, or even ‘crew negligence’, but to examine
the detail of so many of them is to reveal other contributors to the chain of causation. Training could have been deficient or even completely missing, as there is often an assumption that people ‘can look after themselves’ and must take responsibility for their own actions. The environment, which is mostly a function of design, may well have been a contributor, if there was inadequate lighting, or the dangers were not obvious, or the particular design of the ship required people to put themselves ‘in hazard’ just to get a job done. And the procedures aboard ship may have been devised without proper consideration of the risks of carrying them out.

‘We have always done it this way!’ may be no guarantee that it will be the safest way, and may involve people in taking hazardous short cuts. But because of the huge costs of these claims, and because of the human suffering represented by each of them, the Club strongly believes that a concerted attack must be made on the incidence of slips, trip and falls. These are accidents which occur for a reason, and if we understand the reasons behind the existence of these hazards rather better, then we can put in place controls that will hopefully prevent accidents occurring, but will also mitigate their consequences.

A proactive and precautionary approach can be very useful in reducing the incidents of slips, trips and falls, in first of all identifying hazards which have the potential to hurt people. Very often accidents occur because nobody has considered that what they are doing might be hazardous. Just walking around the ship with a sharp eye and an open mind can help to identify features which might, in an unguarded moment, hurt people.

A Bow Tie has been developed highlighting that 'controls' that reduce the risk of slips trips and falls include:

* Adequate lighting
* Hazards/Obstructions identified/clearly marked
* Non-slip surfaces in place/maintained
* Appropriate footwear used
* Good housekeeping of working areas - oil/rubbish/equipment
* Access control - guardrails/wires etc
* Safety equipment in use - harness/nets etc

And mitigation to reduce the risk of a significant claim include:
* Accident reporting system
* Personal protective equipment
* Adequate first aid
* Evidence collection/retention
* Use of third party assistance

DNA Contamination blamed on human error

Channel 4 News 9 May 2012

The error occurred at what is described as the most advanced automated DNA testing system in the UK at LGC forensics labs in Teddington. A used plastic sample holder containing up to eight vials of DNA was mistakenly reloaded into the machine by a laboratory worker, instead of being put into a bin. The system had been installed in March 2011, and the contamination occurred in October.
Every DNA sample in that seven month period has been checked, and LGC said no other instance of contamination had been uncovered. The regulator is now working with the company in monitoring new procedures that have been put in place, to ensure the mistake is not repeated.

The DNA mix up was discovered by Greater Manchester Police detectives, after they had charged a 20 year old suspect in October last year with raping a woman in a park.
At that time LGC had informed the GMP that there was a strong match with DNA extracted from clothing. But detectives found that the suspect could not have been at the scene, because he was in prison 300 miles away, awaiting trial on other unrelated offences.

Greater Manchester Police were informed of the mix-up in March, and the Crown Prosecution Service dropped the case against Adam Scott from Exeter, in Devon.

There was some concern that the blunder could have implications for the convictions in the Stephen Lawrence case, which depended heavily on DNA evidence, and for which some of the tests were carried out at the same laboratory, but further tests to double check results were carried elsewhere.

Your doctor is only human, but patient safety is priority

This is Nottingham 4 May 2012

Numerous studies from around the world have shown that sometimes doctors make mistakes when prescribing, and occasionally patients are harmed as a result.
Along with colleagues from the University of Nottingham, and several other universities, we have recently completed the largest study ever of prescribing errors in general practices.

This week the General Medical Council (GMC) launched our report at a press conference in London and life has been a bit of a whirlwind since with headline news on Wednesday, and me being asked to do numerous radio interviews (including a 5:30am call from Radio 4!).

The likely reason for this level of media interest has been the uncomfortable finding that around one in 20 prescriptions issued by GPs contains an error.

It is important, however, to emphasise that we found the vast majority were safe. Also, many of the errors we found were relatively minor. The study showed the need for improvement in terms of typing clear dosage instructions on prescriptions, getting the dose and timing right, and making sure blood tests are done if these are needed.

We are now looking at ways of helping GPs.

We have published an important study in The Lancet showing how pharmacists can help GPs reduce errors.
And we are developing a "patient safety toolkit" to help general practices with patient safety.

Millions of GP prescriptions contain dangerous errors: research

The Telegraph 2 May 2012 by Rebecca Smith

Almost two million GP prescriptions contain potentially life threatening errors with mistakes in those given to one in five patients, research by the General Medical Council has found. 

Errors including wrong dosages, lack of instructions and insufficient monitoring of patients on dangerous drugs were 'common'.

Elderly and young children are twice as likely to be given a prescription with an error because the over 75s are often on several drugs and the correct dose can be difficult to calculate in youngsters because it is usually based on body weight, the study found.

Time pressures during GP consultations are thought to be to blame along with complex computer software that makes it easy to select the wrong drug or incorrect dose from drop-down menus and frequent distractions and interruptions.

Several GPs said practice nurses who are responsible for managing some long-term conditions often asked them to sign prescriptions without seeing the patient and this made them 'uneasy' and also interrupted them during clinic meaning they may make mistakes themselves.

Also repeat prescriptions were often issued without questioning if the patient still needed the medicine, or if superior ones were available and results from separate clinics were often not relayed to the GP meaning drug doses were not adjusted, it was found.

Human error and not a lack of understanding or knowledge was behind most mistakes, the study said.
Extending the average GP consultation from 13 minutes to 15 and better training in safety would help, lead author, Prof Tony Avery, of Nottingham University, said.

Pharmacists and GP receptionists can also help by carrying out medicine reviews and checking monitoring arrangements.

Errors classed as severe included, a 62-year-old woman with a documented allergy to penicillin who was prescribed flucloxacillin, a similar drug, and elderly patients prescribed blood thinner warfarin, who should have been closely monitored but who were not tested for two years.

Moderate errors included a four-year-old girl with a stomach upset who was prescribed a drug that should be used 'with caution' in children.

Minor errors found in the study included a one-year-old girl who was given two prescriptions for antibiotics in the same consultation but with different doses stipulated.

Failing to request that the patient be monitored was the most common serious error followed by prescribing a drug the patient was allergic to.

Almost all of the serious errors related to one drug, warfarin, which has been used as rat poison. It is prescribed to thin the blood in people at risk of blood clots. It must be carefully monitored because it interacts with other drugs and some foods and patients with levels too high can suffer potentially life threatening stomach bleeds.

Repetitive strain? Try repetitive rest

Morgan Hill Times 2 May 2012 by Nancy Lowe


Many computer users stay in a “ready-to-go” position at all times without giving arm, hand, shoulder and neck muscles enough opportunities to rest. There's a simple method to correct this. I call it repetitive rest, but one of my clients called it the “zen” of ergonomics, and once you try it you may agree.

During computer interactions there can be many, many moments when your hands are not actively engaged in keying or mousing. You are reading an email, composing creative thoughts in your mind or waiting for a page or application to open. These instances may last a few seconds or over a minute. Instead of hovering over the keyboard or grasping the mouse to be ready for the next click, this is a wonderful opportunity to give your body a breather by resting your hands and arms in relaxed, neutral positions.

Air France Flight 447: 'Damn it, we’re going to crash’

The Telegraph 28 April by Nick Ross

With the report into the tragedy of Air France 447 due next month, Airbus’s 'brilliant’ aircraft design may have contributed to one of the world’s worst aviation disasters and the deaths of all 228 onboard.

In the early hours of June 1 2009, Air France Flight 447 from Rio de Janeiro to Paris went missing, along with 216 passengers and 12 crew. The Airbus A330-200 disappeared mid-ocean, beyond radar coverage and in darkness. It took a shocked and bewildered Air France six hours to concede its loss and for several agonising days there was no trace.

The official report by French accident investigators is due in a month and seems likely to echo provisional verdicts suggesting human error. There is no doubt that at least one of AF447’s pilots made a fatal and sustained mistake, and the airline must bear responsibility for the actions of its crew.

But there is another, worrying implication that the errors committed by the pilot doing the flying were not corrected by his more experienced colleagues because they did not know he was behaving in a manner bound to induce a stall. And the reason for that fatal lack of awareness lies partly in the design of the control stick – the “side stick” – used in all Airbus cockpits.
 

The plane’s pitot (pronounced pea-toe) tubes – small, forward-facing ducts that use airflow to measure airspeed had apparently frozen over, blanking airspeed indicators and causing the autopilot to disengage. From then on the crew failed to maintain sufficient speed, resulting in a stall which, over almost four minutes, sent 228 people plummeting to their deaths.

But why? Normally an A330 can fly itself, overriding unsafe commands. Even if systems fail there is standard procedure to fall back on: if you set engine thrust to 85 per cent and pitch the nose five degrees above the horizontal, the aircraft will more or less fly level. How was it that three pilots trained by a safe and prestigious airline could so disastrously lose control? Either there was something wrong with the plane, or with the crew. Airbus and Air France, both with much to lose, were soon pointing accusing fingers at each other.

In July last year the French air crash investigation organisation, the Bureau d’Enquêtes et d’Analyses (BEA), published its third interim report. For Air France the conclusion was crushing: the crew had ignored repeated stall alerts and kept trying to climb, instead of levelling off or descending to pick up speed. The A330 had become so slow that it simply ceased to fly. Its reputation on the line, Air France came as close as it dared to repudiating the finding. The pilots, said the airline, had “showed unfailing professional attitude, remaining committed to their task to the very end”.

But the airline’s case seemed thin. All indications suggested the aircraft had functioned just as it was designed. The black box recordings showed that the plane was responsive to the point of impact. The case against the pilots looked even worse when a transcript of the voice recorder was leaked. It confirmed that one of the pilots had pulled the stick back and kept it there for almost the entirety of the emergency. With its nose pointed too far upwards, it was little wonder that the Airbus had eventually lost momentum and stalled. But this analysis begs the question: even if one pilot got things badly wrong, why did his two colleagues fail to spot the problem? The transcript of increasingly panicky conversations in the cockpit suggests they did, but too late.

UK firm's 1,300 staff accidentally given marching orders

Reuters 20 April 2012


Workers at investment firm Aviva Investors got a shock on Friday when the company accidentally sent an email with leaving instructions intended for one departing employee to the entire worldwide staff of 1,300 people.
The firm's human resources department realized its mistake and recalled the offending message 25 minutes later and soon afterwards sent out another email apologizing to staff for the error, company spokesman Paul Lockstone said.

"An email which was intended for a member of staff who was leaving today was accidentally sent to all Aviva Investors staff worldwide," Lockstone said.

"People were pretty quickly aware of the fact that this was a mistake ... I don't believe any of our staff would have seen it really as anything other than the mistake that it was."

The email was a standard message sent to people leaving the company, covering things such as handing back company equipment and confidentiality rules, and did not tell recipients they were fired, Lockstone said.

Pilots admit they 'nod off' – and their hours are set to soar

The Independent Jonathan Brown 23 February 2012


The lives of air passengers could be put at risk by tired pilots falling asleep or making an error as a result of new European rules increasing their working hours, MPs were warned yesterday.


The pilots' union, Balpa, said that even under the present system, which limits the amount of time they can spend in the air after waking, nearly half of its members admitted nodding off in the cockpit.

Giving evidence to the Transport Select Committee, the union's head of safety, Dr Rob Hunter, said the real figure was likely to be much higher because of under-reporting by pilots who were often unaware they'd been asleep.

Balpa is opposing the harmonisation of rules between Britain and the rest of Europe which it said could lead to some pilots working for up to 22 hours at a stretch. Current safety laws limit this period to 16 and a half hours.

In a survey of 500 pilots Balpa found that 43 per cent had involuntarily fallen asleep while flying. Of these a third said they had woken to find their co-pilot slumbering as well. Even under the present system the union estimated that pilots could be landing when they had a one in five chance of falling asleep – meaning their reactions would be those of a pilot with a blood-alcohol level four times the current legal limit for flying. Balpa said the new rules would make the situation "much worse".
A crash involving a Colgan Air flight in New York three years ago, in which 50 people died, led to a change in US rules to minimise pilot fatigue.

After a sudden loss of cabin pressure pilots have 15 seconds to put on their oxygen masks before they lose consciousness. Even when flying on autopilot they must make routine checks and monitor radio transmissions.

Current0700 Pilot awakes
0800 Arrives at airport to begin shift – take-off and landing; post-flight checks
2400 Finishes shift; starts rest period including 10 hours of hotel availability
1000 Begin new shift

Proposed
0700 Pilot awakes
0800 Arrives at airport and begins four hours on standby
1200 Flight begins
0400 Discretionary rest period starts
0600 Shift ends – eight-hour sleep period
1400 Begins new shift

Natural Disasters Influence Mental Mistakes

Psych Central By Rick Nauert PhD on February 13, 2012 

A new study in the journal Human Factors finds that survivors of disasters may experience intellectual challenges in addition to stress and anxiety. This mental decline may cause survivors to make serious errors in their daily lives. It was published by New Zealand researchers after the Christchurch earthquake.

Studies have found that more traffic accidents and accident-related fatalities occur following human-made disasters such as the September 11, 2001, terrorist attacks. Experts believe the mishaps are due to increased cognitive impairment that can lead to higher stress levels and an increase in intrusive thoughts. 

This study was looking at human performance and required two sessions with volunteers.  The earthquake occurred between the sessions so the researchers took the opportunity to compare before and after.
Normally, participant performance would improve during the second session, but the authors found an increase in errors of omission following the earthquake.

If the participants reported being anxious following the quake, their response times sped up and they made more errors of commission, whereas those who reported depression logged slower response times.


“People would find themselves zoning out and making more errors than usual after the quake.”
Investigators believe future research is needed to explore this phenomenon further, but the scientists’’ findings may point to potentially serious complications arising from post-disaster performance in daily life and work tasks.

These findings also suggest that police, emergency responders, and others working in the aftermath of the disaster may also experience cognitive disruption, which can interfere with their ability to perform rescue-related tasks.

“Presumably people are under increased cognitive load after a major disaster,” Helton continued.
“Processing a disaster during tasks is perhaps similar to dual-tasking, like driving and having a cell phone conversation at the same time, and this can have consequences.”

Taking a stand at the office

Montreal Gazette Jill Barker, 9 February 2012

Jimmy Rogers got rid of his office furniture while recuperating from a herniated disc, which made sitting painful. First he put his laptop on top of a filing cabinet and stood up to work. Then he went for "something more ergonomic,”

Now he spends a full day working standing up. Part of a growing trend of office workers who work at a at a standing desk

There is growing amount of evidence suggesting that too much time spent in a chair isn’t good for your health.

The American Cancer Society recently released a report stating that women who spent more than six hours a day sitting had a 37-per-cent higher risk of mortality, compared to those who sat fewer than three hours a day, within the study’s 13-year time period. As for men, six hours a day spent in a chair increased the likelihood of death by 18 per cent over men who spent less than half that time seated.

Researchers believe excessive sitting causes the body to go into a type of “sleep mode,” which shuts down muscle activity and has a negative effect on the body’s metabolic functions.

Standing, on the other hand, encourages movement, which boosts muscle activity, calorie burn and, according to some health experts, alertness. Yet despite its seemingly obvious benefits, there’s little research proving that more time standing will negate the health risks associated with too much sitting.

McGill University kinesiology professor Julie Côté, a specialist in ergonomics and biomechanics, is currently gathering data on the physiological responses of incorporating more standing postures in the workplace.
Her study measures blood flow to the legs and muscle activity in the low back during occupational standing and sitting.

Finding just the right desk and adjusting it to just the right height is the easy part of the switch from sitting to standing. Finding the endurance to stand for extended periods of time is the real challenge.

“Start gradually,” Côté said. “And never stand longer than 90 minutes without changing your position. The worst thing you can do is stay static.”

Most people don’t spend the whole day on their feet, rather they alternate between sitting and standing, which is where the adjustable desk helps.

Rogers suggests getting around the expense of an adjustable desk by using a chair the height of a bar stool. This inexpensive option allows you to install a stationary platform to hold your computer, monitor and phone, while still being able to move easily from sitting to standing.

As for suggestions on how to ease the discomfort associated with long periods spent standing, Rogers recommends placing a cushioned mat under your feet, wearing footwear with good support and alternating elevating one foot on a riser.

Côté says finding out what works best for you is all part of the learning curve associated with moving from sitting to standing. And since there is no clear research suggesting that one strategy works better than another, it’s okay to experiment.

Nudge theory trials 'are working' say officials

BBC Website 8 February 2012

Nudge theory  involves making minor changes in communications such using simpler language in letters, highlighting key messages and stressing "social norms." Trials have been taking place across a number of UK government departments, and it appears that some of these are working by boosting compliance and reducing fraud, error and debt.

Eight trials have shown that "relatively minor changes to processes, forms and language can have a significant positive impact on behaviour". A local authority saved £240,000 on false council tax claims. Letters from Revenue and Customs.that emphasised "social norms" produced a 15% higher response rate than the standard letter. Including images of untaxed vehicles in demands for payment of duties had proved successful.

Examples of the ideas being tried include:

• Using handwritten fonts to personalise letters
• Asking people to complete an "honesty code" in letters
• Sending a "thank you" letter to people who have complied
• Highlighting key information in bold or "strong" colours
• Using lotteries or prize draws to encourage people to pay tax returns early
• Linking tax evasion to the impact on council services
• Naming and shaming late payers on a website

The report summarising these findings is available at The Cabinet Office"

Human Factor Named Biggest Challenge Facing Offshore Oil and Gas [SURVEY]

Article at gCaptain 23 January 2012

Survey of industry professionals released today by Oil & Gas IQ.

Found that 48.6% said that human factors and behavioral safety is the biggest challenge regarding offshore safety.  Also, nearly three-quarters of survey respondents claimed there was more pressure on offshore operators regarding Health and Safety (HSE) than there had been in previous years, no doubt fueled by recent oil spill disasters such as the Deepwater Horizon spill.

The survey noted that 10.8% of respondents named problems with technology and equipment as a worry, with a similar number saying that having the right processes in place and reacting to new legislation were their firm’s biggest challenges. The study was released ahead of the 2012 Offshore Safety Summit, taking place March 19-21 in Aberdeen

'Human error' blamed for €3.6bn mistake

RTE News Ireland 2 November 2011

Minister for Finance Michael Noonan has said the mistake in the national accounts of €3.6bn was down to "human error". He explained in the Dáil that the double count arose because the Housing Finance Agency had borrowed directly from the NTMA instead of from the open market in 2010.

The miscalculation was described as "a humiliating schoolboy error".

Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records

Pulished in draft from the National Institute of Standard and Technology September 2011

The report summarises the rationale for Usability Protocol for an Electronic Health Record (EHR) that encompasses procedures for (1) expert evaluation of an EHR user interface from a clinical perspective and a human factors best practices perspective, and (2) validation studies of EHR user interfaces with representative user groups on realistic EHR tasks.


Examples of usability issues that have been reported by health care workers are include:
• Some EHR workflows do not match clinical processes create inefficiencies,
• Poorly designed EHR screens slow down the user and sometimes endanger patients,
• Large numbers of files containing historical patient information are difficult to search, navigate, read efficiently, and identify trends over time,
• Warning and error messages are confusing and often conflicting
• Alert fatigue (both visual and audio) from too many messages leading to users ignoring potentially critical messages, and
• Frustration with what is perceived as excessive EHR user interaction (mouse clicks, cursor movements, keystrokes, etc.) during frequent tasks.

A three step process is proposed for the design and evaluation of EHR as follows:

Step One: During the design of an EHR, the development team incorporates the users, work settings and common workflow into the design. Two major goals for this step that should be documented to facilitate Steps Two and Three are: (a) a list of possible medical errors associated with the system usability, and (b) a working model of the design with the usability that pertains to potential safety risks.

Step Two: The Expert Review/Analysis of the EHR step compares the EHR’s user interface design to scientific design principles and standards, identifies possible risks for error and identifies the impact of the design of the EHR on efficiency. This review/analysis can be conducted by a combination of the vendor’s development team and/or by a dedicated team of clinical safety and usability experts. The goals of this step are: (a) to identify possible safety risks and (b) identify areas for improved efficiency.

Step Three: The Testing with Users Step examines the critical tasks identified in the previous steps with actual users. Performance is examined by recording objective data (measured times such as successful task completion, errors, corrected errors, failures to complete, etc.) and subjective data (what users identify). The goals of this step are to: (a) make sure the critical usability issues that may potentially impact safety are no longer present and (b) make sure there are no critical barriers to decrease efficiency. This is accomplished through vendor-evaluator team review meetings where vendor’s system development and evaluation teams examine and agree that the design has (a) decreased the potential for medical errors to desired levels and (b) increased overall use efficiency due to critical usability issues.

Current training programs may not prepare firefighters to combat stress

Medical Xpress 2 November 2011
Article summarises findings from a study by Michael R. Baumann, Carol L. Gohm, and Bryan L. Bonner in an article titled "Phased Training for High-Reliability Occupations: Live-Fire Exercises for Civilian Firefighters,"

The authors assessed the value of current scenario-based training programs and found they may not effectively prepare firefighters for the range of scenarios they are likely to encounter

Firefighters must make complex decisions and predictions and must perform extreme tasks at a moment's notice. Failure to keep a level head in the face of a dangerous situation may result in disastrous consequences. The most common form of training exposes firefighters to one or a very small set of live-fire scenarios designed to reduce stress and encourage calm decision-making skills. But repeated exposure to the same scenario may fail to adequately prepare firefighters for changing situations, as lessons learned in that scenario may not transfer to a different scenario. "If you learn the scenario, you can predict what will happen in that one scenario, but you can't predict what will happen in situations that look a little different," said Baumann. "If you learn general principles, then you can predict what is going to happen in a wide range of situations."

The authors suggest that trainers should increase the range of scenarios to which firefighters are exposed. Desktop-based simulators are available to supplement live-fire training with a variety of scenarios to enable trainees to learn basic principles, even though such simulators cannot replicate a live-fire environment.

The Four Phases of Design Thinking

Harvard Business Review blog by Warren Berger 29 July 2011

A good designer has the ability to bring original ideas into the world. They seem to share the same behaviours:

1. Question - Designers ask, and raise, a lot of questions including "stupid questions" that challenge the existing realities and assumptions. Asking "why" can make the questioner seem naïve while putting others on the defensive but it does require people to question and rethink basic fundamentals.

2. Care - Step out of the corporate bubble and actually immerse yourself in the daily lives of people you're trying to serve. Really observing and paying close attention to people. "Focus groups and questionnaires don't cut it."

3. Connect - Taking existing elements or ideas and mashing them together in fresh new ways. You don't necessarily have to invent from scratch but designers know that you must "think laterally" to connect ideas that might not seem to go together.

4. Commit - It's one thing to dream up original ideas. But designers quickly take those ideas beyond the realm of imagination by giving form to them. There is a risk that committing too early increases the possibility of short-term failure but "designers tend to be much more comfortable with this risk than most of us." Innovation is an iterative process and small failures are actually useful because they show the designer what works and what needs fixing.

The Best Approach to Training

Richard Catrambone's Blog from Harvard Business School 20 October 2011

"One of the ironies of being an expert is that you often lose touch with what it is like to be a novice. Part of becoming an expert is that certain aspects of problem-solving just become automatic......

Experts often are unable to articulate the many "obvious" (to them) things they do when carrying out a procedure or solving a problem." "First, the focus must be on identifying what a learner needs to know."

Task analysis is often used to assess problem solving but they often involve the expert to saying what he/she does without necessarily requiring the expert to justify the steps taken.. An approach taken by Catrambone has been to get experts to go through a problem solving exercise, getting them to talk out loud at every step. He asked them to justify every step as they went through.

"One particularly striking result of this process was how often the instructors had to stop and scratch their heads as they tried to provide a justification for their steps." The notes taken have been used to develop improved training material. "The best way to start to train a novice in any field or to develop good instructional materials is for the expert to actually do the tasks in question. There is just no substitute." But a comment on the blog does call into question the approach: "I believe your premise is flawed from a business application perspective. First there is a difference between teaching and training which you seem to use interchangeably.

The deeper issue however is when you state the fundamental premise of your article, what does the individual need to know? This is not the best question to use as the foundation for "the best approach to training." And quite frankly, because too many corporate (and I would venture a guess - too many academics) training efforts start here is why the training they design suck. The starting and end point must be "what does the individual need to do?" "The best approach to training" is to take accountability for designing learning opportunities that change behavior and ultimately impacts results In a positive way."

Power cut kills Pembroke nursing home man on ventilator

BBC News 19 October 2011

A power cut during the night killed a man with muscular dystrophy as nursing home staff were unable to connect a back-up power supply, an inquest heard. Gavin Proctor, 35, a resident at the Ashdale home in Pembroke, was on a ventilator to help with his breathing. A jury, which returned a narrative verdict, heard he probably would have lived if an emergency generator or a battery pack was connected.

The power failure happened early on 4 January 2009, cutting off the supply to his ventilator and knocking out all the lights. Senior managers at the home told the jury staff were told regularly how to switch on a back-up generator in an emergency. However the inquest heard even if the generator had been switched on, it would not have saved Mr Proctor's life because it did not provide power to his room. Staff would have had to run extension leads to him in the dark, or use back-up battery packs.

The nurse on duty that night, Helen Corcoran, said she had never connected the battery pack before, which Mr Proctor used for going outside, and was not able to see because the torch she found was not working. Mr Proctor suffered a cardiac arrest and died at the scene.

Peru air crash deaths a 'tragedy of errors' says grieving father

The Guardian 27 September 2011

The crew and four British passengers died when their Cessna plane came down in a field near the Nazca Lines markings in October 2010. An inquest at High Wycombe law courts heard that all six died instantly when the aircraft hit the ground. The verdict was misadventure Fuel could not reach the engine because a cut-off switch had not been checked. .

The pilot had been drinking, the crew argued and preparations were rushed because the booking was made late in the day and the flight had to be completed before a curfew.

The Fallacy of People Problems and How to Resolve Them

PharmaPro blog by Jamie Weiss posted 2 September 2011

Statistics in pharmaceutical manufacturing suggest that 80 percent of all reportable deviations are “people problems,” deficiencies of human performance. Despite the pervasiveness of people-caused problems the specific causes attributed are few in number: failure to follow standard operating procedures, skipped or mis-sequenced steps and improper documentation.

But do all of the problems classified as “human factors issues” really indicate a deficiency on the part of a person? Perhaps not. Even classic “people problems,” such as skipping a step in the standard operating procedure (SOP), needs to be examined. This means knowing who the person was, what they did, when it happened etc.. But this requires people to report issues and this can have consequences. Even if they do not fear reprimand, they are likely to be given ownership of the problem and expected to come up with a solution. However, if they keep quiet the chances are production will continue, no one can know and the person does not get landed with the extra work.

When we do look at problems we will sometimes find that people are doing jobs that they are not qualified to do. The test question is: “Could this person do this task if their job or their life, depended on it?” If the answer is yes, then there is no deficiency in the performer. However, for each of us some tasks are simply out of our capabilities and no amount of training would improve our performance.

In this case, retraining is not the option, replacing is. People cannot be expected to do what is impossible for them to learn. Next, consider the response. This asks, “How clear is the desired behaviour that we want from the performer?” “Are we asking for a quantum leap in performance or just a slight tweak?” The response often exposes problems caused by changing the SOP. Perhaps the standards are unclear, the changes too drastic or the expectations unreasonable. If it cannot be changed, training will be required on a constant basis.

The performance system model leaves room for retraining as a corrective action to a people problem, but only when the deficiency is in the performer and even then, only some of the time. Some people are simply not trainable, some skills are not transferable and the optimal solution is rarely “more of the same.” Instead, most corrective actions for performance problems involve addressing the system itself. In short, the solution lies with management to communicate clearly that quality in all its aspects is the priority. This is not done with words and slogans but with rewards, measures ,metrics and behavior. And finally, the solution lies with addressing the common people problem with as much rigor and analytical precision as the most challenging mechanical or biochemical problem.

Tests show fastest way to board passenger planes

BBC Website 31 August 2011
The most common way of boarding passenger planes is among the least efficient, tests have shown.

Boarding those in window seats first followed by middle and aisle seats results in a 40% gain in efficiency. However, an approach called the Steffen method, alternating rows in the window-middle-aisle strategy, nearly doubles boarding speed. The approach is named after Jason Steffen, an astrophysicist at Fermi National Laboratory in Illinois, US. Dr Steffen first considered the thorny problem of plane boarding in 2008, when he found himself in a long boarding queue. He carried out a number of computer simulations to determine a better method than the typical "rear of the plane forwards" approach, publishing the results in the Journal of Air Transport Management.

The approach avoids a situation in which passengers are struggling to use the same physical space at the same time.

Only now, though, has the idea been put to the test. Jon Hotchkiss, a television producer making a show called This v That, began to consider the same problem of boarding efficiency and came across Dr Steffen's work. Mr Hotchkiss contacted Dr Steffen, offering to test the idea using a mock-up of a 757 aeroplane in Hollywood and 72 luggage-toting volunteers.

The block approach fared worst, with the strict back-to-front approach not much better. Interestingly, a completely random boarding - as practised by several low-cost airlines that have unallocated seating - fared much better, presumably because it randomly avoids space conflicts.

Birmingham hospital error paralysed Newport teenager

BBC Website 31 August 2011

A teenager was left paralysed from the waist down after a spinal anaesthetic was wrongly left in place for too long, a hospital has admitted.

A pain-killing epidural infusion was not removed for two days after gallstone surgery, permanently damaging her spinal cord. A day after the surgery the patient complained of leg numbness. The following day an MRI scan revealed that the anaesthetic had entered the spinal cord and damaged the membranes, paralysing her from the waist down.

The patient's solicitor called for lessons to be learned. He hoped the staff responsible had already been retrained so that similar "tragedies" could be avoided.

Key Performance Indicators (KPI) for Health and Safety

Taken from RapidBI website, published November 2007

* Cost of solved safety non-conformances for the month
* Employee perception of management commitment
* Health and safety prevention costs within the month
* Lost time (in hours) due to accidents (including fatalities) per e.g. 100,000 hours worked
* Lost time (in hours) due to non-fatal accidents per e.g. 100,000 hours worked
* Number of fatalities per e.g. 100,000 hours worked
* Number of non-conformance with legal or internal standards in safety inspections
* Number of reportable accidents per e.g. 100,000 hours worked (including fatalities)
* Number of reportable non-fatal accidents per e.g. 100,000 hours worked
* Number of safety inspections for the month
* Number of solved safety non-conformances for the month
* Percentage of attendance at occupational health and safety (OHS) committee meetings
* Percentage of corrective actions closed out within specified time-frame
* Percentage of fatal accidents relative to all accidents (non-fatal and fatal) per e.g. 100,000 hours worked
* Percentage of health and safety representatives (HSR) positions filled.
* Percentage of issues raised by H&S Reps actioned
* Percentage of occupational health and safety (OHS) committee recommendations implemented
* Percentage of products/services assessed for health & safety impacts
* Percentage of significant products and services categories subject to procedures in which health and safety impacts of products and services are assessed for improvement
* Percentage of staff with adequate occupational health and safety (OHS) training
* Total of hours in safety and health training in the month

Why should businesses invest in ergonomics?

Central Wisconsin Business 22 August 2011 - the Raikowski column

Statistics from the article:

* The Occupational Health and Safety Administration indicates that MSDs account for one-third of the 1.7 million occupational injuries and illnesses in the U.S. every year and represents its largest work-related injury and illness issue
* Including workers' compensation costs and factors such as restricted duty time, reduced worker productivity, and diminished work product and quality, OSHA estimates that MSDs annually cost the U.S. workforce $54 billion.
* The National Institute for Occupational Safety and Health reviewed hundreds of scientific studies. The estimated cost savings associated with averting a single musculoskeletal disorder-related workers' compensation claim is a whopping $22,546. This total includes the value of lost production, medical costs, insurance administrative costs, and indirect costs to employers.

The FOH cites examples of employers reporting positive returns on their ergonomics program investments including:

* Between 1992 and 1996, the New York Times reported that it reduced its workers' compensation claims by 84 percent, reduced lost work time by 75 percent and decreased lost workdays by 91 percent as a result of its ergonomics program.
* Intracorp reported that a public service company with 330 employees realized a return of $7.35 for every $1 invested in its ergonomics program.
* Northwest Aerospace Company realized a 10- to 15-percent increase in productivity (a benefit of greater than $200,000) following implementation of an ergonomics program.
* Jerome Foods Inc. reported saving $3 for every $1 invested in an ergonomics program.

Air traffic overhaul hinges on 'human factor'

CNN Website on 10 March 2011 by Thom Patterson


"Even amid the amazing technological achievements and wondrous capabilities of the 21st century, the most critical connection in the airline industry remains the same as it was at the birth of aviation: the human touch."

According to the article the role of the human factors engineer "is to ensure that information is being presented at the right time to a pilot and in the right form so that the human cognitive capabilities are not simply overwhelmed." In particular "What should you put in front of a pilot and in what form should that information be?"

Referring to new air traffic control technology called Automatic Dependent Surveillance-Broadcast (ADS-B) that allows pilots to see a real-time cockpit display that shows the locations of their aircraft and any surrounding aircraft. The challenge is to keep the human in the loop. The plan calls for pilots and air traffic controllers to share more information -- allowing them to better collaborate in avoiding mistakes. They have proven that the human remains in charge and pulls the whole system together, but it requires a rethink in the way information is processed and used.

Another system being developed is a very sophisticated kind of "text message." The aim is to cut confusion caused by misunderstood voice radio transmissions and to improve efficiency by "texting" routine information. Obviously, it is important to make sure this doesn't cause distraction. A lot of messages will be pre-programmed and sent by pilots with the touch of a single button.

$10 piece of equipment could’ve saved $128K in compensation benefits

HR Morning 11 August 2011 by Christian Schappel

The brief article illustrates the potential financial benefits of applying ergonomics. I would add that the employee in question also suffered significant physical harm.

"Angela Grott, a finance clerk at the Menard Correctional Center in Illinois had requested a headset for her phone. The reason: She often had to type while speaking on the phone. Her request was denied, and she carried on with her work — holding her phone receiver in the crook of her neck for hours at a time while typing."

Grott started to suffer from severe neck, shoulder and arm pain and headaches. She underwent surgery in an attempt to relieve her pain. The medical bills came to $128,424 for medical bills and Grott received $7,304 for 12 weeks of temporary disability pay. She may even be able to claim a permanent partial disability claim, which be more than $100,000.

And a headset would have cost about $10.

Smart Keys: Not So Smart for Motorcycles?

Wall Street Journal 30 April 2011 by Jonathan Welsh
"Imagine beginning a ride only to find that you cannot steer.That’s what could happen with certain Ducati motorcycles because of a potential problem with their electronic steering locks, which are part of their anti-theft systems."

The bikes affected are the latest models that come with an electronic ‘smart key” that allows the rider when carrying the key (i.e. in their pocket) to get on the bike, start it and ride away without having to actually handle the key. However, during testing it was found that “under very specific conditions” the electronic steering lock could fail to disengage automatically during the process of turning on the bike’s ignition on and starting the engine. If this happens a rider could potentially start the bike and begin riding while the steering is still locked – an obvious hazard!.

Ducati are recalling the bikes.

CF-18 Hornet crash focuses on human factors

Bonnyville Nouvelle 28 July 2011

Preliminary report into a crash of a CF-18 Hornet crash has found the aircraft was operating normally and focuses on human factors. It was undergoing two-aircraft formation night vision goggles training mission, The pilot ejected and was unharmed.

The report states that as the pilot selected the landing gear, a sudden rush of falling snow, illuminated by his landing light, disoriented him. It reflected through his head up display and washed out the instrument references used to control the aircraft. He thought he was going to crash, could not tell if his avoidance actions were working so ejected.

The pilot was inexperienced at night flying and had not undergone a night vision goggles mission in 224 days. Direction has been given for night vision goggles training to now start “only after a pilot has increased flying experience.”

The investigation continues.

Poland finds Russia at fault for presidential jet crash

BBC Website 28 July 2011

Human factors in motor racing

Article in the Washington Post on 13 July 2011

An interesting view of human factors vs technology in Formula 1 and Nascar racing.

It suggests the human factor is being taken out of Formula 1 because so much data is streamed back to technicians in the pits. However, Nascar does not allow this in order to "highlight the human element in racing" and "to make the events more interesting to the consumer."

The implication is that technology means human factors are less relevant in Formula 1 than Nascar. I can see what they are getting at, but not sure I agree with their conclusion. I would suggest that human factors in Nascar is limited to one person (the driver) whereas in Formula 1 it is far more of a team effort, which means different and more complex human factors are involved.

Apparently Williams F1 has worked with AT&T to increase the speed at which data gets transmitted, which is now 25 times faster than a standard broadband setup. "The technology has helped cut down on the number of support staff traveling with F1 teams, as well as the cost."

Spelling mistakes 'cost millions' in lost online sales

BBC Website by Sean Coughlan 14 July 2011

Online entrepreneur Charles Duncombe says that poor spelling is costing the UK millions of pounds in lost revenue and that a single spelling mistake can cut online sales in half.

He says he measured the revenue per visitor to the tightsplease.co.uk website and found that the revenue was twice as high after an error was corrected.

"If you project this across the whole of internet retail then millions of pounds worth of business is probably being lost each week due to simple spelling mistakes," says Mr Duncombe, director of the Just Say Please group.

Spelling is important to the credibility of a website, he says. When there are underlying concerns about fraud and safety, then getting the basics right is essential.

When a consumer might be wary of spam or phishing efforts, a misspelt word could be a killer issue”

William Dutton Oxford Internet Institute

"You get about six seconds to capture the attention on a website."

Spelling and grammar are not so important on informal parts of the internet, such as Facebook. However, home pages or commercial offerings that are not among friends and mistakes raise concerns over trust and credibility.

Figures from the Office for National Statistics published last month showed internet sales in the UK running at £527m per week.

Ineos fined over Grangemouth refinery oil spill

BBC Website 5 July 2011

The owners of Grangemouth refinery have been fined £100,000 over a spill of highly flammable oil. In the incident, a pipeline became pressurised and sprayed crude oil across a nearby pumphouse and pipelines containing other dangerous liquids.

An investigation found the company had been aware of the risk and the need to install controls.

But it also found Ineos chose to rely on staff to reduce pressure by manually draining oil from the pipeline, and storing it in a skip that was not designed for storing oil.

Further information from SHP magazine 8 July 2011

An incident occurred in May 2007 that resulted in more than 100 litres of crude oil being released on to the floor of a pumphouse. The HSE advised the company to install a hydrostatic release valve, which would divert some of the oil to a storage container once it reached a certain pressure.

However, INEOS failed to act on this suggestion, and it continued to be common practice to allow pressure to build up in the pipes until a warning alarm sounded in the control room when the pressure reached 19 bar. The controller would then instruct a field operative to drain oil from the pipeline to release the pressure.

On 7 May 2008, following a shift change in the control room, staff became confused by the method of work. When the pressure alarm sounded, the controller was unaware that the method of work required him to arrange for the pressure to be released manually. Four hours after the alarm sounded a gasket on the pipeline ruptured and oil began spraying across a nearby pumphouse and adjacent pipelines containing other dangerous substances. Nobody was injured during the leak but it posed a serious risk of causing a fire, or explosion.


According to HSE "Despite having recognised the need for engineered thermal relief on their crude-oil pipelines, following an incident at their refinery a year earlier, INEOS chose instead to rely on a manual system for managing thermal expansion. This system of work actually increased the risk of fire and explosion and ultimately failed to prevent the pipeline from becoming over-pressurised. The risk of over-pressurising pipelines and storage vessels, as a result of thermal expansion, are well-understood, as are the required control measures."

Society has to learn to abhor distracted driving.

NTSB investigation findings 7 July 2011 By Deborah Hersman

The NTSB has determined that a 2010 accident in the Delaware River involving a barge towed by the tugboat Caribbean Sea and killed two Hungarian tourists was caused by the tugboat mate’s failure to maintain a proper lookout due to his repeated use of a cellphone and a laptop computer.

"What’s scary is that no one on board the tugboat objected to the mate’s blatant violation of company policy in making 13 calls and receiving five during the 80 minutes preceding the accident. None of the crew members reported his repeated use of his personal cellphone."

The NTSB has found such use of personal electronic devices to be widespread across all modes of transportation. They included:

* October 2009 - Two airline pilots were out of radio communication with air traffic control for more than an hour because they were distracted by their personal laptops resulting in them overflying their destination by more than 100 miles.
* September 2008 - A commuter train running a red signal in suburban Los Angeles in September 2008 killing 25 and injuring dozens. The engineer, had sent and received 250 text messages during the three days leading up to the accident.
* The driver of a tractor-trailer made 97 calls and received 26 during the 24 hours preceding an accident. And in the half-hour prior to the crash, the driver spent 14 minutes — nearly half his time — on the phone. Ten people died that day after the truck crossed a median.

"Despite company policies, public education campaigns, and, in some places, laws designed to minimize driver distraction, many people continue to engage in unsafe and unacceptable behavior, thinking." "We have to change public tolerance for such distractions and elevate society’s disapproval of the use of personal electronic devices while operating a vehicle."

In 1967, the NTSB investigated the midair collision of a Piedmont Airlines Boeing 727 and a private twin-engine aircraft, which killed all 82 people aboard both planes. The original investigation showed that shortly after takeoff, crew members aboard the 727 discussed a fire in a cockpit ashtray and joked among themselves as they put it out. At the time, cigarette smoking and burning cockpit ashtrays were so common that the NTSB did not even mention the “detail” in the final report.

Today, of course, we can’t imagine smoking in an airplane, much less the cockpit, without anyone’s taking notice. So what has changed since 1967? Cultural and societal expectations. Smoking on airplanes is not only not allowed; it’s not even remotely considered.

Congress first banned smoking on planes in 1988. That law, which applied to flights of two hours or less, took two decades of pressure from health and consumer organizations, as well as repeated warnings about the dangers of secondhand smoke by the National Academy of Sciences and the surgeon general. Today, more than two decades after that initial legislation, society’s disapproval of smoking on airplanes — and in many other public places — is pervasive.

We have to reach the point where texting, phoning, and engaging in other distracting behaviors while operating a vessel, train, or motor vehicle are just as unacceptable as smoking on an airplane. How many more lives will we lose before we correct our tacit and deadly acceptance of distraction?

Electoral Commission sorry for out-of-date AMs advice

BBC news 5 July 2011

The elections watchdog has apologised after a new Welsh assembly member fell victim to out-of-date guidance for candidates and was disqualified.

An independent investigation found Liberal Democrat Aled Roberts did everything reasonably expected.

The relevant guidance was changed before the election, but only the English language document was updated. The AM only referred to the Welsh language version, which was out of date.

Why? How? Prove it

Just googling around looking at tips to improve my presentation skills. Came across www.whyhowproveit.co.uk

The suggestion is a four stage approach.

1. Key Message - Leave your audience in absolutely no doubt what you came to tell them in a succinct way

2. Explain to your audience "why should I do that?"

3. Explain how they can do it (this is examples, and actually the least important part of the presentation)

4. Use personal examples, case studies and statistics to prove you are talking sense.

WHPI - seems like a good way of focussing the mind when preparing.

Homicide verdict for CEO after health and safety cuts

International Law Office website 27 June 2011

An Italian court has sentenced the chief executive officer (CEO) of a company to 16 years' imprisonment for an offence related to the deaths of seven employees. This is the first such case in Italy in which a CEO has been found guilty of homicide, rather than manslaughter. The court found the company liable under Law 231/2001 and ordered it to pay a fine of €1 million. In addition, it confiscated a further €800,000 and banned the company from receiving public funds for six months.

The case concerned an incident at a factory operated by the company ThyssenKrupp. On the night of December 6 2007 a fire broke out on the production line and could not be extinguished because of a lack of fire extinguishers and the absence of other safety features. Seven workers were killed.

At trial, the prosecutor claimed that ThyssenKrupp's senior management had decided not to invest in health and safety at the factory, since they had decided to relocate production to another site. Therefore, the management knew that it was accepting a risk that a serious accident could occur and was aware of the potential legal consequences of the decision.

The prosecutor argued that if a senior manager decides to reduce investment in health and safety, he or she is aware that there is a high probability of a serious accident. If an accident occurs and someone dies as a result, the manager in question must be deemed guilty of homicide. Although the grounds have not yet been published, the decision indicates that the court appears to have agreed with this argument.

FDA's new guidance tackles device usability, safety

http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM259760.pdf

Osprey pilots were blameless victims, widow says

Article at newsobserver.com by Marth Quillin and Bob Cox on 19 June 2011

On 8 April 2000 a newly developed V-22 Osprey crashed during a 'mock exercise,' killing those on board. This is an aircraft with tilting rotors, which can land and take off like a helicopter but fly more like a fixed wing aircraft. Following the crash the Marine Corps investigation concluded that "This mishap appears not to be the result of any design, material or maintenance factor specific to tilt-rotors. Its primary cause, that of a MV-22 entering a Vortex Ring State (Power Settling) and/or blade stall condition, is not peculiar to tilt rotors. The contributing factors to the mishap, a steep approach with a high rate of descent and slow airspeed, poor aircrew coordination and diminished situational awareness, are also not particular to tilt rotors." And in announcing the findings of the report, the Marine Corps said in a press release that it "confirms that a combination of 'human factors' caused the April 8 crash of an MV-22 Osprey tilt-rotor aircraft that killed 19 Marines near Marana, Ariz."

However, the families of those who died feel the language used by the Marine Corps was intended to put most of the blame for the accident on the pilots. They feel that the tragic accident "was the direct result of the crewmen being tasked with an insurmountable, premature mission in a dangerously immature aircraft and not "human factors." They feel the fact that another fatal accident occurred later that year and the aircraft had to be grounded for 18 months for further testing and development back up their opinion.

These were experienced pilots who believed in the Osprey project. In the exercise, pilots were to rescue a group of "hostages" and bring them back to base. The task introduced several variables: night flight, a heavy load of Marines and their gear, and a different environment from the coastal one where the pilots had done most of their training. But as the mission unfolded that night in Arizona, not everything went according to plan. A computer malfunctioned in the lead plane, the pilots decided to continue with the exercise and try to reset the computer after landing. As they approached the landing zone, the planes were too high and were hit with an unexpected tailwind. They began a steep descent aiming for the runway - a piece of cake for an experienced military helicopter pilot. The pilots, doing as they were trained, were following the lead plane, but got out of position and tried to manoeuvre back into line. They had little forward airspeed, and the rotors began to stall, losing the lift that holds the aircraft in vertical flight. Just 200 feet above the ground, in a span of about three seconds, the aircraft rolled uncontrollably to the right and turned upside down before slamming into the ground.

The pilots had gotten into an aerodynamic condition called "vortex ring state" or "blade stall." The lead plane may have had the same problem, but it simply landed very hard, crushing the landing gear and skidding several hundred feet and off the runway.

The family feel there were so many factors in the accident that the pilots should exonerated so that the dishonour can be removed.

I think the comments left on the article make some great points:

* "This aircraft was called the widow maker. This Crash was not an isolated incident."

* "Given the many lessons learned from the tragedy that claimed the lives of the aircrew and the passengers, it seems reasonable to assume that had they not been the ones to experience this mishap, another crew and aircraft would have at another time. Clearly none of the pilots involved in the mishap understood the hazards they faced that evening, or both lead and trail aircraft would certainly have gone around for another pass."

* "If Boeing felt compelled to add warning devices to the cockpit to alert pilots, it sounds that the greatest cause of the crash may well have been the initial design. I hope that the powers that be might eventually reconsider."

Pilot's bereavement 'crash factor'

Belfast Telegraph 9 June 2011

A helicopter crash involving a police air crew assisting at the scene of an earlier accident may have happened because the pilot was coping with a recent family bereavement, a report has said. The helicopter was destroyed but the occupants suffered only minor injuries.

The pilot, who had completed all the helicopter and role training required by the operator, arrived in Northern Ireland from England two days before the accident, for the start of a five-day period of duty.

"Immediately beforehand, he had suffered a family bereavement. He did not report this to his company and considered on the day that he was fit for flying duty. However, when the pilot subsequently informed the AAIB of the fact, he thought it possible that it may have been a contributory factor in the accident."

The report says that the pilot lost control of the helicopter, which was engaged on a task for the Police Service of Northern Ireland, while manoeuvring at low speed to approach a hilltop landing site in quite strong wind conditions. It descended rapidly before striking the ground short of the point of intended landing and passing through a substantial stone wall.

"The investigation determined that an error of judgment or perception led the pilot to attempt a downwind approach. A combination of human factors was thought to have contributed to the accident," the report said.

The report quoted experts who said the death of a close family member has been found to lead to higher levels of stress than any other experience, with the exception of the death of a spouse or partner, and that such stress will likely to cause loss of concentration and performance. The task to be carried out on the day of the accident, although demanding, was within the capabilities of the pilot.

"However, although the effects on an individual of a recent family bereavement cannot be measured, it is considered that this was probably the most significant contributory factor in the cause of the accident," the report said.

Book priced at $23,698,655.93 on Amazon

A post on Michael Eisen's blog about genomes on 22 April 2011.

An unusual but great example of the potential pitfalls of automation.

Michael wanted to buy a book by Peter Lawrence called The Making of a Fly. He went onto Amazon. Although it was out of print 17 copies were listed for sale: 15 used from $35.54, and 2 new from $1,730,045.91 (+$3.99 shipping).

Michael knew the price of over a million dollars had to be wrong, but he was quite sure it was from legitimate sellers. However, he was even more surprised when the next time he looked the price was nearly $2.8 million. The price peaked on 18 April 2011 at $23,698,655.93 (plus $3.99 shipping).

The explanation is as follows (taken from The Risks Digest)

* Seller A didn't really have the book, but planned to buy it from
Seller B if someone placed an order. They had a better feedback
record than B, so someone might buy it from A even at a higher
price, and had programmed their price to be 27.0589% higher than A's,
so they'd make a profit.

* Seller B, meanwhile, was trying to ensure they just barely had the
lowest price, and had programmed their price to be 0.17% lower than
their competition.

* Both prices were updated automatically once a day—thus rising
exponentially until somebody noticed.

Make Them Uncomfortable (Avoiding Complacency)

Article from Aviation Week by Heather Baldwin on 11 May 2011

Complacency occurs when people become comfortable in their jobs and begin taking shortcuts, such as not using checklists or using an out-of-date tool rather than making the trek to get a serviceable replacement. It spreads because see someone taking a short cut and think they can get away with it.

Complacency is most likely to occur in job that require repetition. Maintenance technicians are particularly vulnerable because they are often performing similar tasks and end up working in automatic. This narrows their focus and leads to a loss of situational awareness. It is a classic example of where lots of training and experiences leads to problems.

According to Dr. Terry Tolleson of Blue Tuna Training and Documentation "It’s not about skill level; it’s about mental attentiveness." When you’ve done something again and again, "There is a tendency to see what you expect to see." This can lead to very serious errors.

Complacency is one of the harder problems to identify because it is intangible. But there can be warning signs including people not following their own manuals, not completing documentation as it should be and shelf-life sensitive items not being managed in a shop.

Technician workload can have a big influence. Mental underloading and mental overloading can both lead to complacency. Keeping people mentally stimulated but not overloaded is important. Also, creating professional development plans that continually challenge people with new responsibilities and new skill development opportunities. In other words, getting people out of their comfort zone.

Talking about complacency can help.