By Sarah Junek, Associate Editor
Human performance is an outcome of what someone does, which is influenced by not just one human factor but many. An integration of the factors of human error – plant, process and people – will determine a particular outcome. Equipment might have a good/bad design feature, a procedure might not be explained or hidden in a manual that is too thick, and fatigue or organizational culture might influence the final result. Every situation and job site is different, so it’s important to look at how human factors can be integrated and determine how they influence each other in a particular decision, Sandra Adkins, Global Wells Organization Safety Advisor for Human Performance at BP, said at the 2019 IADC HSE&T Conference on 6 February in Houston.
While 80% of incidents that occur are due to human error, identifying deeper details around the incident can point to the root cause of the error. Ms Adkins noted that 70% of the time, the root cause lies not with the individual but in system weakness.
Getting to system weakness around an incident relies primarily on leadership and culture. “It matters how leaders respond when things go wrong,” Ms Adkins said. Leaders who get angry when they receive a near-miss report will drive reporting down. However, if a leader demonstrates that he or she really wants to understand what is going on behind incidents that occur, people will report them. When a leader seeks what is to blame and not whom, system weakness and its role in performance can be identified. Although this may take more time, it is more likely to target the integrated causes of an incident rather than the surface-level “blame and train” model of analysis, Ms Adkins said.
Let’s take, for example, an incident where someone using a new pipe-cutting machine traps and injures their hand while reaching in to retrieve the pipe. In lower-level analysis, the individual is blamed for reaching into the machine while it is on and is disciplined. At a higher-level analysis integrating all factors, the procurement procedure is amended because the individual received training on a machine with a safety interlock. However, because the machine was needed quickly, the machine that was purchased did not have a safety interlock.
Part of what human factors integration does is help leadership think about the context first and the individual second. Deeper layers behind the behavior of the person drive the outcome. Optimizing human performance issues means asking questions such as: Did the individual have the right tools and proper access? Were things properly labeled? Deeper still are the system weakness behind the behavior, such as staffing levels, equipment procurement or training, which often leads to deeper organizational issues that might be more complicated and uncomfortable to address, Ms Adkins said. “Leaders need to be humble enough and accountable enough to say thank you for the opportunity to learn and do that,” she added.
Anticipate Mistakes: Task Improvement
Work can also be designed so that mistakes can be anticipated, Ms Adkins noted. “We want to get away from the human that’s at the sharp end of the stick and understand what’s further back in the system that we can change to support them.”
In a bowtie analysis, breaking barriers down into critical tasks and critical equipment allows someone to look at the real-world process going on around key events. She discussed a tool the Energy Institute, a nonprofit professional association that supports and produces cutting-edge research, plans to release that is an adaptation of BP’s Human Factors Investigation Toolkit. This tool will help guide HSE professionals to get to specific behavior that may not be easy to understand. The toolkit helps to classify errors and helps interviewers identify the rich context involved in various situations during the investigation process.
Another tool that will be made available through the Energy Institute is the Task Improvement Process (TIP). Developed by BP to integrate human factors, TIP is a simplified safety-critical task analysis tool to help operations personnel identify the differences between “actual work” vs “imagined work.” In the TIP analysis, individuals who conduct the work talk about points in the task that are difficult or more troublesome and where a mistake is most likely to occur.
From there, “you can see how there is often a disconnect between how people imagine work is going to be executed in the office and how it really happens,” Ms Adkins said. When these two are addressed side by side, errors and performance-shaping factors are more easily seen. DC