The Promotion of Human Factors in The Onshore

Health & Safety Executive
HSE
The promotion of human factors in the onshore and offshore hazardous industries
Prepared by Greenstreet Berman Ltd for the Health and Safety Executive 2003
RESEARCH REPORT 149
Health & Safety Executive
HSE
Michael Wright, Mark Bendig, Carol Hopkins, Bill Gall Greenstreet Berman Ltd First Base Gillette Way Reading Berkshire RG2 0BP Jacki Holmes, Linda Landles Woodholmes ksa Ltd 15 Lansdowne Terrace Newcastle Upon Tyne NE3 1HN
The HSE, in recognition of the role of human error in major accidents, aims to promote the application of Human Factors in the onshore and offshore chemical, oil and gas hazardous industries. This study explored duty holders awareness and attitudes towards Human Factors and how best to promote integration of human factors into major accident prevention. Duty Holders appear to be a willing audience but lack a consistent understanding of Human Factors, often relying on intuitive presumptions of what is meant by Human Factors. The lessons learnt from other examples of shifts in safety management thinking have been combined with survey respondents suggestions, to identify methods for increasing and maintaining duty holders awareness, understanding and motivation to apply Human Factors. This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and donot necessarily reflect HSE policy.
HSE BOOKS
Crown copyright 2003 First published 2003 ISBN 0 7176 2739 X All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner. Applications for reproduction should be made in writing to: Licensing Division, Her Majesty's Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ or by e-mail to hmsolicensing@cabinet-office.x.gsi.gov.uk
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CONTENTS
INTRODUCTION .................................................................................................... 1
1.1 1.2 1.2.1 1.2.2 1.3 1.3.1 1.3.2 1.4 BACKGROUND ............................................................................................................................1 HIDS CURRENT HUMAN FACTORS PROMOTIONAL STRATEGY ....................................................1 Aims ......................................................................................................................................1 Tactics ..................................................................................................................................2
OTHER HUMAN FACTORS PROMOTIONAL EXAMPLES ...................................................................5
Overview...............................................................................................................................5 Discussion...........................................................................................................................11
SCOPE OF THIS WORK ................................................................................................................12
EXPLORATORY DISCUSSIONS......................................................................... 13
2.1 2.2 2.3 2.3.1 2.3.2 2.3.3
INTRODUCTION .........................................................................................................................13 EXPLORATORY DISCUSSION AND PILOT METHOD .....................................................................13
FACE TO FACE SEMI-STRUCTURED SESSIONS ............................................................................15 Findings regarding topic guide design...............................................................................15 Findings regarding promotion of human factors................................................................16 Conclusions from face to face sessions...............................................................................20
MAIN TELEPHONE SURVEY .............................................................................. 21

3.1 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 3.2.7 3.2.8 3.2.9 3.2.10 3.2.11 3.2.12
INTRODUCTION .........................................................................................................................21
SUMMARY OF KEY FINDINGS ...................................................................................................21 Overview of respondents ....................................................................................................21 Ease of getting resources....................................................................................................25 Main sources of information for major accident prevention advice and guidance ............25 Understanding and application of human factors ..............................................................27 Correlation of understanding and application of human factors .......................................31 How do respondents react to incidents?.............................................................................32 What companies lead the way in preventing human error? ...............................................34 Heard of term human factors..............................................................................................35 Attitude towards human factors..........................................................................................36 Correlations between attitude to and understanding of human factors. ........................38 What would prompt more attention to human factors?..................................................44 What stops companies from considering human factors?..............................................44
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3.2.13 3.2.14 3.2.15 3.2.16 3.2.17 3.2.18 3.2.19 3.3 3.4
Roles and responsibilities ..............................................................................................47 Have you received training or information on human factors?.....................................49 What format would you like advice in?..........................................................................52 What should the HSE do to encourage companies to apply human factors?.................52 When should advice be given? .......................................................................................52 Why is the concept of SMS better established? ..............................................................55 Other suggestions by respondents..................................................................................55
MAIN IMPLICATIONS ................................................................................................................57 SURVEY-BASED RECOMMENDATIONS .......................................................................................57
LESSONS LEARNT FROM OTHER PARADIGM SHIFTS.................................. 59

4.1 4.2 4.3 4.4 4.4.1 4.4.2 4.4.3 4.5 INTRODUCTION ........................................................................................................................59 KEY FINDINGS ..........................................................................................................................60 IMPLICATIONS FOR THE PROMOTION OF HUMAN FACTORS ........................................................62 CASE STUDIES ..........................................................................................................................63 Safety Management Systems ...............................................................................................63 Crew Resource Management..............................................................................................66 QRA in Safety Cases ...........................................................................................................68 CASE STUDY CONCLUSIONS ......................................................................................................71
CONCLUSIONS ................................................................................................... 73
APPENDIX A: SEMI-STRUCTURED TOPIC GUIDE APPENDIX B: FINAL TELEPHONE QUESTIONNAIRE APPENDIX C: SURVEY DATA TABLES
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Executive Summary
The HSE, in recognition of the role of human error in major accidents, aims to promote the application of Human Factors in the hazardous industries. This study explored duty holders awareness and attitudes towards Human Factors and how best to promote a higher uptake of Human Factors. The lessons learnt from other examples of shifts in safety management thinking have been combined with the principles of marketing, and survey respondents suggestions, to identify methods for increasing and maintaining duty holders awareness, understanding and motivation to apply Human Factors. We have used the term Human Factors in this report in a slightly restricted sense, as short hand for the process of assessing human error, and identifying and implementing measures to prevent error and enhance performance, ranging from matters such as the ergonomics of equipment through training and assessment to safety culture. Survey findings A series of semi-structured exploratory discussions with persons and a telephone survey of 141 persons were completed, covering both the onshore hazardous installations (as covered by COMAH) and offshore oil and gas platform operators, drillers and support services. The findings from the discussions and the telephone survey are consistent. The HSE is regarded to be a credible source of advice The HSE is the main source of information on major accident prevention, followed by trade associations. Respondents use HSE Books and the HSE website as sources in particular. However, there was little apparent awareness of HSG48. Other key sources include training from consultants, NEBOSH and university courses and attendance at seminars / conferences. Human Factors is associated with the HSE and major accident prevention Human Factors is associated with the HSE and the prevention of accidents. In particular, many respondents cite the HSE as the source from which they have heard of Human Factors, along side other safety sources such as NEBOSH courses. Whilst Human Factors is thought to offer incidental commercial benefits, it is primarily conceived of as a part of accident prevention. Indeed, nearly all respondents agree that Human Factors is an essential part of major accident prevention. The audience is receptive to the concept of Human Factors Survey respondents tend to agree that Human Factors is a useful concept and few if any respondents could suggest an alternative phrase that captures this topic. It is regarded as a worthwhile investment and is not thought to be a barrier to getting the job done.
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Few people have a clear or comprehensive understanding of what is meant by Human Factors. When asked what is meant by Human Factors respondents tend either to offer an intuitive this is what Id imagine it means response or to equate it to a small number of issues they have had exposure to, such as behavioural safety. A minority of respondents spontaneously offer a more comprehensive view of Human Factors. In addition, a small minority is certain that they have heard of the term Human Factors and our assessment of the extent to which they address human factors or understand it is mixed. Many respondents fail spontaneously to mention human error as a cause of accidents, and display a minimal understanding of why people make errors. Human Factors is though to be difficult to grasp and ill-defined Whilst respondents accept the notion of Human Factors, it is also thought to be a difficult subject to grasp, with many respondents seeing it as fuzzy and ill-defined. The perceived reasons for this fuzziness, reasons that are believed to be inherent aspects of Human Factors, are illustrated below:
Its difficult to have one term to give it sufficient focus. Different steps are needed to address different issues. An all-encompassing term like human factors doesnt allow you to understand the detail. It needs to be broken down into identifiable small bites. Companies deal with human factors issues without referring to it as human factors. Its a fairly new topic in its own right but some aspects have always been there. For example, weve always been training its just not called human factors. Its not deliberately managed as human factors. Im aware that we do a bit of this and that but its not coherent.
Human Factors is driven by major accidents and the HSE The primary drivers for firms addressing human performance issues under the umbrella of Human Factors is the wish to avoid major accidents and to satisfy HSE expectations. Within this comes the wish to follow good practice. Accordingly many respondents cite the illustration of good practice by exemplar firms, and the provision of clear advice from the HSE as important promotional tactics. Indeed, when asked which firms lead the way in the prevention of human error, well known leading examples of firms that are perceived to have a good safety record, evidence of safe behaviour and good safety culture are cited, such as Du Pont, BP, Shell and ICI. Human Factors is inhibited by lack of understanding and cost. Respondents indicate that the application of Human Factors is held back by lack of understanding of the area, failure to recognise Human Factors issues and concerns about the cost of interventions.
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A correlation of respondents understanding of human factors with their attention to human factors in responding to incidents shows a low but positive link between their level of understanding and management of human factors. Why is the concept of safety management systems better established? When asked why the concept of safety management systems is better established, respondents (few of whom challenged the assumption within this question) say that this is because SMS is a system that is easier to grasp. Respondents ask for more of the same from the HSE On the whole respondents are positive about the HSE work in the field of Human Factors and suggest the HSE simply does more to raise awareness, provide practical guidance and interactive inspection. A very clear preference is expressed for website-based advice and information along with leaflets, although seminars are also cited. Lessons learnt from other paradigm shifts We have briefly reviewed the chronology of the conception and introduction of Crew Resource Management, Quantitative Risk Assessment and Safety Management Systems, including interviews with key industry experts. First it is pertinent to note that we could not identify any examples of where industry has made a sudden radical change in thinking. All examples occur across periods of 5 or more years. In addition, there appears to be a broadly common sequence of events that lead to a change in thinking in the field of safety, as follows: A major accident or costly event occurs creating concern and demands for change The causes of the event are identified (and these causes are accepted by industry and regulator alike); A well-bounded solution for this cause(s) is developed that industry agrees does address the real cause of the event.
In all cases the main prompt is the wish to avoid another major accident. Incidental commercial benefits (beyond the prevention of a costly accident) reinforce the case for change, but do not comprise drivers for change. The lessons include: The importance of industry involvement in developing the rationale and accepting the solution; The need to promote a solution rather than restricting debate to causes; The need to have a well-bounded solution that can be clearly linked to the causes of previous accidents.
Subsequently, the continued acceptance of the solution is influenced by evidence of its continued effectiveness. As any intervention that entails the involvement of staff depends in part
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of their acceptance of the intervention, it is important to secure staff participation and buy-in. Continued company management buy-in is facilitated by the use of performance indicators that demonstrate that the intervention is working. Conclusion It is concluded that there is a continued and clear need to increase awareness, understanding and commitment to the management of human error, and in particular the principles and methods encompassed by the term Human Factors. This study reinforces the need for the HSE, as the main recognised opinion leader in this area, to continue with its current promotional work. Our study offers a number of ideas on how to take these promotional activities forward in an effective manner.
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1 INTRODUCTION
1.1
BACKGROUND
It has long been recognised that human performance is a major contributor to risk in hazardous industries, underlying most major accidents. Accordingly the Health and Safety Executive (HSE) aims to increase the level of application of human factors in the hazardous industries. Although many human factors issues require further research, a large body of expertise and experience is available. Indeed, the HSE has developed and/or sponsored a sizeable body of guidance and research on human factors, covering issues such as contractor management, violations, control room design, Human Reliability Assessment, self-managed teams and so on. In addition, the newly formed human factors team within the HSEs Hazardous Installations Directorate (HID) has a number of promotional initiatives in place. Notwithstanding the wide scope of the HSEs current human factors strategy, the HSE wish to ensure that their strategy incorporates the most effective means of promoting the application of human factors. For any promotional activity to be effective the chosen media, timing, language, key messages etc. must be matched to the perceptions, knowledge and concerns of the intended audience. Accordingly the development of a sound and thorough understanding of the audience should ensure that HSEs promotional activity in the field of human factors is effective. The HSE also wish to acquire a baseline measure of the industry awareness of human factors. The baseline measure could be used to assess the impact of its promotional work. Therefore, this project aimed to develop the basis for reviewing the options for promoting human factors in onshore and offshore hazardous industries. 1.2 1.2.1 HIDS CURRENT HUMAN FACTORS PROMOTIONAL STRATEGY Aims
The overall aim of the HSE HID human factors strategy is to drive and promote continuous improvement in the effective integration of human factors into major accident prevention in the hazardous installations. This is to be achieved by: Providing guidance and good practice standards on human factors to industry and to inspectors Increasing inspector competence in human factors Providing specialist support in human factor issues to operational units Maintaining foresight into technical developments relating to human factors that may impact on the major hazard industries
The provision of guidance is intended to increase awareness of industry in human factors as well as to help develop an enforcement strategy.
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The strategy aims to: Prompt firms to recognise human factors as an issue on par with engineering matters; Secure buy-in of industry, based on the benefits of human factors; Provide advice and methods that industry can apply and sustain without ongoing consultancy support; Clearly define problems that are specific to industry.
The HSE does not aim to tell firms how to resolve problems because it is the aim to prompt active effort on the part of industry so that they own the work. 1.2.2 Tactics
The approaches used to promote human factors by the HID Human Factors team are summarised in Table 1 below. The strategy combines educational activities such as distribution of free information, with inspection-based activities. The latter inspection-based work entails both the direct involvement of human factors staff and intermediary-based application of human factors by HID inspectors. There are currently no guidelines on when Principal Inspectors should call in human factors support. Inspections are based on site-specific issues identified by area staff. The HSE published HSG48 as an aid for companies and organisations to consider how the human element impacts safety and health in the work place. It provides a clear yet comprehensive introduction to the elements of human factors showing how the individual interacts with the organisation and their job. The guide covers issues such as: Human failure and its contribution to accidents; Designing for people including ergonomic design, designing for mental well-being, designing effective warnings and human reliability assessment; Managing the influences on human performance such as shift work, communication, risk perception, risk taking and safety culture. Through out the coverage of these issues, HSG48 provides practical guidance on how a professional should consider them within their organisation. It offers case studies and examples as learning points. The guide also provides a practical step-by-step approach to managing human factors in the workplace (through risk assessment), in accident investigations in design and procurement and in other areas of H&S management. The final part of the guidance document is a comprehensive set of case studies showing where solutions have been found to human factors problems, hence showing that improvements can be made to problems in the workplace.
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Table 1 Summary of current promotional activities
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Tactic Publications and guidance Example Sale of HSG48 via HSE Books. Contributed to a series of Managing Human Factors videos prepared by the Vision Consultancy. Develop a series of free Chemical Information Sheets, e.g. alarms, fatigue, management of change, procedures. These are publicised via conferences, articles in journals (e.g. Safety & Health Practitioner), operational circulars etc and handed out during inspections. Also, in some areas local HID inspectors may advise sites of publications. For example, the Sheffield HID office wrote to all local sites advising them of HSG48. This was followed by a half-day seminar on incident analysis. Edit and publish material developed by others, such as the HFRG guide on Human Error in Maintenance A set of good practice standards is under development. Ongoing research will lead to further Contract Research Reports and information sheets. As far as possible research aims to have industry participation so that the project acts as a demonstration to industry as well as ensuring outputs are practical. Human factors material and tools are being posted on the HSE website, including a free download alarms information sheet Direct communication with industry Talks are given by HID at: Selected local industry groups Industry conferences / trade association events Consultancy run seminars Institute courses, e.g. the IEE summer school.
These talks aim to raise awareness of the HSEs human factors expectations.
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Tactic Internal inspector support
Example Inspector competence is supported by: = In the context of COMAH, HID provides input to the Assessment Manager course. In addition to operational circulars, articles are placed in the HID Briefing. Input to existing courses for HID inspectors, egg SMS courses, C&I course A dedicated human factors course (as of Autumn 2001) Guest speaker on the H&S Diploma Course Coaching in the form of joint site inspections
Specialist support on human factors
COMAH Safety reports Support includes: Assessment of human factors aspects of safety reports aide memoir (the Qdoc) to assist in reviewing human factors aspects of safety reports; Direct involvement in inspections against COMAH safety report
Human factors staff raise questions on receipt of Safety Reports, participate in Safety Report Outcome Meetings to identify issues to be addressed within subsequent inspections, and then participate in these inspections. The Qdoc is distributed to sites by local assessment managers or HID to advise them of the human factors expectations. It is also expected that the Qdoc will be incorporated into the next issue of the COMAH guidance (Safety Report Assessment Manual) that is available on the HSEs website. Incident investigation This entails direct involvement in incident investigation, including Category A investigations. The issues arising from investigations are built upon by development and distribution of Information Sheets, as in the case of the alarms information sheet.
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Tactic
Example Enforcement This entails direct involvement in inspections prompted either by staff complaints or incidents. Advisory letters or enforcement actions, including improvement or prohibition notices may follow inspections. The human factors team is producing standard inspection reports of a quality that allows local inspectors to issue them directly to firms with a cover letter. It is expected that the outcomes of enforcement action and incident investigations would have a ripple effect on industry. That is, the issues addressed by the HSE and the fact that these have been the subject of enforcement action are communicated by word of mouth within industry.
Maintaining foresight
Research This entails completing research on key themes and providing practical good practice solutions to industry problems. Where possible industry participation is used to enable project to act as a demonstration.
1.3 1.3.1
OTHER HUMAN FACTORS PROMOTIONAL EXAMPLES Overview
There are few, if any, documented examples of government agencies, department and regulators promotion of human factors. Indeed, this study was unable to identify any explanations of past promotional work or evaluation of previous attempts to promote human factors. Notwithstanding this we have drawn out, by inference, the factors influencing past work and described some examples. A variety of dissemination methods and tactics are commonly used to promote the application of new techniques and ideas. The choice of dissemination method appears to depend on a number of factors including the: Level of awareness required; Number of people to be reached; Kind of issue/s under discussion, and; Capability of the organisation to ensure that these issues were properly considered.
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Persuasion vs mandating There is a distinction between persuasive and mandatory styles of promotion, where the former aims to persuade organisations and the latter prescribes at varying levels of detail what organisations should do. Examples are given in Boxes 1 and 2. With regard to this study, it is pertinent to note that the extent to which the promoter seeks to mandate or persuade appears to be linked to the hardness of the human factors issue. As discussed below, it appears that there is a tendency to be more prescriptive in the context of engineering and design types of issues, and more persuasive for softer issues such as safety culture. Soft issues are those issues relating to the influencing of complex human behaviours. Typically, these behaviours involve some aspect of managing people, changing human perceptions (e.g. to risk), or encouraging compliant/desirable behaviours. It would appear from the review that the promotion of behaviour change initiatives relies to a higher level on persuasive forms of promotion. This appears to be, in part, due to the view that the techniques for changing behaviour are less amenable to prescription. Accordingly, it is much harder formally to prescribe, evaluate and audit behavioural change work. It appears that there is a greater need for human factors guidance and support due to the less defined nature of the issues involved in behaviour change. Also, as with hard issues, a case for specialist human factors involvement can be made, but given the nature of the awareness to be achieved and how it can be achieved, the case for specialist human factors involvement could be said to be even stronger. Dissemination methods A variety of dissemination methods and routes have been used to raise awareness of human factors and similar matters. Typically, mass media routes, such as placing information in trade press, are used when there is a need to reach a large or dispersed audience and where a low level of awareness is sufficient. Much more targeted and detailed information is used when communicating with a smaller or more technical audience. Table 2 gives a brief description of the methods and shows how each method typically is used to communicate to its target audience by use of examples.
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Box 1: Examples of human factors mandating Ministry of Defence (MOD): Training Needs Analysis in Procurement (TNAP) (AB25 Paper 1998) TNAP is a mandated procurement method used by the MOD (prescribed by designated/selected personnel). System and training needs development is extensively documented to ensure that work done is undertaken to a MOD specified standard. In this example, the rationale for the adoption of mandated requirements is derived from the identification of past failures to reconcile TNAP with the development and procurement of new equipment. The requirements were implemented by requiring the use of Human Factors Integration (HFI) principles, such as the application of guidelines in key areas (e.g. product development), in the procurement process. Human Factors Integration (HFI) is initiated at the proposal stage and concludes with decommissioning. Human Systems Integration Overview (HSIO previously MANPRINT) HSI is a US Army (the customer) mandate for Human Factors involvement in key areas of system acquisition, development and specification (both technical and human), and is designed to ensure HSI practices are adhered to and carried through to the conclusion of the design cycle. The scope of issues considered is: Human Factors Engineering Manpower/personnel Training Systems safety Health hazards
Methods of dissemination include: Standards, guidelines (& Auditing) Training Internally promoted research programs and reviewing of Human Factors research
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Box 2: A persuasion example STEP CHANGE Initiative The aim of the offshore oil and gas industry Steps Initiative is to reduce the number of accidents, primarily by encouraging a change in behaviour(s). The initiative is intended to accomplish accident reduction in a number of ways. For example, one aspect is to create and expand networks formed at conferences, with people who occupy key decision-making positions in industry and/or commerce. Although not explicitly stated, the agenda for this phase of the initiative was to improve the uptake of human factors (in the form of behavioural change), during key stages of development and production. Key methods used to achieve the goals of this initiative are: Ensuring the initiative was industry led and facilitated by industry representatives Producing tools and methods that can be used by operations management Publication of leaflets, booklets and brochures Seminars and extensive industry networking.
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Table 2 Summary of dissemination methods

Dissemination route Journals Summary
The aim of journals is to keep interested parties usually academics, practitioners or professionals informed about the latest research developments in a specific subject. Journals, such as Ergonomics, Applied Ergonomics and Human Factors, are examples of journals aimed at keeping HF specialists informed. Research programmes enable the systematic investigation of issues that may not be incorporated into the current knowledge base of a discipline or industry, but which are of importance and interest. An example of a research programme in the UK is that conducted by the Nuclear Industry Management Committee (IMC), which promote programmes of research, including HF, in the nuclear industry. Demonstration projects are used as a vehicle for promoting uptake of new methods, as per the Department of Trade and Industry (DTI) Foresight programme.
Research & Demonstration Project Programmes
Practitioners
Practitioners promote awareness via their professional and personal contacts with industry clients. Generally, the aim is to influence people or groups who have the authority to extend awareness within an organisation. Conferences, such as commercial seminars and the Ergonomics Society conference, offer a forum for the dissemination of new methods and discussion amongst specialists, academics and industry professionals. Conferences may focus on general issues, or be structured around a specific theme or themes. In addition to disseminating knowledge, conferences are seen as opportunities to build networks, especially between HF specialists and key decision-makers in industry. Training can be either taught or administered. The aim is to educate participants, and sometimes validate competence in specific aspects of HF awareness. Articles are targeted at specific audiences via publication in appropriate professional and/or trade magazines. An example of such a magazine is the Health & Safety Practitioner, which is used as a vehicle for promoting specific health and safety issues amongst health and safety professionals.
Conferences & Seminars
Training
Magazine articles
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Dissemination route Posters, leaflets and booklets
Summary
Posters, leaflets and booklets contain information that is targeted at specific audiences. The aim is to couch information in a way that is believed to be relevant to the target audience, and hence raise awareness of the issue under consideration. Booklets were recently used by the HSE in an initiative called STEP CHANGE to promote safety leadership amongst supervisory level staff in the Offshore Oil and Gas Industry. Catastrophic accidents, especially high profile types where HF has been implicated, are analysed and reported on so as to demonstrate how HF has contributed to the event. Organisations or individual HF specialists can undertake analysis and write up and apply the lessons learned using other methods, such as seminars or formal publications. The aim is to increase awareness of HF by use of a practical example. An example of this is the Ladbroke Grove report, whilst the Safety Digest, published by the Marine Accident Investigation Branch (MAIB) is specifically aimed at disseminating lessons learnt.
Accident Analysis
Initiatives, Strategies and Campaigns
Initiatives, strategies and campaigns may use any one, or combination of the methods listed here to promote awareness of a specific issue. More generally, a variety of relevant methods are carefully selected to ensure that as many people as possible in the target audience are made aware of the issue being promoted. Campaigns tend to be initiatives that are conducted over extended periods of time, usually in phases. A recent example of an initiative is the STEP CHANGE initiative, as discussed above in posters, leaflets and booklets. Guidelines, standards and codes are specific rules derived either from research or verified examples of good practice. HF Guidelines, such as DEF STAN 00-25, are designed to inform aspects of design and evaluation of equipment, environment and/or procedures. Guidelines are used to illustrate good practice on issues such as design, equipment, environments or procedures. An example of an organisation that frequently uses HF guidelines is QinetiQ, formerly the Defence Evaluation & Research Agency (DERA), for Ministry of Defence (MOD) projects. Adverts are used to transmit a specific message, or messages. They are usually short and either placed or shown where they will be conspicuous to the target audience. Many kinds of media may be used. This medium has been used to promote the HSEs safety climate tool.
Guidelines, Standards & Codes
Adverts
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Dissemination route Themed Inspections
Summary
Themed inspections are inspections that are undertaken with regard to a specific health & safety issue or theme. The idea of themed inspection is to raise awareness about the selected theme. For example, a theme of might be noise, noise reduction and protecting staff against the detrimental effects of noise. Confidential reporting can provide a vehicle for raising human factors awareness. The idea is to provide a confidential vehicle for people to flag up HF issues and concerns. The Confidential Human Factors Incident Reporting Programme (CHIRP), is operated in the UK aviation industry, and is an example of a confidential reporting system specifically aimed at capturing human performance issues that people may not feel comfortable reporting through conventional channels. HF issues deemed serious are flagged up in reports. If necessary the Civil Aviation Authority (CAA), National Air Traffic Services (NATS) or specific operators, may be consulted regarding action to be taken in response to a report. Dis-identified reports are ultimately made available to the industry in general in the form of a quarterly news-sheet.
Confidential Reporting
1.3.2
Discussion
If the methods discussed above are compared with those noted as part of the HSE current approach, it can be indicated that the HSE uses the following methods of dissemination for human factors: Research programmes / Report(s) Magazine articles Guidelines Adverts Themed inspections Conferences and seminars Training Booklets Accident analysis The HSE makes less use of the following methods:
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Regulations specifically enforcing the application of human factors (although human factors is enforced under regulations such as COMAH) Standards Practitioners (i.e. this is not a stated tactic) Demonstration projects Confidential reporting However, whilst it could be argued that the HSE make less use of certain promotional tactics, there appears to be little to be learnt from the published information on past examples of human factors promotional work. 1.4 SCOPE OF THIS WORK
This study has comprised three main stages of work. 1. A brief review of literature on previous initiatives to promote the uptake of human factors by industry, and collation of information on current HSE human factors publications etc; 2. A survey of duty holders in the onshore and offshore hazardous industries, covering issues such as what would prompt them to consider human factors and their awareness of human factors, and; 3. Lessons learnt from previous paradigm shifts brought about by non-regulatory initiatives in analogous areas of health and safety. The study focuses on the prevention of major hazards. Accordingly, human factors (as elaborated in HSG48) is defined here to be any issue that may influence the likelihood or outcome of major incidents, such as: Ergonomics of control room design, procedures, training etc; Safety culture / behavioural safety; Human Resource issues such as multi-skilling, self-managed teams, manning level, bonus schemes, selection and training arrangements; Managerial and supervisory practices; Human Reliability Assessment.
The audience comprises anyone who makes or enacts decisions that impact any of the latter issues, and so may include Human Resource staff, operations managers etc.
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2 EXPLORATORY DISCUSSIONS
2.1
INTRODUCTION
This section of the report provides a summary of the preliminary discussions, development and piloting of the survey pro-formas and the findings from the pilot process. 2.2 EXPLORATORY DISCUSSION AND PILOT METHOD
Piloting The pilot has been split into two phases, namely: A phase of semi-structured face to face sessions, and; A phase of structured telephone interviews.
This approach has been adopted to facilitate the elicitation of rich information from the semistructured sessions through a process of probing questions. The information from the semistructured sessions is used for: Developing more sensitive questions for the telephone questionnaire; Testing and identifying terms that interviewees can use; Providing a forum to capture issues and ideas that may not have been foreseen by the researchers; Testing the interview method; Providing some initial findings regarding the promotion of human factors.
Exploratory discussions A topic guide, as shown in Appendix A, has directed the semi-structured sessions. A statement sheet was passed to interviewees for self-completion. Interviewees were asked to indicate their strength of agreement or disagreement with a series of statements about human factors. The topic guide addressed the following points: Respondents current understanding and application of human factors; What prompts or inhibits firms from applying human factors; Sources of information;
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Terms used to describe the prevention of error; Attitudes towards human factors, and; Suggestions on how best to promote the application of human factors.
Discussions have been held with 11 individuals from a range of large and medium sized firms operating in the onshore and offshore hazardous industry sectors. This included representatives from: Chemical plants; Refineries; Offshore platform operators and exploration, and; Gas plant operators.
Final piloting of telephone questionnaire A telephone questionnaire has subsequently been developed and piloted in two stages. The telephone questionnaire has been designed so as to support a shorter (up to 30 minutes) interview and to enable coding of responses for subsequent quantitative analysis. Key pilot issues include: Acceptability of the interview duration; Interviewees comprehension of the questions; Whether the questions generate the information needed by this study, and; Practicality.
The questionnaire was first piloted by phone with a further six individuals. The outcome of these interviews was reviewed and edits made to the questionnaire. The final version of the questionnaire was tested by a further set of 6 interviews. The questionnaire remained unaltered after these sessions. The final version of the telephone questionnaire is shown in Appendix B.
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2.3 2.3.1
FACE TO FACE SEMI-STRUCTURED SESSIONS Findings regarding topic guide design
As a general point, it was found that the semi-structured nature of the sessions enabled the elicitation of a "rich body of responses and feedback on the effectiveness of the questions. Specifically, it was found that: Respondents provided a higher level of feedback regarding the HSEs approach to human factors once it became apparent that they were the client. The withholding of the client raised suspicion. Interviewees indicated that they could be more informative and focused in their responses once they were aware of the HSE being the client; A number of questions failed to generate informative responses, namely questions 1, 2, 4 and 5; A number of questions were responded to in an inconsistent manner, particularly questions 11 (where people talked about occupational accidents or cited examples without human factors issues), 13 (people referred to their own organisations) and 6 (where people referred to firms in other sectors); Interviewees required an explanation of question 17; Some of the attitude statements were too polarised and appear to generate forced positive responses; More direct questions were needed regarding the work of the HSE, as the open ended questions about sources of information did not provide a sufficient focus on the HSE; It was noted that a number of the open-ended questions generated very informative responses and hence should be retained in the survey. Indeed, the probing aspect of the session discovered useful unforeseen points of information and hence should be retained as far as is practicable; The idea of withholding the term human factors until later in the interview, once awareness test questions have been asked, was confirmed; Many respondents gave similar answers, thereby enabling coding of responses in the main survey.
NR= = = =
2.3.2
Findings regarding promotion of human factors
The key findings from the face-to-face semi-structured sessions are summarised below: Prevention of major accidents Many but not all of the interviewees mentioned some form of human factors as a part of major accident prevention, although the discussion on this was limited possibly because of the phrasing of the question. Sources of information The most common sources of information are: The HSE (website, publications, ACOPs etc) Consultants Trade associations and journals / codes / guides In-house experts
All interviewees mentioned the HSE as a source of information, and most used industry networking as a way of getting information. All mentioned the term human factors in the context of the HSE. Most mentioned that they would use the HSE if they wanted information, as well as other sources, particularly consultants. There was little apparent awareness of HSG48, although one interviewee applauded it and said it had been influential. The term human factors Most interviewees had heard of the term human factors and could cite examples of human factors issues, such as shift work, control room design, competence, training, human error, behavioural safety and so on. Some interviewees did not mention the term human factors until prompted. Many interviewees stated they first heard the phrase from the HSE. However, they all felt that it was a difficult concept, as illustrated by the following quotes:
Grey and difficult Engineering is well-defined, human factors is not so much a science its a well kept secretits complicated
Interviewees generally felt it was not a helpful term or a term they used with respect to major accident prevention. Some people preferred terms such as safety culture and appeared to equate
NS= = = =
human factors with behavioural safety issues. Notwithstanding concerns about the looseness of the term human factors, no one could offer a better alternative. Some indicated that no single phrase would be adequate. This is illustrated below:
Its difficult to have one term to give it sufficient focus. Different steps are needed to address different issues. An all-encompassing term like human factors doesnt allow you to understand the detail. It needs to be broken down into identifiable small bites. Human factors is not considered as a separate topic. You can talk about training, competency etc.people dont know what your talking about when you use human factors. You can focus on one area e.g. design of a control panel, but this goes better with the designers of control panels.
All seemed to feel that they had been adopting human factors approaches before the term was used. This is illustrated below:
Companies deal with human factors issues without referring to it as human factors. Its a fairly new topic in its own right but some aspects have always been there. For example, weve always been training its just not called human factors. Its not deliberately managed as human factors. Im aware that we do a bit of this and that but its not coherent.
Attitude statements The number of interviewees who agreed or disagreed with each statement about human factors is given below. It should be noted that these statements were revised for the next stage of work due to the belief that their wording may have encouraged positive responses. Notwithstanding this note of caution, the responses indicate that human factors is regarded to be a key issue of growing importance that needs to be addressed as part of major accident prevention and is a worthwhile investment. It is interesting to note that 4 out of the 10 people who completed the form regard human factors to be common sense.
NT= = = =
Table 3 Responses to attitude statements (n = 10)

Considering human factors in major accident prevention is: a key issue just common sense a worthwhile investment a barrier to getting the job done an effective approach to improving major hazard safety just a compliance issue of growing importance abstract nonsense not part of MY job an issue that should be considered throughout the organisation Strongly disagree 0 0 0 2 0 Disagree Neither Agree Strongly agree 2 1 2 0 2
0 3 0 6 0
0 2 2 1 2
8 4 6 1 6
4 0 9 6 0
5 0 1 3 0
1 0 0 1 2
0 4 0 0 4
0 6 0 0 4
Response to last major incident The described responses to previous incidents suggested that the majority looked at the broader system and adopted a no blame approach, although some appeared to focus on individuals. Prompts for considering human factors The most commonly cited prompt was an accident, followed by: Regulations such as COMAH; HSE pressure; Benchmarking; Organisational change.
NU= = = =
Barriers to implementing human factors The most commonly cited barrier was lack of understanding. It was also noted that: Firms are reluctant to spend time and money on something they do not feel they understand; Engineering is well-defined whilst human factors is not; Cost cutting can be a barrier; Many interviewees felt that smaller companies would have more difficulty in preventing human error.
Good practice examples BP, ICI, Shell, Novartis, Dow and DuPont were mentioned as companies that were leading the way in this area. Comparison with safety management systems It was generally felt that it is much easier to understand the concept of safety management systems because it is more clearly defined and bounded, and similar to ideas such as quality management. The idea of SMS is easier to understand. HF is not necessarily a system in itself. HF covers more issues and must be understood by a wider range of people than SMSs.
SMS brings it all together and draws a ring-fence around it. Once you understand the structure of SMS, it contains everything Human factors has a series of places but no map. SMS scores because its a map. You can plug into a map
Ways of promoting human factors A wide variety of suggestions was offered: All felt that the learning experience of incidents prompted companies to take on human factors. They all felt that was the way to sell the concept to the industry, by using examples of incidents and accidents. Standards need to be tailored to the industry. HF could be promoted on the back of Responsible Care and via trade associations. The issue of HF needs to be serialised and broken into smaller chunks. HF could be integrated with safety management systems. Increase coverage in the Loss Prevention Bulletin.
NV= = = =
Learn the lessons from the Step Change initiative; such as working with trade associations and producing industry focused case studies.
As regards the role of the HSE, it was suggested that the HSE needs to improve its advisory role and offer more personal contact. It was noted that: the HSE only tell you when youve got it wrong
the HSE need to specify what theyre looking for.
2.3.3
Conclusions from face to face sessions
It would appear that: HF is primarily driven by the occurrence of accidents and the activity of the HSE; It appears that human factors is viewed as being driven by negative factors, i.e. avoidance of accidents, rather than by positive factors such as a better company image or improved productivity; There is a variable level of understanding of human factors and general concern about the recognition of the issue; There is concern about the wooliness of the topic; A wish to improve level of explanation of human factors and a better use of industry sources; Consultants are a key source of advice on human factors, and; Interviewees believe more use could be made of industry sources such as trade associations and Responsible Care.
The initial findings reinforce the idea that there remains a clear need to educate industry regarding human factors and better brand or ground for the concept.
OM= = = =
3 MAIN TELEPHONE SURVEY
3.1
INTRODUCTION
The questionnaire provided in Appendix B has been administered by phone to a sample of staff from the hazardous industries. People were recruited by: Sending a fax with a cover letter from the HSE to the site or company health and safety manager requesting their participation; A consultant telephoning the health and safety manager to confirm their participation and to complete an interview; Asking the health and safety manager to nominate other staff within the organisation for a follow-on interview; Pursuing nominated colleagues and completing interviews as possible.
All responses have been documented and placed on a database, minus contact details. The results are summarised in the remainder of this section and tabulated in Appendix C. In most cases the results are presented for all respondents and, separately for Onshore and Offshore firms. The survey was not intended to derive statistically robust samples of onshore and offshore firms. However, where it is judged that the there are large differences in responses between onshore and offshore respondents, these have been highlighted. 3.2 3.2.1 SUMMARY OF KEY FINDINGS Overview of respondents
The survey was managed with the aim of acquiring responses from large, medium and small organisations that operate top tier and lower tier sites and offshore installations. The achieved sample structure is summarised below in Table 4. Figures 1 to 4 show that respondents are typically from large or very large firms, often multi-national firms with multiple sites frequently more than 10 sites, especially offshore firms. This reflects the composition of the industry. The majority of respondents are health and safety professionals, followed by plant/operations managers. The profile of onshore respondents is given in Table 5. It is noticeable that a significant number use hazardous materials incidentally, such as food manufacturers, unlike refineries and chemicals manufacturers.
ON= = = =
Table 4 Profile of responding organisations

Onshore Top tier Very large Large Medium Small Total 10 14 14 5 43 Lower tier 6 10 6 1 23 Other 1 3 1 1 6 Offshore operators 18 9 4 0 31 Offshore Drillers etc 25 3 5 0 33 Other 1 0 3 1 5 Total 61 39 33 8 141
Table 5 Profile of onshore firms

Number Chemicals manufacture Oil and gas Explosives Manufacture of non-hazardous products Distillers Water utility Other manufacture Food and drink Hazardous material storage & distribution Power supply Total 6 6 5 6 14 4 72 22 5 3
OO= = = =
Figure 1 Respondent's company sizes

70% 60%
% of respondents
Onshore Offshore All
50% 40% 30% 20% 10% 0% Very large Large
Medium
Small
Figure 2 Job titles of respondents

80% 70%
% of respondents
60% 50% 40% 30% 20% 10% 0%

Healt h and saf et y Engineers Pl ant managers HR st af f Direct ors Ot her
OP= = = =
Figure 3 Number of sites at respondents' companies

70% 60%
% of respondents
>10 <10 1
50% 40% 30% 20% 10% 0% Onshore Offshore
All
Figure 4 National status of respondents' companies
100% 90% 80%

% of respondents
Multinational Nat ional Regional
70% 60% 50% 40% 30% 20% 10% 0% Onshore
Offshore
All
OQ= = = =
3.2.2
Ease of getting resources
The vast majority of respondents indicated that they can get resources for safety without question. This question was asked in order to correlate the responses with the attitude towards human factors, as reported in subsequent sections. Figure 5 summarises the self-reported ease of getting resource. Figure 5 Ease of getting resources
(1 = get resources w ithout question, 10 = fight tooth & nail) 50% 45%
% of respondents
40% 35% 30% 25% 20% 15% 10% 5% 0%
Score
10
3.2.3
Main sources of information for major accident prevention advice and guidance
The five main sources, in approximate rank order, are: HSE Books and Trade Associations equal first; HSE Website; Site health and safety staff; HSE visits.
Onshore firms appear to make less us of the HSE website and site Health and Safety staff, relying more on HSE Books, consultants, ICheme etc, and magazines/ journals. The full results are shown in Figure 6 for sources cited by over 5% of respondents.
OR= = = =
Figure 6 Main sources of information about major accident prevention

25%
20%
% of responses
15%
10%
5%
0%
HSE books T r ade assoc i at i ons HSE webs i t e Si t e H&S HSE v i si t s Ot her CRONA et c I ndust r y codes
OS= = = =
3.2.4
Understanding and application of human factors
Respondents free text answers to a series of questions aimed at probing their understanding and application of human factors were rated by the interviewers. Respondents are rated as, typically, having a reasonable understanding and application of human factors. The average scores on each question are given in Figure 7. The percent of respondents with each rating are given in Figures 8 to 12. The figures show that: On average respondents do make some mention of human factors / error issues when asked what they think the main causes of major accidents are about one third clearly mention human error as shown in Figure 8, although a third make a minimal mention and about a quarter make no mention of human error as a cause of accidents; On average respondents have between a Minimal and Reasonable understanding of why people might make errors nearly 50% have a reasonable understanding as shown in Figure 9, but one third have a minimal understanding; There is between a Minimal and Reasonable level of attention to human factors in respondents response to the last incident on site, as shown in Figure 10; The majority of respondents use some valid terms such as culture, training, competence, when asked to describe the process of preventing human error about 20% use the term human factors, as shown in Figure 11; Respondents have, on average, between a Minimal and Reasonable understanding of the term human factors when prompted to explain what the term means about 45% have a reasonable understanding, 15% an excellent understanding and about 40% have a minimal or poor understanding, as shown in Figure 12.
Onshore respondents are rated as having a slightly better understanding of why people make errors than offshore firms. However, there is little significant difference in the understanding of human factors between onshore and offshore respondents.
OT= = = =
Figure 7 Citation and understanding of human factors

4.0 Onshore 3.5 Offshore All Max = 5 Max = 5
Average score
3.0 2.5 2.0 1.5
Max = 4 Max = 4 Max = 3
1.0 0.5 0.0

M ent io n HF as a cause o f major accid ent s Underst and ing of why peop le make errors A t t ent io n t o HF in last incident Sp ont aneo us ment ion of HF t erm Underst anding of t erm HF
Figure 8 Mention of human error as a cause of major accidents

45% 40% 35%
% of respondents
Onshore Of f shore All
30% 25% 20% 15% 10% 5% 0%
No ment ion of HF
Minimal mention of HF
Mentions HF
OU= = = =
Figure 9 Rated understanding of why people commit errors
60% 50%
% of responses
40% 30% 20% 10% 0% Poor understanding Minimal Understanding Reasonable understanding
Excellent understanding
Figure 10 Rated level of attention to human factors in response to last incident

50% 45% 40%
% of responses
35% 30% 25% 20% 15% 10% 5% 0%

Don't know
HF no t addressed
M inimal at t ent ion t o HF
M oderat e level of HF
High level of at t ent io n
OV= = = =
Figure 11 Terms used to describe the process of preventing human error
80% 70%
% of responses
60% 50% 40% 30% 20% 10% 0%
Term HF already Term HF used mentioned here
Some valid terms used
Invalid terms used
Figure 12 Rated level of understanding of term human factors

60% 50%
% of responses
40% 30% 20% 10% 0%

Can't answer
Poor underst and ing
M inimal underst and ing
Reasonab le underst and ing
Excellent underst and i ng
PM= = = =
3.2.5
Correlation of understanding and application of human factors
A series of correlations have been made between the level of citation of human error in the causes of accidents, understanding why people make errors, and the level of attention to human factors in the response to the last incident, with each other and with the rated ease of getting resources for safety, terms used to describe error prevention and understanding of human factors. The correlations are shown in Table 6. It appears that: There are few strong correlations between any of the questions; The largest correlations, of about 0.3 are between: The level of attention to human factors in the last incident and mentioning Human Error as a cause of accidents; Understanding why people make errors and understanding the term human factors; Understanding why people make errors and using valid terms to describe the process of preventing error. There are lesser correlations of about 0.2 between: Level of attention to human factors in the response to the last incident with: understanding human factors, using valid terms to describe the process of preventing human error, mentioning Human Error as a cause of accidents and understanding why people make errors; Mentioning Human Error as a cause of accidents with: understanding the term human factors. The ease of getting resources is correlated at less than 0.1 with these questions. Thus, it appears that there is an association between understanding the term human factors and the extent to which respondents understand human error and its contribution to major accidents. Perhaps more importantly there is also an association, if weaker, between understanding human factors / human error and the level of attention to human factors issues when responding to incidents. It should be noted that on the question Terms used to describe error prevention, scores of 1 and 2 reflect use of the term human factors, a score of 3 was assigned to the use of other valid terms and a score of 4 was used for invalid terms. Thus, a negative correlation reflects an association between (say) mentioning Human Error as a cause of accident with use of the term human factors when describing the process of preventing error.
PN= = = =
Table 6 Correlations between questions probing understanding of human factors

Onshore Offshore Correlation of mention of human error as a cause of accidents with Understanding of error Attention to HF in last response to an incident Ease of getting resources Terms used to describe error prevention Understanding of term HF Correlation of understanding of why people make errors with Attention to HF in last response to an incident Terms used to describe error prevention Understanding of term HF Ease of getting resources Correlation of attention to HF in response to last incident with Terms used to describe error prevention Understanding of term HF Ease of getting resources 0.12 0.33 0.06 -0.30 0.08 0.07 0.15 -0.04 -0.21 0.27 0.09 0.23 0.01 -0.25 0.17 All
0.28 -0.40 0.51 -0.18
0.05 -0.28 0.24 -0.13
0.15 -0.33 0.37 -0.15
-0.14 0.27
-0.03
-0.35 0.20
-0.13
-0.25 0.24
-0.07
3.2.6
How do respondents react to incidents?
The actions taken in response to the last incident on the respondents sites were categorised by the interviewers. As shown in Figure 13, the most common response entails an investigation of the causes of incidents, followed by revising procedures and training. Other human factors and engineering responses account for 10% of reactions respectively. A small minority of responses are categorized as blaming the individual or disciplining.
PO= = = =
Figure 13 Categorized response to last incident
35% 30% 25%

% of responses
Onshore
Offshore
All
20% 15% 10% 5% 0%

Cause anal y s i s Reengi neer ed
Di s c i pl i ne
B l amed
per son
Look ed at SM S
M or e s t af f chec k s
Revi sed pr oc edur es
T r ai ni ng
Ot her HF ac t i ons
Ot her non-HF Can't ans wer
PP=
= = =
3.2.7
What companies lead the way in preventing human error?
As shown in Figure 14, the most commonly cited company is Du Pont, accounting for one quarter of citations. They are followed by: BP at 14%; Shell at 12%; ICI 8%, and; Other major oil, gas and chemicals firms at 13%.
Other firms include, Esso, BOC, Diamond Offshore Drilling, Zeneca, Dow, Exxon. Total Fina, Conoco, Air Products and Haliburton. The remaining citations are for industries, including the aviation, nuclear and chemicals industries. These firms are cited for a number of reasons, including: Evidence of a good safety record; Evidence of safe behaviour and good safety culture; Known to have done a lot of work in the area of human error.
Certain industries are cited as leading the way because of the wish to avoid a major accident, and hence they are assumed to have a good approach to preventing human error. Figure 14 Companies cited as leading way in error prevention
50 45
Num ber of suggestions
40 35 30 25 20 15 10 5 0
Du Pont BP Shell Ot her oil & gas Ot her s ICI
Onshore offshore All
Nuc l ear ind'
Avi at i on Chemi cals Conoco sect or ind'
Of f shor e ind'
Air product s
PQ= = = =
3.2.8
Heard of term human factors
The vast majority (90%) of respondents say they have Possibly heard of the term human factors. Virtually none have definitely heard of the term human factors. There is no one predominant source from which respondents have heard of the term. The sources include; Courses, particularly NEBOSH courses; Conferences; Read about it, and; The HSE. Figure 15 Proportion of respondents who have heard of term human factors
100% 90% 80%
% of responses
70% 60% 50% 40% 30% 20% 10% 0%
Poss ibly
Unsure
No
Yes
Figure 16 Source of possibly hearing term human factors

50% 45% 40%
% of responses
35% 30% 25% 20% 15% 10% 5% 0% HSE
Conference Read about Consultants it
Cannot recall
Other
PR= = = =
3.2.9
Attitude towards human factors
Respondents were asked to agree or disagree with a series of statements about human factors, where 1 = strongly disagree and 5 = Strongly agree. The average scores are shown in Figure 17. Respondents agree that human factors is: An essential part of Major Accident Prevention, and is; A useful concept.
Indeed: Only 1.4% disagree that human factors is an essential part of Major Accident Prevention 96% agree that its an essential part of major accident prevention; Only 0.7% disagree that its a useful concept 95% agree it is a useful concept
There is a tendency to agree that it is common sense (67% agree) and is a difficult subject to grasp (60% agree). On average respondents have no opinion on whether human factors is fuzzy, ill-defined, or something they spend a lot of time on. Slightly more respondents agree that human factors is fuzzy than disagree, with 47% agreeing it is fuzzy. 67% agree that it has incidental commercial benefits, and 90% disagree that it is a barrier to getting the job done or only done for reasons of legal compliance. Thus, the attitude towards human factors is, broadly, positive.
PS= = = =
Figure 17 Average agreement with attitude statement about human factors
( 1 = strongly agree, 5 = strongly disagree )
5.0 4.5 4.0
Onshore
Offshore
Average score
3.5 3.0 2.5 2.0 1.5 1.0

ess' par t of MAP a usef ul concept common sense commer cial
benef i t s dif f i cult t o
All
spend a l ot of t i me on
f uzzy, illdef ined
a barr ier
onl y done f or only a saf et y compli ance

i ssue
gr asp
PT= = = =
3.2.10 Correlations between attitude to and understanding of human factors. The answers to the attitude statements about human factors shown in Figure 17 have been correlated with the questions exploring understanding and application of human factors shown in Figure 8 to 12. The correlations are shown in Figures 18 to 22. It can be noted that, whilst all correlations are low, the strongest ones of 0.2 or more occur between: Understanding of why error occurs and: Regarding human factors to be an essential part of major accident prevention; Finding human factors to be a difficult subject to grasp (a negative correlation); The level of attention to human factors in the response to the last incident and; Finding human factors to be a useful concept; The ease of getting resources for safety and; Regarding human factors to be a barrier to getting the job done; Regarding human factors to be a compliance matter only done for safety, and; Spending a lot of time of human factors (a negative correlation). Understanding the term human factors is negatively correlated with perceiving human factors to be a barrier, and, amongst onshore respondents, a difficult subject to grasp. Offshore respondents who better understand the term human factors are more likely to regard it to be an essential part of major accident prevention and a useful concept that offers incidental commercial benefits. The use of terms to describe the process of preventing human error is not correlated strongly with the attitude towards human factors, although onshore respondents who do use invalid terms are much more likely to regard human factors to be common sense. Thus, it does appear that increasing awareness and understanding of human factors is helpful in getting it applied as part of major accident prevention.
PU= = = =
Figure 18 Understanding of why error occurs with attitude to human factors
1.00 0.80 0.60 0.40 0.20 0.00

spend a lot of common sense a barr i er part of acc i dent prevent ion dif f i cul t t o grasp onl y f or compliance i nc i dent al benef i t s f uzzy, il ldef i ned a usef ul concept onl y a saf et y issue
-0.20 -0.40 -0.60 -0.80 -1.00
t ime on
PV= = = =
Figure 19 Correlation of attention to human factors in response to last incident with attitude to human factors
1.00 0.80 0.60 0.40
Onshore
Offshore
All
Correlation
0.20 0.00
spend a l ot of t ime on common sense a barr ier part of acc i dent prevent i on
di f f icul t t o
grasp
only f or
compli ance
i nc i dent al
benef i t s
f uzzy, illdef i ned
a usef ul concept
only a saf et y issue
-0.20 -0.40 -0.60 -0.80 -1.00
QM= = = =
Figure 20 Correlation of ease of getting safety resource with attitude to human factors
1.00 0.80 0.60 0.40

Correlation
0.20 0.00
spend a l ot of t i me on common sense a barr ier part of acc i dent prevent ion di f f icul t t o grasp only f or compliance i nc i dent al benef i t s f uzzy, illdef ined a usef ul concept only a saf et y i ssue
-0.20 -0.40 -0.60 -0.80 -1.00
QN= = = =
Figure 21 Use of terms to describe error prevention with attitude to human factors
1.00 0.80 0.60 0.40

Correlation
Onshore
Of f shore All
0.20 0.00
spend a l ot of t i me on c ommon sense a bar r i er par t of acc i dent pr ev ent i on di f f i c ul t t o gr asp onl y f or c omp l i ance
i nc i dent a l
benef i t s
f uzzy, i l l def i ned
a us ef ul concept
onl y a saf et y
-0.20 -0.40 -0.60 -0.80 -1.00
i ssue
QO= = = =
Figure 22 Correlation of understanding of human factors with attitude to human factors
1.00 0.80 0.60 0.40

Correlation
0.20 0.00
s pend a l ot of t i me on common sense a bar r i er par t of acc i dent pr ev ent i on di f f i cul t t o gr asp onl y f or c ompl i anc e i nc i dent a l benef i t s f uz zy , i l l def i ned a usef ul concept onl y a saf et y i ssue
-0.20 -0.40 -0.60 -0.80 -1.00
QP= = = =
3.2.11 What would prompt more attention to human factors? As shown in Figure 23, the four main things cited by respondents that would prompt companies to give more attention to human factors issues, which account for about 60% of responses, are: Occurrence of a major accident; Recognition that human factors is good practice; HSE enforcement, and; A wish to avoid costly accidents.
Review of the free text responses to this question indicates that few respondents cite prompts that are specific to human factors, with a few exceptions. In the main they cite prompts such as greater enforcement, fears about the impact of a major accident, and demonstrating the business benefits. The exceptions relate to increasing the understanding of human factors, showing the link between human error and accidents and de-cluttering the presentation of human factors. 3.2.12 What stops companies from considering human factors? As shown in Figure 24, the top four factors cited by respondents as stopping companies from considering human factors are: Lack of understanding- nearly 50% of responses; Cost; Failing to recognize human factors issues, and; Other reasons.
The factors Lack of understanding and Failing to recognize human factors issues account for 65% of responses. It appears that cost is cited more frequently by onshore respondents, accounting for 39% of onshore responses compared to just 8% of offshore responses. In addition, onshore respondents are more likely to say that firms may not believe people will make mistakes that could cause a major accident and are more likely to adopt a short-term view. Offshore respondents are more likely to cite Lack of understanding than onshore respondents, 53% compared to 40% of responses for offshore and onshore responses respectively. No respondents cited Relying on common sense, and barely any respondents mentioned practicality or the tendency to just blame the individual as factors for inhibiting the consideration of human factors. Time was the most commonly cited Other reason, cited in 17 out of 25 Other responses. A few respondents mentioned having the wrong people in HAZOP teams, not being aware of appropriate tools, difficulty in communicating about human factors.
QQ= = = =
Figure 23 What would prompt companies to improve management of human aspects of major accidents?
30%
25%
% of responses
20%
15%
10%
5%
0%
Acc ident
Good pract i ce
HSE act ion
Cost ly accident s
Ot her
Concern f or Poor saf et y st af f
Publ ic pr ssur e
HSE adv i ce
COMAH
QR= = = =
Figure 24 What stops companies from considering human factors of accident prevention?
60%
50%
Onshore
% of responses
40%
Offshore All
30%
20%
10%
0%
Lack of under standi ng Cost Don't r econgi se HF Other Pr ef er engi neer i ng HFi s f uzzy Don't bel i eve peopl e er r Fatal i si ti c Unsur e
QS= = = =
3.2.13 Roles and responsibilities The main group of respondents comprised health and safety professionals, followed by managers. As shown in Table 7, over half of respondents had a significant involvement in activities labelled as safety matters, including: Accident investigation & follow up Safety policy or strategy How to improve accident prevention Risk assessments Safety culture initiatives Design of SMSs Operating procedures
45% had a significant involvement in safety cases. Less than 50% had a significant involvement in organisational and Human Resource issues such as organisational change and supervisory practices. Indeed, less than 20% had a significant involvement in Human Resource issues including: Manning levels Working hours/shift systems Job or task design Recruitment of operators etc
When asked who else has a significant involvement in these matters, the four main responses were: Operations managers; Health and safety staff; Other All line management.
QT= = = =
Table 7 Extent of involvement in various human factor areas
Significant
Some
None
Accident investigation & follow up Safety policy or strategy How to improve accident prevention Risk assessments Safety culture initiatives Design of SMSs Operating procedures Physical working conditions COMAH / safety case production Selection & man'gt of contractors Organisational change Training / selection of operators etc Supervisory practices Team organisation/structure Design of plant Manning levels Working hours/shift systems Job or task design Recruitment of operators etc
70% 70% 67% 65% 65% 60% 60% 46% 45% 34% 33% 30% 29% 26% 22% 18% 18% 16% 14%
22% 27% 30% 34% 30% 35% 33% 45% 34% 48% 56% 49% 54% 45% 48% 44% 41% 60% 28%
8% 4% 4% 1% 6% 5% 7% 9% 21% 18% 11% 21% 17% 28% 30% 38% 41% 24% 57%
QU= = = =
3.2.14 Have you received training or information on human factors? Just over 60% of respondents had personally received information or training about human factors, as shown in Figure 25. Figure 25 Proportion of respondents who have had human factors information / training
70.0% 60.0%
% of responses
50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Onshore Offshore
Yes No
All
As shown in Figure 26, the most common forms of contact are: Training at 41%; Leaflets etc at 25%; Seminars at 18%, and; Consultancy at 6%.
There is an apparent difference between onshore and offshore respondents, with a higher citation of seminars by offshore respondents at 25% compared to 9%.
QV= = = =
Figure 26 Types of information/contact about human factors
50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

Leaf l et I ns pec t i on Saf et y c as e quer i es Semi nar Webs i t e T e l ' He l pl i ne Consul t anc y T r ai ni ng Can't r eca l l Ot her
The most commonly cited source of best advice was Other at 54%, followed by the HSE at 27% of responses. 10% cited consultants and 8% cited institutes such as IOSH. Many of the Other responses actually fell into the latter categories, specifically the HSE, consultants and trade associations. Once all the results are adjusted to account for the reclassification of Other sources, the most common source of best advice are: Consultants at 21%; HSE at 19%; University courses, including MSc at 15%; NEBOSH at 14%; Trade associations at 7%, and; IOSH etc at 5%.
RM= = = =
% of responses
When asked about the support from the HSE, the majority of responses were positive. A minority were indifferent. When asked how the HSE could improve its advice, the respondents mentioned three main types of improvements. There were More interactive inspection wherein the HSE work with firms rather than take an adversarial approach, more and better guidance and promotion, and thirdly less charging (onshore). These are summarised below in Table 8. Table 8 Suggestions for improving HSE human factors support
Suggestion More interactive inspection More guidance, practical examples and case studies Faster and better resourced response to human factors issues More promotion of human factors, including seminars Clearer guidance More use of Videos and the web Charging More industry specific guidance Work with trade associations Number of citations 7 7 5
5 5 4 3 2
RN= = = =
3.2.15 What format would you like advice in? The most common preferred form of advice was a website, cited by nearly 70% of all respondents, as shown in Figure 27. This was followed by leaflets / publications cited by 50% of respondents, and then by human factors seminars and Videos / CDROMs cited by 20% of respondents. In total 30% preferred seminars, when the citations for a specific human factors seminar and a broader seminar are added together. Just 10% cited site visits and 13% cited a telephone help line. It should be noted that, as respondents could offer more than one suggestion, the percentages add to more than 100%, i.e. 79% of respondents can suggest websites and 50% can suggest publications. There are no obvious differences between onshore and offshore respondents regarding their preferred format. 3.2.16 What should the HSE do to encourage companies to apply human factors? The most common suggestion was Other followed by More promotion of human factors, More guidance and more site-based advice. If you add together examples of error, best practice examples with case studies and more guidance, they account for one third of responses. The free text responses to this question focus on raising awareness and educating companies regarding human factors, including provision of more practical advice and guidance. Less than 5% suggested more enforcement or working with trade associations. The Other responses focus on the provision of clearer advice, more promotion in the form of seminars and demonstrating that human factors works, whilst also working in a co-operative manner with companies. Some specific ideas include training packages and road shows 3.2.17 When should advice be given? As shown in Figure 28, the most common response is Earlier the better, accounting for one third of responses, followed by Continuously at 20% and At college by 15% of responses. If you add At college with Outset of professional training and NEBOSH courses, these responses account for 24% of responses. This was an unprompted question. No one mentioned when doing safety cases and only 0.44% of responses were After a major accident.
RO= = = =
Figure 27 Preferred form of advice/information
( Multiple answ ers allow ed so total % exceed 100%) 80% 70%

% of respondents
60% 50% 40% 30% 20% 10% 0%

Websi t es Leaf l et s HF seminar Vi deos/ CDs Tel ephone helpli ne Par t of r out i ne visit
Par t of broader seminar
Spec if ic visi t s
Ot her
No Answer
RP= = = =
Figure 28 Best point in time to receive human factors training / information
45% 40% 35%

% of responses
30% 25% 20% 15% 10% 5% 0%

Earlier t he bet t er Cont i nously At college
When assume Out set of prof ' man' gt r ole t r aining
Ot her
NEBOSH t ype of cour ses
Out set of engi neer ing pr oject s
RQ= = = =
3.2.18 Why is the concept of SMS better established? The survey asked respondents why the concept of Safety Management Systems (SMS) appears to be better established than the concept of human factors. The free text responses were categorised by the interviewers. The results are shown in Figure 29, for options mentioned by 5% or more of respondents. With the exception of Other, the top four main reasons cited are: SMS is a system; SMS is easier to grasp; SMS can be documented, and; SMS has been around longer.
The first three reasons account for nearly 40% of all responses. If you add together SMS is a system, SMS is better defined, SMS is similar to Quality and SMS is well bounded, these account for 31% of responses. Thus, the perception that SMS is a better-defined system that is easier to grasp accounts for a large proportion of responses. The Other responses include: Human factors should be part of SMS; SMS is established in law, and; Clients ask for SMS.
3.2.19 Other suggestions by respondents. Respondents were given the opportunity to offer any comment or advice they saw fit. These comments reinforced earlier points that the HSE should promote human factors via seminars and site advice, advice and guidance (avoiding academic terms) at low cost, focusing on practical advice and demonstrations of how error can cause accidents. Many respondents indicted that the HSE were already on the right track, regarding the promotion of human factors, and simply needed to do more.
RR= = = =
Figure 29 Why is concept of Safety Management Systems better established than human factors?
16% 14% 12%

% of respondents
10% 8% 6% 4% 2% 0%
SMS is a system SMS is easier to grasp SMS can be SMS been documented around longer Other Unf amiliar w ith HF SMS is better defined HSG65 is easy to follow
RS= = = =
3.3
MAIN IMPLICATIONS
The main conclusion of the survey is that an educational approach is required for the promotion of human factors, alongside ensuring that advice and guidance is practical and clear. Most respondents believe human factors is a useful concept and accept the need to manage human error as part of major accident prevention. It appears to be a question of demonstrating how human factors can help, and ensuring firms have a valid and comprehensive understanding of the scope of human factor issues. The main implications of the survey are: Awareness and understanding of human factors is a critical factor in both its application and acceptance by industry; The perceived affordability and practicality of human factors solutions is also important; Promotion should focus on increasing awareness and understanding of human factors, including demonstration of how error causes accidents and how human factors can solve these problems; There is a need to provide a well-bounded and defined view of human factors, and; The preferred format for HSE guidance is the website although there is a general need for training and seminars.
Respondents appear to have a reasonable understanding of human factors and believe it is an essential aspect of major accident prevention and a useful concept, but regard it to be somewhat ill-defined in itself and harder to grasp when compared to Safety Management Systems. Thus, the survey reinforces the need for the continued promotion of human factors and provision of guidance and information, particularly via the website, publications and seminars. It is also pertinent to note that many respondents cite NEBOSH and other safety training courses as a source for human factors guidance, as well as consultants. Consideration could be given to increasing the inclusion of human factors in common safety courses and providing materials for use by organisations who offer training to industry. It is also pertinent to note that Health and Safety professionals have less input into matters such as manning levels and recruitment. Promotion should cover operations managers and line management in general as well as health and safety professionals. 3.4 SURVEY-BASED RECOMMENDATIONS
The recommendations for the HSE arising from this survey are: To continue with as large a scale of promotion of human factors as HSE resources allow; Make more use of the HSE website to promote human factors and provide guidance; Produce examples of where error has caused accidents and examples of how human factors has solved problems / prevented accidents;
= = RT
Include information on the incidental commercial benefits of human factors interventions; Try to increase the attention to human factors in courses, such as NEBOSH courses; Provide human factors training materials for use by firms and consultancies, and; Target advice and promotional work on operations managers and line managers as well as health and safety professionals.
It is also recommended that, on the one hand, guidance should aim to illustrate the scope of human factors issues whilst at the same time being well-bounded and easy to grasp.
= = RU
4 LESSONS LEARNT FROM OTHER PARADIGM SHIFTS
4.1
INTRODUCTION
This section of the report identifies the lessons learnt for the promotion of human factors in the UK hazardous industries from three examples of paradigm shifts in the approach to the management of major hazards. As far as possible we sought examples of change that were not simply a result of new regulations. Initial exploratory discussions focused on the identification of appropriate examples. The examples had to meet the following criteria: There was a significant and sustained change in the approach; The change in thinking occurred in a relatively short period of time namely less than a decade, and; The topic is analogous to one or another aspect of human factors, such as an example of analysis or an approach to the management of people.
This was followed by in-depth discussions with 18 leading industry figures and experts whose tenure enables them to outline the circumstances and factors prompting each respective change in thinking. A review of publicly available information on the causes of changes in thinking was also completed. The examples of paradigm shifts chosen are: Safety Management Systems (SMS); Quantitative Risk Assessment (QRA), and; Crew Resource Management (CRM).
These examples have been selected because: SMS is cited as an example of a concept that has progressed from a new term in the late 1980s to a standard and well accepted aspect of safety today; QRA provides an example of the uptake of a new form of analysis this may throw some light on how to encourage the uptake of human factors analysis methods such as task analysis, which often form part of the human factors input to safety cases; CRM is cited as the most successful example of the application of applied psychology to the prevention of major accidents.
We focused on the uptake of QRA and SMS in the UK offshore oil and gas industry on the assumption that these methods have enjoyed relatively more application offshore than onshore. In the case of CRM, we focused on the aviation industry where CRM has similarly been applied the most.
= = RV
In each case the discussions explored: 4.2 What events formed a background to the paradigm shift, such as a major incident or new regulations? Was emphasis placed on required outcomes, the process of assessment, prescriptive standards etc? Who within companies was targeted? Who else was targeted, such as consumers, customers etc? What evidence is there that these initiatives have been successful? KEY FINDINGS
Before discussing the three examples, it is pertinent to note that our initial exploratory discussions found that few leading industry figures can confidently identify examples of rapid changes in thinking in the field of safety or human factors. Indeed, in cases such as the application of ergonomics in the military sector, it is suggested that there has been an incremental and gradual uptake of ergonomics over a number of decades. A review of the three examples suggests that there is a number of factors that contribute to the successful initial uptake of a new way of safety management thinking, namely: The occurrence of one or more major accidents; Identification of causal factors and the acceptance of this view by industry; A clear and accepted link between the cause of the major accident and the proposed solution; A well defined and bounded solution, and; High level industry sponsorship of the solution.
A number comments received during the course of the interviews suggest very strongly that the uptake of CRM and QRA in industry can be attributed to a large extent to the fact that these are small, well-delineated technologies that can be easily understood by management and employees of an organisation. This is in contrast to human factors, which, as a term, can in itself cause confusion and is not perceived as a clearly defined single entity, but as a range of disparate elements with no apparent coherent structure. Some interviewees spontaneously raised the issue of human factors, others were prompted for their views towards the end of discussions. Inasmuch as there was any consensus between the interviewees, it was that human factors had not yet been adequately presented to them in a way that convinced them of its value, although most had experience of specific human factors initiatives having been introduced into their organisation, for example, behavioural modification methods. It seems, then, that there is a need to present human factors in an intelligible way to industry setting out in a transparent and easily accessible manner the broad subject matter and illustrating the value of taking a human factors approach to problems of human performance.
= = SM
The acceptance of the solution often occurs against a background of public debate and research that raises awareness of the causal factors and common acceptance of the proposed way forward. The citation of incidental business benefits may reinforce the case for the solution but the prevention of another major accident is typically the main driver. A further conclusion from the interviews is that a typical evolution for paradigm shifts is as follows. An accident (or series of accidents) occurs. Industry and the regulator either together or independently analyse the underlying causes (there may also be a formal public inquiry if the accident is of sufficiently high profile, which provides a detailed analysis of the event). Industry rapidly responds to the event by developing initiatives intended to solve the problem. In parallel with this, the regulator develops a set of requirements for industry and supporting guidance or codes of practice. HSE enforce against the new requirements. In due course, both industry and the regulator will develop a common understanding of requirements and the manner of demonstrating compliance. However, although there will clearly be dialogue between industry and regulator, it is possible that their expectations from the initiatives will not be exactly aligned. Industry will have embarked on a course of action based on its intimate understanding of its business processes and safety systems. HSE will have developed its own view based on within-industry and cross-industry comparisons, research and its expertise in safety legislation. These two approaches may not necessarily match. The view of interviewees appears to be that industry is always ahead of HSE and sometimes feels forced to apply an approach that the industry believes has already served its purpose and no longer provides a benefit to safety. The lesson for human factors is perhaps to increase the level of industry involvement in developing a rationale for using its tools and techniques with clear guidance emanating from HSE to support the process. The term solution is intentionally used here to emphasis that the examples of paradigm shifts focused on how the accident could be prevented. Whilst the analysis of the cause of the preceding accident(s) is a pre-requisite for acceptance of the solution, the analysis is followed by an explanation of how the proposed solution will prevent re-occurrence. As time progresses, the continued uptake of the solution is influenced by: The attitude of the workforce, and; The attitude of the regulator.
The workforce attitude is important in a number of respects. Firstly, company management commitment to an initiative is more likely to be sustained if they can see evidence of success. The success of an initiative, particularly ones focused on the behaviour and performance of staff, is significantly affected by its acceptance by the workforce. Thus, if the workforce accepts the initiative and provides positive feedback, this is likely to reinforce and maintain management commitment. Secondly, the voluntary uptake of an initiative is often patchy. The encouragement of uptake amongst laggards by the regulator reinforces and extends the application of the new way of thinking.
= = SN
Once the initiative has been implemented, its continued acceptance can be influenced by the evidence of success, particularly whether there are any measurable indications of performance improvement. 4.3 IMPLICATIONS FOR THE PROMOTION OF HUMAN FACTORS
It is suggested that these paradigm shifts hold a number of lessons: The promotion of human factors should focus on solutions rather than restrict itself to an explanation of the cause of accidents; It is vital to have a well-defined and bounded method; It is useful to be able to demonstrate the link between the proposed method and the (potential) causes of the major accidents, and; It is useful to generate high-level industry support for the way forward and active involvement in developing and promoting the method.
As time progresses and the method is implemented, it is important to solicit workforce acceptance of the new method, and thereafter develop measures of safety performance. The continued uptake of a method can be influenced by evidence of its success. The enforcement action of the regulator becomes relatively more important after the initial stages of implementation, with respect to encouraging the unconvinced to apply the new method. Whilst the publication and presentation of explanations of the cause of accidents and the possible resolution of these is an essential activity, successful paradigm shifts are distinguished by being well defined and bounded methods that are characterised as a means of accident prevention. In the case of human factors analysis, such as Human Reliability Assessment, the lesson from QRA is that it should be promoted as a means of: Ensuring potential causes (errors) of major accidents have not been overlooked; Helping to choose between (say) two engineering options (when there is a significant cost issue or uncertainty about whether the risk is acceptable); Providing an input to training, such as highlighting potential errors and their consequences to staff, and; Demonstrating that probability of a major accident is low enough.
In the case of human factors interventions such as control room ergonomics and competence, the lesson from CRM is to develop a standalone method of addressing each of these matters that is well defined and bounded and focuses on solving and pre-empting performance problems. The lesson from SMS for human factors matters such as safety culture is to again well define and bound the communication, specifically by providing a discrete method / management model.
= = SO
4.4 4.4.1
CASE STUDIES Safety Management Systems
Discussions indicate that the uptake of safety management systems can be split into three phases, namely; Pre-Piper Alpha; Early 1990s; Late 1990s.
Pre-Piper Alpha Prior to the Piper Alpha disaster legislation already contained requirements for companies to attend to safety management. For example, Sections 2 and 3 of the Health and Safety at Work Act make it clear that the employer has a duty to set out a safety policy and to provide systems of work, information, instructions and training for the health safety and welfare of employees. Initially, this aspect of the legislation was not enforced centrally. Inspectors tended to operate within their local area inspecting local plant. It was only later that they began to target poor performers and to take a view of corporate arrangements for health and safety. They could then consider local issues as a reflection of overall organisation and management arrangements and to present the company rather than the local site with inspection reports and requests for improvement. HSE published a number of documents such as, Success and Failure in Accident Prevention in 1976. This set out the factors distinguishing companies that performed well from those that performed poorly in terms of their safety record. It drew attention to the safety management practices that the regulator would expect to see in good companies. The ACSNI 3rd report, Organising for Safety published in 1993, drew similar conclusions to this earlier document, and collated a wide range of source information to support those conclusions. Other HSE publications concerned with managing and monitoring safety appeared in the early 1980s. Early 1990s In 1991, HS(G)65, Successful Health and Safety Management was published. This was a watershed document that was released, coincidentally, following a number of notable accidents in the preceding years: the Kings Cross fire, Piper Alpha and Clapham. The public inquiries into those accidents referred to safety management as a key issue. The Offshore Safety Case Regulations then appeared (in 1992) and made explicit reference to Safety Cases and Safety Management. The Management of Health and Safety at Work Regulations were published in the same year. The CIMAH Regulations followed in 1994. Thus, a considerable amount of activity took place focusing on safety management and a number of conferences publicised the issue even further. At around the same time, quality management began to receive increased attention. ISO 9000 was published in 1994 following the increasing adoption of BS EN 5750 published in 1979.
= = SP
There was a widespread belief within industry that a safety management standard would not be far behind and organisations wanted to prepare for this. It was also noted that: In the case of the offshore industry, these events were reinforced by the interest taken by OIAC (Oil Industry Advisory Committee) and further interest was stimulated by the universities in Aberdeen who produced a considerable amount of work on the subject and hosted a number of conferences. One industry interviewee reported that the Management of Health and Safety at Work Regulations forced organisations to attend to SMS. Prior to the existence of MHSW, companies did what they believed to be reasonable and, at that time, HSEs approach appeared rather prescriptive leaving little room for individual initiatives. SMS was a talking point for a long time. HSE in particular raised the debate and this led the industry to feel that it was perhaps being left behind in this new approach. Industry Directors and senior managers did not wish to appear nave in their interface with the regulator or with their peers and made sure they were familiar with the concepts. Knowledge of safety management also became an essential element in career progression: managers would be expected to be familiar with SMS and to be able to put safety management ideas into practice. It was also generally accepted that safety is good business and that SMS were seen as supporting business through the prevention of major losses. It is noted it is also important for management to acquire some measure of success. In the case of SMSs they can be audited and the results can be rated to provide a measure of success. Thus, it is suggested that SMSs offer features that meet management expectations and requirements.
Thus, interviewees report that offshore oil and gas companies, and others, adopted safety management systems in the early 1990s partly because this subject was given increased emphasis by HSE and by the public inquiry into the Piper Alpha disaster, which culminated in the Cullen report. But SMSs were also adopted because they were similar to other management systems that companies could understand and identify with. Late-1990s (Step Change) The late 1990s in the offshore industry are dominated by the Step Change initiative. The Step Change initiative came about when a small number of individuals within industry became concerned that safety performance had reached a plateau. BP in particular was a driving force. The industry had typically focused on engineering improvements making systems more intrinsically safe then later focused on systems and procedures. The next push was felt to be in the area of behaviours improving individual attitudes and behaviours. It was felt that there were many areas of good practice in industry that needed to be shared to bring the industry up to the same standard. The Step Change initiative was launched at a press conference by the Chairmen/ Presidents of the 3 main trade associations: UKOOA, IADC and OCA at the Offshore Europe conference in September 1997. Several work groups were formed and comprised individuals from different companies and at different levels in those companies from Senior Managers to workforce
= = SQ
level. They addressed certain key topics, for example, rig floor safety, and worked to provide methods of solving them. A cross-industry forum was also established involving industry leaders: Managing Directors etc. Other industry associations joined until all the major groups were involved including unions. HSE participated in the industry forums. It was felt, however, that after 12 months, a dedicated resource for step change was required. Some of the groups had become fragmented and communications needed to be improved. For this reason, a support team was formed. The forum was good for information sharing, but not for decision-making. So a steering group was established comprising MDs and Senior Managers. The steering groups role was to support the working groups. The steering group met monthly and the support team provided support to the steering group. The four individuals on the support team were loaned by their companies to the group and represented a cross section of trades across the industry. These individuals also participated in the working groups. They produced a monthly newsletter and created a website for information sharing. Networks have also been established via safety representatives. They share information, mostly by e-mail, but they also attend regular meetings, approximately every 3 months for steering group members. From an early stage, it was decided that behavioural change was a key focus for Step Change. However, the industry is more project-based it tends to identify a given issue and proceed to solve it providing a defined deliverable at the end. Step Change was not really organised in the same way and the focus on safety behaviour did not lend itself to this approach and outputs were less tangible. The support team was particularly interested in supporting engagement (buy-in, ownership) of the industry, again, a fairly intangible end. This seemed to have been achieved, however. Facilitators, who supported the initiative and who engaged with people within the industry only occasionally, noticed a change in the dialogue over a number of visits. People were listening to each other more and were more accepting of ideas presented. Tangible measure of success, not surprisingly, were based on injuries, more specifically, injury rates (injuries per 100 000 of the workforce). It can be difficult to measure the size of workforce however, especially when a given worker can spend some of his time off- and onshore. But, taking into account the gross amount of work performed offshore, there has been a significant improvement in injury rates over the last 3 years as much as a 40% reduction. The safety culture maturity model was used to gauge the position of the offshore industry. If was found that the industry was very mature on techniques it knew what was available and how to use them, but it did not implement recommendations and ideas for improvement in a mature way. There was tendency to see the tools as providing a tick in a box. This area still needs to be improved. The key to the success of introducing Step Change was in involving the workforce at an early stage. There was initial scepticism the workforce had seen it all before, but people did get involved nevertheless. Step Change was encouraged by UKOOA. This caused some of the initial scepticism, but the workforce then saw the value of the initiative and that it was not a matter of simply doing as management dictated, but that they themselves had some input and therefore control over the outcome.
= = SR
The initiative was scheduled to last for 3 years, i.e. to end in September 2000, but, with the launch of HSEs Revitalising Health and Safety initiative in the same year, it was decided to continue Step Change and to link it with HSEs scheme. Industry has recommitted to it; this in itself is a measure of its success. More conventional measures of success are partly statistical based on accident and incident rates. However, these are regarded as poor measures, particularly in the climate of downsizing where, the smaller workforce may have commensurately fewer incidents, but where morale is low, and thus incidents have increased as a result. Lessons learnt from SMS A number of lessons were suggested by interviewees: A companys reputation is a major issue. It would not like to be seen to have a major incident because it had not applied a commonly-available technique. Ideas for paradigm shifts should be made at the most senior level Vice President or very senior management in order to make sure the company takes it up. Middle managers are largely instructed to implement the ideas passed down to them from this higher level. Success measures should not be based on accident rates. There are few accidents and it would be difficult to attribute any change to the introduction of a particular practice or method. The measure of success in SMS audits is that the results of those audits are not random. That is, that the results are consistent with what was expected and problems do not appear from one audit to the next that come as a surprise to the organisation. Consistency would suggest that the SMS approach is valid and that the audits are measuring what they are suppose to measure. Concerning human factors, it was suggested that HSE should translate the appropriate regulations for the industry, that is, describe clearly which aspects of the regulations are concerned with what HSE regard as the human factors issues. HSE should avoid the danger that industry sees the introduction of human factors as this months idea. Crew Resource Management
4.4.2
CRM in the aviation sector There are some differences of opinion about the year in which CRM was first considered in the aviation industry, when it became a legal requirement and which organisations require CRM training to be provided. One possible origin of CRM is a NASA workshop in 1979 that described research into air crashes and indicated that a primary cause was human factors. In this context, human error includes failures of communications, decision-making and leadership. Analysis of aviation accidents through the 1980s concluded, again, that many were caused by problems of coordination between flight crewmembers. Human Factor specialists within Eurocontrol confirm that CRM was established because investigations indicated that although technical skills were good among crews, non-technical skills were not. This led to accidents that were extremely costly to the industry. Three accidents were particularly influential: the KLM/PanAm collision in Tenerife 1977; Eastern Airlines flight into the Everglades in 1972 and the mid-air collision over Zagreb in 1976.
= = SS
Crashes thus seem to have stimulated the interest, rather than a realisation of the inherent value of CRM. CRM became a requirement within the aviation industry in the early 80s and variations on the original idea have been formulated and applied. Interviewees generally agreed that CRM training has been provided within the industry for around 20 years. More recently, regulators in the industry, CAA and JAA in particular, have mandated the adoption of CRM in airlines, and audit and inspect these organisations to check compliance. CRM training has been a requirement by CAA and JAA since 1995 but there is no requirement to assess the training. It is also a CAA licence condition that pilots must pass human factors examinations. Certain companies require crew that they hire under contract to have undertaken CRM training. Shell Aviation is one example. In the USA, CRM training is also included in Federal Aviation Regulations - Code of Federal Regulations 14 (CFR 14) Parts 121 and 135 in particular (although one interviewee believed it was not mandatory under FAA regulations). CAA actively sets rules and regulations for CRM. To assist the industry, they established a pan-European working group that, among other things, sent out a skeleton syllabus/prototype course. They targeted the CAA-equivalent organisation in each European state represented, or the appropriate authorities where such an equivalent organisation did not exist. Different aviation authorities regulate in different ways; some are more prescriptive than others, some are more goal-setting and some regulate lightly, providing guidance and encouragement rather than strict enforcement. Some companies and pilots within those companies maintain that CRM has no value. Notwithstanding this, it is reported that a driver for some companies is cost saving (or cost avoidance). Aircraft can be forced out of service as a result of minor incidents caused by ground crew. The costs in terms of loss of revenue, repairs and increased insurance premiums can be very high. In determining the success of CRM, again, it was noted that there remain some dissenting voices. The feeling was expressed that CRM has been in place for a long time, the aviation industry has spent a lot of resource on it and yet there is still no firm evidence to prove its success or failure. Whilst CRM has been validated, according to Helmreich (a key advocate and researcher of the technique) in that it produces the desired changes in attitudes and behaviour, Helmreich also agrees that CRM does not have the desired effect on all trainees: some have worse attitudes following training. Furthermore, CRM training can decay over time, thus, there is a need for recurrent training. CRM does not always export well to other cultures both within and beyond country boundaries. Differences in cultures, between airlines and between nationalities, therefore need to be taken into account in presenting CRM to the industry. Some cultures do not question authority, others do. Newer recruits tend to be naturally more questioning and less subject to authority than former recruits. The extension of CRM to other members of the crew: flight attendants and maintenance, has not always been helpful. In some cases it has had the effect of diluting the value of the training by losing focus on the main issues of human error.
= = ST
It is difficult to assess the success of CRM against accident rates because it is impossible to relate the CRM training to the improvements made: there are too many variables. Evaluating the impact of CRM training is not straightforward. Research teams from Aberdeen University have generated a means of tracking attitudes pre- and post-training. They have also established a taxonomy of indicators for observing and measuring behaviours. Accident rates are used, but these are not regarded as particularly valid or reliable measures. JAA has sanctioned work to develop measures. Two projects in particular, NOTECHS and JARTEL are due to produce final reports soon. NOTECHS is concerned with non-technical skills and JARTEL aims to produce measures based on observable tangible behavioural markers. The research group at Aberdeen University believes that any means of quantifying results is most effective in demonstrating the value of an initiative such as CRM. They attribute the success of HSEs Safety Climate Tool to the fact that this provides a measure. Thus, the concern about validating the effectiveness of CRM is pertinent to the issue of how best to promote an initiative. Notwithstanding these concerns, Air Traffic Control organisations have begun to adopt the principle of CRM (known as TRM) and similar training initiatives have been introduced into the medical profession. Aviation maintenance teams in the UK are beginning to adopt CRM, although an interviewee expressed the view that maintenance teams will need to be forced to adopt CRM and to be closely regulated. CRM in the offshore industry An ongoing initiative is taking place to introduce CRM in the oil and gas industry. This has received mixed support from the industry with some companies paying for studies in this area, and Shell, for example, is providing a workforce as guinea pigs. Some companies are more advanced in their approach. Maersk was cited as an example, and a wide range of their personnel receive CRM training. This company has reduced the rate of serious accidents from 1 in every 30 years to 1 in every 90 years. The interviewee believes this convinced the insurance underwriters to reduce the premiums paid by the organisation. One interviewee felt that there was still a need fully to engage management and to ensure that they are involved in the training, and felt that a primary purpose of CRM is to close the gap between management and workforce: to ensure that they work more closely together. His personal view is that the oil and maritime industry do not learn well from other industries. Management in these industries is also generally poor. 4.4.3 QRA in Safety Cases
Interviewees report that there were two drivers for the uptake of QRA. Safety Case Regulations Firstly, the Safety Case Regulations have been the primary driver for encouraging organisations to use QRA. Indeed, one interviewee argued that QRA was adopted because the regulations dictated it (strictly speaking, the requirement for QRA was not in the Safety Case Regulations themselves, but in the accompanying guidance). QRA was the only means of showing that the Temporary Refuge impairment criterion was met.
= = SU
QRA was introduced because the Cullen report suggested the need for a suitable and sufficient QRA to be produced by the industry. Operators did not understand their hazards well enough and were therefore taking risks. Some companies were using QRA before Cullen, others were operating intuitively applying what they would deem to be good engineering judgement. QRA is a method for taking an objective look at risk, although organisations often make decisions despite the evidence of the QRA. There are still some problems with QRA: it carries a degree of uncertainty, but provides a best estimate of risk. Thus, QRA is considered by regulators and the industry to give a clear and systematic presentation of potential areas of risk. One interviewee believes that the Safety Case Regulations must have had a positive influence on safety if only because it forced companies to consider problems in a formal way and to present them in one (albeit large) document. There is also a noticeable increase in the uptake of human factors technologies, particularly behavioural modification methods, which seems to have stemmed from the formal analysis. Organisations have become more aware of the role of human error in accidents and incidents (96% was quoted as the proportion of accidents and incidents with human error as a root cause). Useful pragmatic job aids have been introduced as a direct result of QRA in safety cases, such as the issuing of plasticised cards indicating the high risk areas in different modules of the installation, and describing the hazards in those modules. Risk assessment has had a significant influence on attitudes, but senior managers need to be conscious of the effect they have down the hierarchy. The offshore oil and gas industry, in particular, has very much a can do attitude and this can have the effect of focusing middle managers downwards on the latest issues to emerge from QRA, to the exclusion of other issues. A safety case, with QRA as a key element, provides clear direction to a company, but sometimes, it is seen as an end in itself and is not used as a guide to improvement: it simply, sits on the shelf. Internal company research The stimulus for introducing QRA into one interviewees company came from internal research and development groups. They discovered the method and proposed its use within the company. It was accepted because it is a convenient way to make an ALARP argument, although one interviewee felt that a major problem is that QRA does not provide an absolute standard. The method generates a risk probability, but there is no guidance as to what is acceptable. Indeed one interviewee felt that QRA was not forced by external legislation, but, as indicated, by internal company policies that prescribe when it should be used. It is used mainly if an investment dilemma arises, that is, as a cost-benefit analysis tool. The interviewee regarded the introduction of QRA as just another aspect of management of change. Another major reason for its acceptance is that it allows the company to cut costs. However, there are some risk-based arguments that the company would not be prepared to present to the Regulator, the interviewee felt, for example, that the risk of visiting unmanned offshore platforms to test lifeboats, could not be justified. His perception was that, more people have been killed than saved by lifeboats.
= = SV
Thus, notwithstanding the background of Safety Case Regulations, QRA was originally adopted because it seemed to be a good method that provided a measure of risk. The industry recognised QRA as a useful idea and it received wide acceptance, in particular, as a means of developing ALARP arguments. Recent developments There is a backlash against QRA, exemplified by an increasing reluctance to use it as a method. This did not come about as a momentous turning point, but as a slow drip feed of disagreements, for example, regarding issues presented in safety cases. Indeed, another interviewee argued that QRA was not regarded as a success but as a burden. The initial learning process was useful, but the industry has moved on. In addition, the company makes decisions on the basis of public relations (recognising the risk of adverse publicity) rather than strict cost-benefit. Whilst QRA is available within the company it is only included in safety cases as a last resort. Another interviewee suggested that the industry learned lessons from the initial use of QRA and some surprises were disclosed. After that, the interviewee believed that no further benefit was gained. The industry had an improved perspective on risk, but felt that they were producing numbers simply to populate the safety case, rather than for any real benefit. In the particular case of TR impairment criterion, many platforms are bridge-linked. Thus, the TR is remote from the hazardous areas and any changes to the working platforms had minimal impact on TR risk. One interviewee felt that HSE had changed its stance on QRA and had begun to promote good practice rather than strictly risk-based arguments for making changes. One interviewee believes that HSE has focused too much on QRA and that this is one of the messages in the publication, Reducing Risks, Protecting People. QRA is still used, but is not as prominent as it used to be. Finally, an interviewee reported that a problem with QRA is that it can result in protracted discussions between HSE inspectors and industry specialists concerning the probabilities generated. It is not clear how certain an analyst can be about the results derived from QRA. A more pragmatic approach may be required based on finding a compromise and asking, did the approach taken seem reasonable? In many cases, the decision to take action, particularly when it results in spending a lot of money on a solution, stems from the fear of adverse public opinion rather than QRA. An example given was the decision not to install a second valve in a system to increase system safety. The decision was reversed when the company considered the consequence, in terms of public relations, if the system failed in its present configuration. Certain company policies are beginning to reflect this overall consequence for the company. Lessons learnt One interviewee suggested that the appropriate targets for innovations are middle management. Senior management need to be convinced of an idea and it is middle managers that typically identify and evaluate new methods and approaches and sell them upwards. Someone will usually act as a champion for a new method and will carry it forward. Finding resources to
= = TM
make this process work, however, can be a problem. It is easier if the prevailing culture regards safety as important. Regarding human factors, the interviewee was not convinced that HSE understood this subject area and believed that HSE is waiting for the industry to generate ideas. The company considers human factors in the design of Control and Instrumentation systems, and also in risk analysis and to account for human behaviour in emergencies. This has led to some innovations in communicating risk to the workforce (a traffic light system indicating the safety state of each linked platform, for example, which shows which platforms are safest in the prevailing conditions). 4.5 CASE STUDY CONCLUSIONS
Companies can be positively influenced by the overall controversy generated by accidents, the subsequent public inquiries and the reports, conferences and guidance that follow. Most companies will also maintain some awareness of the climate of change generated by new ideas emanating from research or publications from independent bodies. Regulation also focuses industry on the need to address certain issues and in some cases appears necessary to ensure that organisations comply with best practice. Workforce involvement and buy in is seen as essential to ensuring that safety management is adopted. This buy-in may not be achieved by focusing on the safety benefits but on other outcomes of introducing the initiative such as cost saving or the intrinsic motivation of being involved in a change process. The workforce should also see the benefits of the new initiatives in the form of simple, practical and transparently useful tools that they can deploy in the workplace. The workforce may also be involved in developing such tools to enhance ownership. Visible acceptance by and support from trade associations, unions, learned societies, international agencies and other respected bodies for the initiative is also important in securing workforce buy-in. Senior managers are a key focus for introducing new initiatives and overall changes in company approach. However, they may require persuasion by middle management or by external bodies to adopt the initiative. This can focus on public relations issues or cost saving/cost avoidance. Networking and information sharing is important to ensure that good practices are transferred within and between organisations. Some measure of success will be required. People generally feel more comfortable with a numerical measure but it may be that the only measures of success available are qualitative and may be fairly intangible such as changes in behaviour, attitudes or cultural maturity. It is unlikely that an obvious safety measure such as accident or incident reduction can be used as a success measure because it is not possible to relate the introduction of the new initiative to the change in safety: there are too many confounding variables. No initiative will receive universal acceptance. There will always be dissenting voices and evidence of failure in specific areas. The prevailing culture, which may accept the change or not, is a key factor. There are likely to be cultural differences within and between organisations to be considered. Some initiatives may gain initial acceptance and then meet with resistance later the progress of an initiative must therefore be monitored.
= = TN
It is important to integrate the new initiative with existing systems so that it is not seen as a stand alone package. This is important in that new initiatives can displace ongoing initiatives and be viewed by the organisation involved as the latest fad rather than a key to performance improvement. The principles of change management should be adopted to ensure that the initiative does not evolve too quickly and thus become diluted in its effect. Although HSE is a large body with many different divisions and a wide variety of personnel, it should be aware that it is regarded by many as a single entity. The corollary of this is that any adverse attitudes towards any part of HSE will be generalised to the entire organisation. However far from the truth are the industry perceptions, they must be accounted for in HSEs approach to introducing change. This is especially true if industry is to regard the change as helpful rather than a burden and a waste of resources.
= = TO
5 CONCLUSIONS
The results of this study reinforce the need for the HSE to promote human factors and vindicate the current range of promotional work being carried out by HID. However, it is clear that the current level of awareness and understanding of human factors is low and that further educational and awareness raising work is required. Human factors is often regarded to be common sense and ill-defined by duty holders. If the aim is to change practices, it remains necessary to demonstrate that human factors entails more than the application of intuitive ideas. Industry does look towards the HSE to provide the lead in this area and expects it to provide appropriate information and guidance. The general reaction to HSE work is positive with a simple request for the HSE to do more. Therefore, it is concluded here that there is a need to create a distinct human factors brand that distinguishes the HSE advice and requirements from common sense, and hence conveys the message that there is scope for improvement in duty holders practices. Our review of past experience and survey of current opinion indicates that the application of human factors is driven by major accident safety concerns and regulatory expectations. Indeed, we are unable to identify any significant paradigm shift in the field of safety management that was not prompted by these concerns. Whilst the wish to avoid the costs associated with a major accident is an obvious motivation, it is difficult to find any evidence of human factors being applied for the sake of productivity or other commercial or productivity reasons. Accordingly we would conclude that the message and brand should draw the idea of human factors for major accident prevention, and associate with this the values of corporate responsibility and a credible set of safety claims.
= = TP
= = TQ
APPENDIX A
Topic guide Purpose of the interview:
TOPIC GUIDE
Hello, my name is ________ I work for Greenstreet Berman Ltd. We are consulting with industry on behalf of a national government organisation in order to ascertain the best way of promoting good practice in major accident prevention. The results of this consultation will be used to improve the advice, training and education available to your industry regarding major accident prevention. The information you give us will not be used for sales or marketing purpose. Introduce self & Greenstreet Bermans role (i.e. independent, experts etc.) We are an independent research and consultancy organisation. We would like to tell you the name of the government organisation near the end of the session, so as to avoid biasing your responses. All responses will be aggregated and reported anonymously. (if they insist on knowing who has commissioned the work, say its is the HSE Head Office, and then say your company will not be identified in the report and no information on individual companies will be communicated to area inspectors). This is the first stage in a research programme, and will be followed with a telephone survey to quantify some of the issues arising. Topics for this interview: During this consultation we wish to explore: 1. Your view of some specific aspects of major accident prevention 2. What prompts companies to considering new ways of preventing major accidents 3. What stops companies from considering new ways of preventing major accidents 4. What types of support, information etc. people might need
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Complete any outstanding basic company information details on the sheet. Basic company information: Company
Address & postcode Telephone Contact name
Job Title
Job Classification (tick one): Operations managers HR staff H & S staff/ professionals Engineers/ designers Employees/ Safety reps Senior mgt/ Directors Other
Company size (number of employees) small, medium, large, very large (>1,000)
Number of company sites (approx.) (eg 1, <10, >10) Geographic coverage (regional, national, multinational) Sectors in which company operates
Company Classification (tick one): Top tier COMAH Lower Tier COMAH Offshore operator Offshore drillers & Other support services
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Topic Guide Section 1 1. Contacts primary responsibilities PROBE any relating to major accident prevention 2. What factors should be taken into account in order to avoid major accidents in hazardous industries like yours? PROBE (Anything else?) 3. What are the main sources of information for major accident prevention advice & guidance? 4. What experience/involvement have you had of preventing major accidents? PROBE consideration of human error/behaviour. PROBE How easy they found it in practice. 5. Who would you regard as responsible for considering human error/behaviour in accident prevention in this company? PROBE Names/job titles 6. What companies do you think lead the way in preventing human error & optimizing staff performance in respect of avoiding major accidents ? PROBE Why them? PROBE Which do you think would be the last to take it on board? PROBE Why? Section 2 7. How would you normally refer to the consideration of human error on an organisations safe operation? PROBE for terminology 8. Have you come across the term human factors before? IF YES, PROBE Where did you first come across it? Understanding (What does it mean to you?) Critical aspects of human factors in avoiding major accidents in your industry How well are human factors issues assessed and managed in your industry?
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IF NO, SKIP TO Q9 9. PROBE. If they have not heard the phrase human factors ask, what do you imagine this term may mean? How would you brand or what catch-phrase would you recommend to describe this area? IF SAY DONT KNOW/ NONE, EXPLAIN HUMAN FACTORS THEN CONTINUE TO STATEMENTS SHEET, OTHERWISE CONTINUE TO STATEMENTS SHEET STATEMENTS People have made the following statements about human factors. Please indicate how strongly you agree or disagree with each, by using a scale, where 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree and 5 = strongly agree. (Circle the appropriate response for each statement)
Considering human factors in major accident prevention is: a key issue just common sense a worthwhile investment a barrier to getting the job done an effective approach improving major hazard safety just a compliance issue of growing importance abstract nonsense not part of MY job An issue that should be considered throughout the organisation to
Strongly disagree 1 1 1 1 1
Disagree
Neither
Agree
Strongly agree 5 5 5 5 5
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
5 5 5 5 5
Are there any other statements you feel are more relevant?
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10. What do you think prompts companies to improve the management of the human factors aspects of major accident prevention? PROBE, then PROMPT WITH: e.g. lessons learnt from major accident, bad experience, inspection, reminders, internal champion, PR implications, awareness, education, potential org. change, business case. 11. What happened as a result of the last major accident/ near miss in your industry/ in your company? 12. And why do you think companies may not consider human factors in relation to minimising the chance of accidents/major incidents occurring? PROBE, then PROMPT WITH eg cost, org structure, lack of awareness, unclear responsibility etc. 13. If you had to sell human factors to your industry, what would you do? PROMPT ON: who sell to, what Agencies/trade/professional associations/staff groups/ partners etc. to work through/what approach to take/ what support to provide/ integrated into all H & S, or kept separate Section 3 14. If you wanted to get information/advice/guidance/training/support about the whole issue of human factors, where would you expect to get the best information/ support etc. from? PROBE Why there? PROBE And how would you prefer to access it? PROMPT ON email/web/letter/newsletter/HSE etc. PROBE At what stage? (When is the best time to receive/access any such information eg at University/ in risk assessments/ specific business planning cycles?) 15. Have you had any information/advice/training/contact about human factors? IF YES: PROBE What was it? PROBE Where from? PROBE What did you think of it/How did you feel about it? PROMPT ON: useful /easy to understand/to use etc. IF DO NOT MENTION HSE AS A SOURCE, ASK Q16 IF NO: SKIP TO Q18 16. Have you had any contact/advice/training/support etc. on human factors from the HSE? IF YES, PROBE What? PROBE What did you think of it? PROBE What could they have done better?
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IF NO, SKIP TO Q18 17. How does it compare with the information/advice/guidance/training/support you have seen/used on Safety Management Systems? 18. Is there anything else about human factors you would like to comment upon? 19. Is there anyone else you would suggest we speak to about human factors? PROBE FOR NAMES, JOB TITLES AND CONTACT DETAILS
Thank and close.
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APPENDIX B
TELEPHONE QUESTIONNAIRE, FINAL VERSION
81
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Purpose of the interview:
Hello, my name is ________ I work for Greenstreet Berman Ltd. We are consulting with industry on behalf of the Health and Safety Executive in order to ascertain the best way of promoting good practice in major accident prevention. We are an independent research and consultancy organisation. The results of this consultation will be used to improve the advice and information available to your industry regarding major accident prevention. We can assure you of complete anonymity. All responses will be aggregated together. We would be most grateful if you could help by answering some questions? It is anticipated that it will take up to 30 minutes. If this is not a convenient moment, when would be a good time to call back.
Time and date to call back:
Complete any outstanding basic company information details on the sheet.
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Basic company information: Complete before the interview as far as possible
Company Address postcode Telephone Contact name &
Job Title
Job Classification (tick one): Site / platform / HR staff plant /Operations managers H & S staff/ Engineers/ professionals designers Safety reps Directors Maintenance mgr Other
Company size (number of employees) Small (<50) Medium (51 249), Large (>250), Very large (>1,000)
Number of company sites (approx.) 1 <10 >10
Geographic coverage (regional, national, multinational) Regional National Multinational
Sectors in which company operates:
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Company Classification (tick one): Top tier COMAH Lower Tier COMAH Offshore operator Offshore drillers & support services Other
1. What do you think are the main causes of major accidents, such as fires, explosions, major spills / leaks & toxic releases? LIST CAUSES AND CODE AFTER INTERVIEW:
Mentions HF / error 3
Minimal mention of HF / error 2
No mention of HF/ error 1
2. Please consider your companys approach to health & safety using the following scale, where 1 = My company makes resources available for major accident prevention without question through to 10 = In my company, you have to fight tooth and nail to get the resources for major accident prevention, and tell me where you would place your company. MARK ON SCALE BELOW 1____2____3____4____5____6____7____8____9____10 3. What are the main sources of information for major accident prevention advice & guidance? PROMPT BRIEFLY ONLY IF NECESSARY
Source HSE inspections /visits
Circle all that apply Named examples 1. 2. 3. 4. 5. 6. 7.
HSE Books HSE website HSE seminar Trade associations (UKOOA, CIA, PIA etc) Universities Industry codes / standards
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Site health and safety staff Corporate H&S department Health and safety magazines & journals Trade press Consultants Professional journals Legislation CRONA / BARBOUR IChemE/ IOSH/ ROSPA/ CCPS etc
Non-HSE Conferences / seminars
8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
Other
4. In what way might human error and human behaviour cause a major accident? (PROBE: Why might people make such errors?)
4
Reasonable understanding 3
Minimal understanding 2
Poor understanding 1
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5. What actions did your company take in response to the last leak, dangerous occurrence, or process safety incident / near miss caused by human error? IF NO EXAMPLE OFFERED, ASK What would your company do in response to an incident due to human error? PROBE. Describe response and code after interview.
5a coding High level of Moderate level of Minimal attention to HF attention to HF attention to HF 5 4 3 HF not Dont know addressed 2 1
5b coding
Root cause assessment
1 2 3 4 5 6 7 8 9 CIRCLE CODE (DESCRIBE OTHERS)
Engineering solution Discipline Blamed the individual Looked at SMS More checks on staff Revised procedures Training Other HF actions specify
Other non-HF actions.specify
10
Invalid response / cant answer
11
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6. What companies do you think lead the way in preventing human error, in respect of avoiding major accidents? PROBE WHY THEM?
Companies cited Reasons
7. a) What words would you use to describe the process of preventing human error and unsafe behaviour?
PROBE FOR TERMINOLOGY AND NOTE BELOW IN SPACE PROVIDED. IF HUMAN FACTORS MENTIONED, GO TO QUESTION 7d.
CIRCLE APPROPRIATE Term Human Factors already used in interview
AS
1 2 3 4
Term Human Factors mentioned here Some valid terms used / partial knowledge Invalid / none-meaningful terms used
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7b
Have you come across the term Human Factors before?
Yes
o
nsure ossibly
7c).
IF YES to 7b), ask Where did you first come across it? CIRCLE ONE ONLY
HSE
AT A CONFERENCE / 2 SEMINAR READ ABOUT IT CONSULTANTS CANNOT RECALL OTHER - SPECIFY 3 4 5 6
ASK ALL INTERVIEWEES QUESTION 7d 7d) What does the term Human Factors mean to you? PROBE
5
Reasonable understanding 4
Minimal understanding 3
Poor understanding 2
Cant answer 1
IF DEMONSTRATE MINIMAL OR NO UNDERSTANDING, EXPLAIN HUMAN FACTORS BEFORE ASKING Q 8
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8. People have made the following statements about Human Factors. Please indicate whether you Strongly agree, Agree, Have no opinion, disagree or Strongly Disagree with each. CIRCLE THE APPROPRIATE RESPONSE FOR EACH STATEMENT
Considering human factors in major accident prevention is: something we spend a lot of time on compared to other safety issues common sense a barrier to getting the job done an essential part of major accident prevention a difficult subject to grasp only done for legal compliance has incidental commercial benefits fuzzy, ill-defined a useful concept only a safety issue
Strongly disagree 1
Disagree 2
No opinion 3
Agree 4
Strongly agree 5 a
1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5
b c d e f g h i j
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9. What do you think would prompt companies to improve the management of the human / people aspects of major accident prevention? NOTE RESPONSE AND CODE AFTER INTERVIEW. PROBE
Circle all that apply and describe other

Major accident / inquiry reports from the HSE etc
1 HSE advice / inspections 2
HSE enforcement (notices, prosecutions, prohibitions etc) 3 COMAH / safety case requirements 4 Poor safety performance / a wish to improve safety 5 Organisational change 6 HF is good practice 7 Public pressure / PR concern 8 Concern about frequency of error 9 Productivity / lost time / loss avoidance 10 Avoid costly accidents 11 Insurance claims 12 Concern about staff welfare 13 Its part of safety management 14 Other, specify 15
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10. What do you think stops companies from considering human factor issues in relation to major accident prevention? Describe response and code after interview. PROBE IF OFFER NOT PRACTICAL Why is this?
Circle all that apply Human factors is second best option Not practical for smaller firms Lack of understanding of HF Just blame the individual Do not recognize how design etc effects error Do not recognize HF/ not aware of role of error Cost HF is fuzzy Prefer engineered solutions Firms do not believe people will make errors that cause major accidents Rely on common sense Fatalistic (error is inevitable) Short term view Unsure / no valid answer Other SPECIFY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
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11. How much input do you personally have on: (read out) CIRCLE ONE RESPONSE FOR EACH:
Significant Some None
Safety policy or strategy
1 2 3 4 5 6 7
1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3
Accident investigation & follow up COMAH / Safety case production / implementation Risk assessments How to improve major accident prevention Design of safety management systems, eg audits, PTWs Safety culture / behavioural safety initiatives
Design of plant, processes, Controls & Instrumentation, control rooms 8 etc Manning levels Working hours or shift systems Training or selection of operators, maintenance staff &/ or supervisors Recruitment of operators, maintenance staff and / or supervisors Team organisation /structure Supervisory practices Job or task design Organisational change / new ways of working Physical working conditions / environment, eg lighting, workspace Operating, maintenance or emergency procedures Selection and management of contractors
9 10 11 12 13 14 15 16 17 18 19
1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3
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12
Who else has a significant input into these decisions? PROBE
Job titles
Health and safety, loss prevention, EHS, QEHS
Circle apply
all 1 2 3 4 5 6 7 8 9
that
Quality Operations managers Engineering managers HR / personnel Finance managers All line management Directors Other SPECIFY.
13. A) Have you personally had any information/advice/training/contact about human factors? CIRCLE ONE RESPONSE
Yes No
1 2
GO TO Q 13B GO TO Q 14
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What type of information/advice/ training/contact did you have? PROBE. CIRCLE ALL THAT APPLY
13b
13c
And who supplied it? CIRCLE SOURCE FOR EACH
13b HSE Leaflet/publication Inspection /Advisory visit Safety case queries Seminar/ conference Website Telephone helpline Consultancy advice Training Cannot recall Other SPECIFY Specify other: 1 2 3 4 5 6 7 8 9 10 1 1 1 1 1 1 1 1 1 1 Journal etc 2 2 2 2 2 2 2 2 2 2 IOSH etc 3 3 3 3 3 3 3 3 3 3
13c Consult ants 4 4 4 4 4 4 4 4 4 4
Trade Assn. 5 5 5 5 5 5 5 5 5 5
Other SPECIFY 6 6 6 6 6 6 6 6 6 6
13d Which was the best source of information/training/advice? Why? CIRCLE ONE SOURCE ONLY & SPECIFY REASON Source Best Reasons HSE 1 Journal IOSH etc Consultant Trade Association Other SPECIFY 2 3 4 5 6
If the HSE are not mentioned here but contact with HSE has occurred, ask question 13e
95
13e
And what did you think of the support from the HSE?
13f
How might the information/advice/training provided by the HSE be improved? PROBE.
14
What format would you LIKE to be able to get the information/advice/support etc. in? PROBE. CIRCLE ALL THAT APPLY
Leaflets/publications
1 2 3 4 5 6 7 8 9 10
Websites Telephone helpline Specific visit As part of a routine visit Specific seminar/training course As part of a broader seminar/training course Videos / CDs No answer Other SPECIFY..
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15. What should the Health and Safety Executive do, to encourage companies like yours to apply Human Factors more? NOTE RESPONSE IN FULL THEN CODE
No response
1 2 3 4 5 6 7 8 9 10 11
More guidance More site based advice Work through/with Trade Associations(s) Advertise/promote Human Factors Work with Universities/Colleges More enforcement Examples of best practice Practical case studies
Give examples of error
Other
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16. When would be the best point of time in a persons career or job to receive training/advice and information on Human Factors? PROMPT WITH EXAMPLES IF NECESSARY
Note response here:
Circle all that apply At college Continuously When doing safety cases During time of major organisational change After a major incident / accident Outset of major engineering projects Earlier the better When assume staff management role Outset of professional training When you have a problem in hand NEBOSH type of courses Unsure No specific time Other, specify 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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17. The concept of Safety Management Systems appears to be better established than the concept of Human Factors. Why do you think this is? PROMPT IF NECESSARY Note response here:
Circle all that apply
No answer / unsure SMS shown to be more important by accidents SMS is better defined SMS is similar to Quality SMS is well bounded SMS is a system SMS is easier to grasp HSG65 is easy to follow SMS can be documented HF is latest buzz word SMS have been around longer SMS is communicated better Unfamiliar with concept of SMS Unfamiliar with concept of HF I do not believe the statement is true Cannot answer question Other
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
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18. Is there anything else about Human Factors and how the HSE may best promote it you would like to comment upon? SPECIFY
20. Is there anyone else you would suggest we speak to about Human Factors? PROBE FOR NAMES, JOB TITLES AND CONTACT DETAILS
Thank and close.
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APPENDIX C
SURVEY DATA
101
102
Table C.1 Onshore company sizes

Onshore Top tier Number Very large Large Medium Small Total 10 14 14 5 43 % 13.89% 19.44% 19.44% 6.94% 59.72% Lower tier Number 6 10 6 1 23 % 8.33% 13.89% 8.33% 1.39% 31.94% Other Number 1 3 1 1 6 % 1.39% 4.17% 1.39% 1.39% 8.33% Total onshore Number 17 27 21 7 72 % 23.61% 37.50% 29.17% 9.72% 100.00%
Table C.2 Offshore company sizes

Offshore Operators Number Very large Large Medium Small Total % Offshore driller Number % Other offshore Number % Total offshore Number %
18 9 4 0 31
26.09% 13.04% 5.80% 0.00% 44.93%
25 3 5 0 33
36.23% 4.35% 7.25% 0.00% 47.83%
1 0 3 1 5
1.45% 0.00% 4.35% 1.45% 7.25%
44 12 12 1 69
63.77% 17.39% 17.39% 1.45% 100.00%
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Table C.3 Number of sizes and national status of onshore firms

Onshore Number of sites Number % Number % Number % Number % All onshore 30 32 10 72 41.67% 44.44% 13.89% 100.00%
Multinational >10 <10 1 Total 17 11 1 29 23.61% 15.28% 1.39% 40.28%
National 11 15 0 26 15.28% 20.83% 0.00% 36.11%
Regional 2 6 9 17 2.78% 8.33% 12.50% 23.61%
Table C.4 Number of sizes and national status of offshore firms

Offshore Number of sites Number % Number National 0.00% 3 4.35% 0.00% 3 4.35% 1 5 6 % Number Regional 0.00% 1.45% 7.25% 8.70% % Number %
Multinational >10 <10 1 Total 60 45 15 65.22% 21.74% 0.00% 86.96%
All onshore 45 19 5 69 65.22% 27.54% 7.25% 100.00%
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Table C.5 Respondents job classification

Job title Onshore Offshore All
Number Health and safety Engineers/designers Site/platform/plant managers HR staff Directors Other Total 42 4 19 3 4 1 73
% 57.53% 5.48% 26.03% 4.11% 5.48% 1.37% 100.00%
Number 47 2 11 1 2 2 65
% 72.31% 3.08% 16.92% 1.54% 3.08% 3.08% 100.00%
Number 89 6 30 4 6 3 138
% 64.49% 4.35% 21.74% 2.90% 4.35% 2.17% 100.00%
Table C.6 Ease of getting resources (1 =m without question, 10 = fight tooth and nail)
Onshore Score 1 2 3 4 5 6 7 8 9 10 Total responses Number 20 19 18 8 5 1 0 0 1 0 72 % 27.78% 26.39% 25.00% 11.11% 6.94% 1.39% 0.00% 0.00% 1.39% 0.00% 100.00% Offshore Number 30 21 13 3 1 0 0 0 0 1 69 % 43.48% 30.43% 18.84% 4.35% 1.45% 0.00% 0.00% 0.00% 0.00% 1.45% 100.00% Number 50 40 31 11 6 1 0 0 1 1 141 All % 35.46% 28.37% 21.99% 7.80% 4.26% 0.71% 0.00% 0.00% 0.71% 0.71% 100.00%
105
Table C.7 What are the main sources of information for major accident prevention advice?
Onshore Number of responses HSE books Trade ass's HSE website Site H&S HSE visits Other CRONA etc Industry codes Icheme etc Corp' H&S Consultants H&S mag's HSE seminar Prof journal Legislation Trade press Other seminars Universities Total 45 35 18 15 21 14 14 14 15 4 12 9 6 8 3 0 0 0 233 %
Offshore Number % Number
All % of responses
19.3% 15.0% 7.7% 6.4% 9.0% 6.0% 6.0% 6.0% 6.4% 1.7% 5.2% 3.9% 2.6% 3.4% 1.3% 0.0% 0.0% 0.0% 100.0%
44 50 41 43 27 17 17 13 9 12 1 4 6 3 1 1 1 0 290
15.2% 17.2% 14.1% 14.8% 9.3% 5.9% 5.9% 4.5% 3.1% 4.1% 0.3% 1.4% 2.1% 1.0% 0.3% 0.3% 0.3% 0.0% 100.0%
89 85 59 58 48 31 31 27 24 16 13 13 12 11 4 1 1 0 523
17.0% 16.3% 11.3% 11.1% 9.2% 5.9% 5.9% 5.2% 4.6% 3.1% 2.5% 2.5% 2.3% 2.1% 0.8% 0.2% 0.2% 0.0% 100.0%
106
Table C.8 Average scores on questions probing understanding and application of human factors Onshore
Mention HF as a cause of major accidents (1 to 3) Understanding of why people make errors (1 to 4) Attention to HF in last incident (1 to 5) Terms used to describe error prevention (1 to 4) Understanding of term HF (1 to 5) 2.10 2.67 3.53 2.88 3.67
Offshore
2.14 2.67 3.46 2.64 3.57
All
2.12 2.67 3.49 2.76 3.62
Table C.9 Main causes of accidents (q1)

Onshore Number No mention of HF Minimal mention of HF Mentions HF Total 18 29 25 72 % 25.00% 40.28% 34.72% 100.00% Offshore Number 18 23 28 69 % 26.1% 33.3% 40.6% 100.0% All Number 36 52 53 141 % 25.5% 36.9% 37.6% 100.0%
Table C.10 Why do people make errors? (q4)

Onshore Number Poor understanding Minimal Understanding Reasonable understanding Excellent understanding Total 1 29 35 7 72 % 1.39% 40.28% 48.61% 9.72% 100.00% Offshore Number 6 20 34 9 69 % 8.7% 29.0% 49.3% 13.0% 100.0% All Number 7 49 69 16 141 % 5.0% 34.8% 48.9% 11.3% 100.0%
107
Table C.11 Attention to HF in response to last incident (q5a)

Onshore Number Don't know HF not addressed Minimal attention to HF Moderate level of HF High level of attention Total 1 11 19 31 10 72 % 1.39% 15.28% 26.39% 43.06% 13.89% 100.00% Offshore Number 3 11 17 26 11 68 % 4.4% 16.2% 25.0% 38.2% 16.2% 100.0% All Number 4 22 36 57 21 140 % 2.9% 15.7% 25.7% 40.7% 15.0% 100.0%
Table C.12 Use of terms to describe error prevention (q7a)

Onshore Number Term HF already used Term HF mentioned here Some valid terms used Invalid terms used Total responses 7 3 51 10 71 % 9.86% 4.23% 71.83% 14.08% 100.00% Offshore Number 16 1 44 8 69 % 23.2% 1.4% 63.8% 11.6% 100.0% All Number 23 4 95 18 140 % 16.4% 2.9% 67.9% 12.9% 100.0%
108
Table C.13 Understanding of term HF

Onshore Number Can't answer Poor understanding Minimal understanding Reasonable understanding Excellent understanding Total responses 2 7 15 37 11 72 % 2.78% 9.72% 20.83% 51.39% 15.28% 100.00% Offshore Number 1 5 27 26 10 69 % 1.4% 7.2% 39.1% 37.7% 14.5% 100.0% All Number 3 12 42 63 21 141 % 2.1% 8.5% 29.8% 44.7% 14.9% 100.0%
Table C.14 Categorisation of responses to last incident

Onshore Number Cause analysis Re-engineered Discipline Blamed person Looked at SMS More staff checks Revised procedures Training Other HF actions Other non-HF Can't answer Total responses 53 18 11 1 4 4 45 36 10 1 3 186 % 28.49% 9.68% 5.91% 0.54% 2.15% 2.15% 24.19% 19.35% 5.38% 0.54% 1.61% 100.00% Offshore Number 62 19 9 1 2 4 28 31 27 6 2 191 % 32.5% 9.9% 4.7% 0.5% 1.0% 2.1% 14.7% 16.2% 14.1% 3.1% 1.0% 100.0% Number 115 37 20 2 6 8 73 67 37 7 5 377 All % 30.50% 9.81% 5.31% 0.53% 1.59% 2.12% 19.36% 17.77% 9.81% 1.86% 1.33% 100.00%
109
Table C.15 Companies cited as leading the way in preventing error

Company/industry Number of mentions Onshore Offshore All
Du Pont BP Shell Other oil & gas Others ICI Nuclear ind' Aviation sector Chemicals ind' Conoco Offshore ind' Air products Total
25 6 7 10 12 10 5 3 6 0 1 3 88
19 17 13 4 2 3 7 4 0 5 3 0 77
44 23 20 14 14 13 12 7 6 5 4 3 165
110
Table C.16 Have you come across the term human factors before?
Onshore Number % Offshore Number % Number All %
Possibly Unsure No Yes Total
61 4 1 1 67
91.04% 5.97% 1.49% 1.49% 100.00%
52 3 3 0 58
89.66% 5.17% 5.17% 0.00% 100.00%
113 7 4 1 125
90.40% 5.60% 3.20% 0.80% 100.00%
Table C.17 If yes, where did you come across the term human factors?
Onshore Number HSE Conference Read about it Consultants Cannot recall Other Total 8 8 5 0 12 27 60 % 13.33% 13.33% 8.33% 0.00% 20.00% 45.00% 100.00% Offshore Number 3 4 8 1 13 25 54 % 5.56% 7.41% 14.81% 1.85% 24.07% 46.30% 100.00% Number 11 12 13 1 25 52 114 All % 9.65% 10.53% 11.40% 0.88% 21.93% 45.61% 100.00%
111
Table C18 Average agreement with attitude statements about human factors (1 = strongly disagree, 5 = Strongly agree)
Human factors is essential part of MAP a useful concept common sense commercial benefits difficult to grasp spend a lot of time on fuzzy, ill-defined a barrier Onshore 4.54 4.18 3.74 3.60 3.31 3.19 3.01 2.11 Offshore 4.67 4.14 3.57 3.62 3.49 3.25 3.25 2.07 All 4.60 4.16 3.65 3.61 3.40 3.22 3.13 2.09
only done for compliance only a safety issue
2.03 1.82
1.74 1.62
1.89 1.72
Table C19 Agreement with attitude statements about human factors (1 = strongly disagree, 5 = Strongly agree)
Strongly disagree spend a lot of time on common sense a barrier part of accident prevention difficult to grasp only for compliance incidental benefits fuzzy, ill-defined a useful concept only a safety issue 0.0% 2.8% 22.7% 0.0% 3.5% 35.5% 2.8% 0.0% 0.0% 40.4% Disagree 36.2% 22.0% 57.4% 1.4% 31.2% 52.5% 17.7% 38.3% 0.7% 53.2% No opinion 9.9% 7.8% 8.5% 1.4% 4.3% 2.1% 12.1% 14.9% 4.3% 1.4% Agree 49.6% 41.8% 10.6% 32.6% 44.0% 7.8% 50.4% 42.6% 73.0% 3.5% Strongly agree 4.3% 25.5% 0.7% 64.5% 17.0% 2.1% 17.0% 4.3% 22.0% 1.4%
112
Table C.20 What do you think would prompt companies to improve HF? (% of companies)
Onshore Number Accident Good practice HSE action Costly accidents Other Concern for staff Poor safety Public pressure HSE advice COMAH Productivity Its part of SMS Insurance Organisational change Concern re: error Total 31 16 21 10 13 6 5 2 8 6 4 2 1 0 0 125 % 24.80% 12.80% 16.80% 8.00% 10.40% 4.80% 4.00% 1.60% 6.40% 4.80% 3.20% 1.60% 0.80% 0.00% 0.00% Offshore Number 9 23 16 13 12 9 7 9 2 2 0 2 0 0 0 104 % 8.65% 22.12% 15.38% 12.50% 11.54% 8.65% 6.73% 8.65% 1.92% 1.92% 0.00% 1.92% 0.00% 0.00% 0.00% All Number 40 39 37 23 25 15 12 11 10 8 4 4 2 0 0 230 % 17.39% 16.96% 16.09% 10.00% 10.87% 6.52% 5.22% 4.78% 4.35% 3.48% 1.74% 1.74% 0.87% 0.00% 0.00%
113
Table C21 What stops companies from considering HF issues..? (% of respondents)
Onshore Number Lack of understanding Cost Don't recongise HF Other Prefer engineering HF is fuzzy Don't believe people err Fatalistic Unsure Short term view Just blame the individual Not practical for small firms Don't recognise design effects HF is second best Rely on common sense 30 28 15 13 7 5 7 2 3 5 2 1 1 0 0 119 % 41.67% 38.89% 20.83% 18.06% 9.72% 6.94% 9.72% 2.78% 4.17% 6.94% 2.78% 1.39% 1.39% 0.00% 0.00%
Offshore Number 37 6 11 12 5 4 2 0 4 0 0 0 0 0 0 81 % 52.86% 8.57% 15.71% 17.14% 7.14% 5.71% 2.86% 0.00% 5.71% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
All Number 67 34 26 25 12 9 9 7 7 5 2 1 1 0 0 205 % 47.18% 23.94% 18.31% 17.61% 8.45% 6.34% 6.34% 4.93% 4.93% 3.52% 1.41% 0.70% 0.70% 0.00% 0.00%
114
Table C22 Extent of respondents involvement in...

Significant Accident investigation & follow up Safety policy or strategy How to improve accident prevention Risk assessments Safety culture initiatives Design of SMSs Operating procedures Physical working conditions COMAH / safety case production Selection & man'gt of contractors Organisational change Training / selection of operators etc Supervisory practices Team organisation/structure Design of plant Manning levels Working hours/shift systems Job or task design 70% 70% 67% 65% 65% 60% 60% 46% 45% 34% 33% 30% 29% 26% 22% 18% 18% 16% Some 22% 27% 30% 34% 30% 35% 33% 45% 34% 48% 56% 49% 54% 45% 48% 44% 41% 60% None 8% 4% 4% 1% 6% 5% 7% 9% 21% 18% 11% 21% 17% 28% 30% 38% 41% 24%
115
Table C23 Who else has a significant input into these decisions?
Onshore N Operations managers H&S Other All line management Engineering managers Directors HR/Personnel Quality Finance managers 33 25 21 27 25 24 15 4 2 % 45.8% 34.7% 29.2% 37.5% 34.7% 33.3% 20.8% 5.6% 2.8% Offshore N 38 34 34 19 10 7 11 2 2 % 54.29% 48.57% 48.57% 27.14% 14.29% 10.00% 15.71% 2.86% 2.86% N 71 59 55 46 35 31 26 6 4 All % 50.00% 41.55% 38.73% 32.39% 24.65% 21.83% 18.31% 4.23% 2.82%
Table C24 Have you personally received information or advice about human factors?
Onshore N Yes No Total 42 30 72 % 58.3% 41.7% N 44 25 69 Offshore % 63.8% 36.2% N 86 55 141 All % 61.0% 39.0%
116
Table C25 What form of human factors information / contact? (N= 146)
Onshore Leaflet Inspection Safety case queries Seminar Website Tel' Helpline Consultancy Training Can't recall Other 26.47% 0.00% 1.47% 8.82% 0.00% 1.47% 7.35% 45.59% 2.94% 5.88% Offshore 23.08% 2.56% 1.28% 25.64% 0.00% 0.00% 5.13% 37.18% 0.00% 5.13% All 24.7% 1.4% 1.4% 17.8% 0.0% 0.7% 6.2% 41.1% 1.4% 5.5%
Table C26 Which was the best source of information/training/advice?

Onshore N HSE Journal IOSH etc Consultant Trade association Other Total 9 0 5 4 0 12 30 % 30.0% 0.0% 16.7% 13.3% 0.0% 40.0% 100.0% N 8 0 0 2 1 22 33 Offshore % 24.24% 0.00% 0.00% 6.06% 3.03% 66.67% 100.00% N 17 0 5 6 1 34 63 All % 26.98% 0.00% 7.94% 9.52% 1.59% 53.97% 100.00%
117
Table C27 What format would you like to be able to get the information/advice in?
Onshore N Websites Leaflets HF seminar Videos/CDs Telephone helpline Part of routine visit Part of broader seminar Specific visits Other No Answer Total responses 51 36 15 11 13 8 3 9 6 2 154 % 70.8% 50.0% 20.8% 15.3% 18.1% 11.1% 4.2% 12.5% 8.3% 2.8% N 46 35 16 16 5 6 11 4 4 1 144
Offshore % 65.71% 50.00% 22.86% 22.86% 7.14% 8.57% 15.71% 5.71% 5.71% 1.43% N 97 71 31 27 18 14 14 13 10 3 298
All % 68.31% 50.00% 21.83% 19.01% 12.68% 9.86% 9.86% 9.15% 7.04% 2.11%
118
Table C28 What should the HSE do to encourage companies like your to apply human factors more?
Onshore N Advertise HF Other More guidance Site based advice Best practice egs Case studies More enforcement Give egs of error Work via trade ass's No response Work with Universities Total responses 24 24 17 16 7 5 4 3 3 1 0 104 % 23.1% 23.1% 16.3% 15.4% 6.7% 4.8% 3.8% 2.9% 2.9% 1.0% 0.0% 100.0% N 20 25 18 13 8 6 6 6 2 1 0 105 Offshore % 19.05% 23.81% 17.14% 12.38% 7.62% 5.71% 5.71% 5.71% 1.90% 0.95% 0.00% 100.00% N 44 49 35 29 15 11 10 9 5 2 0 209 All % 21.05% 23.44% 16.75% 13.88% 7.18% 5.26% 4.78% 4.31% 2.39% 0.96% 0.00% 100.00%
119
Table C29 When would be the best point in time in a person's career or job to receive training on HF?
Onshore N Earlier the better Continuously At college When assume man'gt role Outset of prof' training Other NEBOSH type of courses Outset of engineering projects Unsure After a major incident When doing safety cases During organisational change When you have a problem No specific time Total responses 34 22 17 14 12 8 3 2 1 1 0 0 0 0 114 % 29.8% 19.3% 14.9% 12.3% 10.5% 7.0% 2.6% 1.8% 0.9% 0.9% 0.0% 0.0% 0.0% 0.0% 100.0%
Offshore N 47 23 19 15 2 2 2 2 0 0 0 0 0 0 112 % 41.96% 20.54% 16.96% 13.39% 1.79% 1.79% 1.79% 1.79% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 100.00% N 81 45 36 29 14 10 5 4 2 1 0 0 0 0
All % 35.68% 19.82% 15.86% 12.78% 6.17% 4.41% 2.20% 1.76% 0.88% 0.44% 0.00% 0.00% 0.00% 0.00% 227 100.00%
120
Table C30 Why is the concept of Safety Management Systems better established than the concept of human factors?
Onshore N SMS is a system SMS is easier to grasp SMS can be documented SMS been around longer Other Unfamiliar with HF SMS is better defined HSG65 is easy to follow SMS is similar to Quality SMS is well bounded HF is latest buzz word SMS is better communicated Don't believe the statement No answer SMS more important Cannot answer the question Unfamiliar with SMS concept Total responses 19 23 16 12 10 13 15 7 6 7 3 5 1 2 1 1 0 141 % 13.5% 16.3% 11.3% 8.5% 7.1% 9.2% 10.6% 5.0% 4.3% 5.0% 2.1% 3.5% 0.7% 1.4% 0.7% 0.7% 0.0% 100.0% N 15 11 10 12 19 7 3 6 4 2 3 0 2 0 0 0 0 94 Offshore % 15.96% 11.70% 10.64% 12.77% 20.21% 7.45% 3.19% 6.38% 4.26% 2.13% 3.19% 0.00% 2.13% 0.00% 0.00% 0.00% 0.00% 100.00% N 34 34 26 24 29 20 18 13 10 9 6 6 3 2 1 1 0 236 All % 14.41% 14.41% 11.02% 10.17% 12.29% 8.47% 7.63% 5.51% 4.24% 3.81% 2.54% 2.54% 1.27% 0.85% 0.42% 0.42% 0.00% 100.00%
121
Printed and published by the Health and Safety Executive C30 1/98 Printed and published by the Health and Safety Executive C1.25 08/03
ISBN 0-7176-2739-X
RR 149
20.00
9 78071 7 627394
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The Promotion of Human Factors in The Onshore

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Health & Safety Executive

RESEARCH REPORT 149

Health & Safety Executive

MAIN TELEPHONE SURVEY .............................................................................. 21

3.2.13 3.2.14 3.2.15 3.2.16 3.2.17 3.2.18 3.2.19 3.3 3.4

MAIN IMPLICATIONS ................................................................................................................57 SURVEY-BASED RECOMMENDATIONS .......................................................................................57

LESSONS LEARNT FROM OTHER PARADIGM SHIFTS.................................. 59

Table 1 Summary of current promotional activities

Tactic Internal inspector support

Specialist support on human factors

OTHER HUMAN FACTORS PROMOTIONAL EXAMPLES Overview

Table 2 Summary of dissemination methods

Research & Demonstration Project Programmes

Conferences & Seminars

Dissemination route Posters, leaflets and booklets

Initiatives, Strategies and Campaigns

Guidelines, Standards & Codes

Dissemination route Themed Inspections

FACE TO FACE SEMI-STRUCTURED SESSIONS Findings regarding topic guide design

Findings regarding promotion of human factors

Table 3 Responses to attitude statements (n = 10)

Conclusions from face to face sessions

3 MAIN TELEPHONE SURVEY

Table 4 Profile of responding organisations

Table 5 Profile of onshore firms

Figure 1 Respondent's company sizes

Onshore Offshore All

50% 40% 30% 20% 10% 0% Very large Large

Figure 2 Job titles of respondents

60% 50% 40% 30% 20% 10% 0%

Onshore Offshore All

Figure 3 Number of sites at respondents' companies

50% 40% 30% 20% 10% 0% Onshore Offshore

Figure 4 National status of respondents' companies

100% 90% 80%

Multinational Nat ional Regional

70% 60% 50% 40% 30% 20% 10% 0% Onshore

Ease of getting resources

40% 35% 30% 25% 20% 15% 10% 5% 0%

Onshore Offshore All

Figure 6 Main sources of information about major accident prevention

Onshore Offshore All

Understanding and application of human factors

Figure 7 Citation and understanding of human factors

3.0 2.5 2.0 1.5

Max = 4 Max = 4 Max = 3

1.0 0.5 0.0

Figure 8 Mention of human error as a cause of major accidents

Onshore Of f shore All

30% 25% 20% 15% 10% 5% 0%

Figure 9 Rated understanding of why people commit errors

Onshore Of f shore All

Figure 10 Rated level of attention to human factors in response to last incident

35% 30% 25% 20% 15% 10% 5% 0%

Onshore Offshore All

M inimal at t ent ion t o HF

High level of at t ent io n

Figure 11 Terms used to describe the process of preventing human error

60% 50% 40% 30% 20% 10% 0%

Onshore Offshore All

Term HF already Term HF used mentioned here

Some valid terms used

Invalid terms used