The top 10 common issues:

1
The top 10 common issues

• Organisational change
• Staffing levels/workload
• Training competence
• Procedures
• Managing human failure

• Fatigue
• Organisational culture
• Human factors in design
• Communications/interfaces
• Integration of HF into risk
• assessment investigations

/

• Behavioural safety human factors

No PPE, No slips and Trips! Its all about HAZARD
No it does not
2
Organisational change

• The BAD
• Objectives not clear
• Not communicated
• Under-resourced
• Lack attention to detail
• PTW and ISSOW
• SAP / MAXIMO

• The GOOD
• Additional supervision
• Staff hot-line for tech support
• Clear communication
• Employee involvement
• TAs offshore

• Tip
• Go to Waterstones,
• Buy a book on Managing Change,
• Do what it says.

It should be impossible for HSE to advise the oil
industry on change!
3
Staffing levels/workload

• The BAD
• Skills shortage
• Old equipment in poor condition
• Auto operation not working obsolete
• Breakdown Maintenance
• New hires not mentored (it takes 10 time)
• Cost cutting not thought though
• Lack of risk assessment for work-load
• No monitoring of workload and stress

• The GOOD
• Increasing manning levels
• Workload monitoring
• Improvement schemes
• Roving supervisor posts

Not being there is a major cause of serious
incidents!
4
Training competence

• The BAD
• Too many new hires
• Commitments to mentor not met
• Training unrelated to tasks
• Training is too generic
• Competence framework seen as training
• Competence not related to hazards
• Supervision used as a quick fix

• The GOOD
• Training supervisor offshore
• Competence framework relates to hazards
  assessment
• Mentoring is included in work plans
• Training is theory and practice knowledge based
• On the job training
• Independent verification and audit
• Apprenticeships
• Innovative hiring, ie marine engineers

5
Procedures
/

• The GOOD
• Include operator involvement in preparation
• Regularly reviewed as part of continuous
  improvement programme
• A good way to do the job
• Balance between procedures and competence
• Linked to training and competence
• Are part of the SMS
• Linked to ISSOW, risk assessment

• The BAD
• Unworkable
• Out of date
• Missing
• Too long
• Nannying
• Conceal hazards
• Obsessed with procedural compliance
• Prefer B-mod to task design

No it still doesnt
6
Procedures
/

• The GOOD
• Include operator involvement in preparation
• Regularly reviewed as part of continuous
  improvement programme
• A good way to do the job
• Balance between procedures and competence
• Linked to training and competence
• Are part of the SMS
• Linked to ISSOW, risk assessment

• The BAD
• Unworkable
• Out of date
• Missing
• Too long
• Nannying
• Conceal hazards
• Obsessed with procedural compliance
• Prefer B-mod to task design

EASY WIN, LOOSE

• Have procedures that are unworkable.
• Bring in a B-Mod programme.
• Punish non-compliance firmly.

• (if that fails talk about how people are our
  greatest asset then bring in contractors to do
  the job)

No it still doesnt
7
Managing human failure

• The GOOD
• Error tolerant systems
• Assume error and plan for it
• Alert to error
• Defences in depth
• High reliability systems are automated

• The BAD
• Ignore human performance imitations ie the
  risk of an accident will keep them alert!)
• High consequences for failure
• Assume unrealistic error rates
• No error correction plan

8
Fatigue

• The BAD
• Long hours
• Overtime!
• No monitoring
• No plan for no-shows
• Call-outs
• Manning too low
• Poor shift pattern
• Do not record hours (WTD)
• Not included in risk assessment and planning
• No policy

• The GOOD
• A clear policy on alertness
• Alertness seen as part of safe system of work
• Part of the SMS
• Monitored and linked to improvement programme
• 12 hour shifts, overtime in exceptional
  situations
• Risk assessment for every task beyond 12 hours
• Hours worked a management measure

9
Organisational culture

• The BAD
• Management never go onto the plant (do they mean
  me?)
• Two class system
• Say one thing, do another (surely not!)
• Hire and fire
• Secretive
• Treat the employees as a hazard

• The GOOD
• Open (and brave)
• Management by walkabout
• Long term employment
• Lead by example
• Engage employees in delivering safety and
  performance the employee as a benefit to the
  organisation

10
Human factors in design

• The BAD
• Usability not in spec
• Lots of in-service modification
• Irrational interfaces
• Overdependence on vendors for design
• No user feedback
• Impossible to maintain
• Lead from the beach
• High error tasks blamed on operator not equipment
• No evidence of corporate learning

• The GOOD
• Operators included in design
• Incidents reviewed a as design resource
• Investigations include design
• Vendors engaged proactively and able to meet
  field operators
• Maintenance and access included in design
• Part of an aggressive continuous improvement
  process
• A man-machine system

11
Communications/interfaces

• The BAD
• Fail to identify high hazard situations
• Use ambiguous terms
• Fail to verify understanding
• Directive style
• Do not listen is is very rare that the cause of
  an incident has not previously been raised to
  management
• Time for communication not included in task plans
  (ie shift handover)

• The GOOD
• Recognise communication as important
• Proceduralize or design out ambiguity
• Open and engaging style
• Look for two way interaction
• Treat communication as a learnable skill /
  competence
• Include in task planning

12
Integration of HF into riskassessment
investigations

• The GOOD
• HF is seen as a positive risk reduction strategy
• The objective of Investigations is to prevent
  reoccurrences
• Operator error is not seen as an explanation
• Risk assessment includes HF as does hazard
  recognition
• HF risk assessment uses realistic and sympathetic
  mitigation

• The BAD
• Everything is operator error
• Proforma risk assessments!
• Blame-based investigations
• No HF in risk assessments
• Investigations stop before reaching a root cause
• Investigation outcomes do not prevent a
  reoccurrence