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Education & Training

Human Factors Can Cause a Disaster—or Prevent One

Process industry plants are complex and potentially dangerous environments, where the consequences of something going wrong can be catastrophic. In safety-related matters, employing best practice to robustly protect the plant or asset, its workforce and the surrounding community, should be of paramount importance for owners. However, one aspect of safety best practice that doesn’t always receive enough attention is human factors.

In 2015 within U.S. industry alone there were 4,836 deaths [1], and 3,652,000 recordable injuries [2]. The financial cost to industry of these incidents is estimated at more than $200 billion. With 75% of industrial accidents traceable to organizational and human factors, managing the potential for human failures is essential if plants are to prevent major incidents that can prove extremely damaging in terms of human lives, company finances and reputation.

WHAT ARE HUMAN FACTORS?

When it comes to defining human factors, the World Health Organization quotes the UK’s Health and Safety Executive (HSE), which is responsible for the regulation and enforcement of that country’s workplace health, safety and welfare. The HSE defines human factors as “environmental, organizational and job factors, and human and individual characteristics which influence behavior at work in a way which can affect health and safety” [3]. It suggests thinking about human factors in three areas–the job, the individual and the organization.

The job. Matching the job to the person, physically and mentally, ensures they are not overloaded. Physically this involves looking at the design of their working environment, while mentally it involves the individual’s decision-making abilities. Mismatches between job requirements and an individual’s capabilities provide the potential for human error.

The individual. Individual characteristics influence behavior in complex and significant ways. Some characteristics such as personality are fixed and cannot be changed. Others, such as skills and attitudes, may be changed or enhanced.

The organization. Plants need to establish a positive health and safety culture. This needs to promote employee involvement and commitment at all levels, emphasizing that deviation from established health and safety standards is unacceptable.

WHEN HUMAN FACTORS LEAD TO TRAGEDY

Accidents are often blamed on the actions, or the lack of action, of someone directly involved in operational or maintenance work. However, the failures leading to an accident are often much more deeply rooted in an organization’s working methods. Here are two examples, one from the aviation industry and the other from the medical profession.

Example 1. On March 27, 1977, two passenger planes collided on the runway of Tenerife’s airport, with 583 people killed. It was the deadliest crash in aviation history and marked the beginning of human factors being properly investigated as a factor in such incidents.

A bomb explosion at Gran Canaria Airport had caused many aircraft to be diverted to the small, single-runway airport at Tenerife, where they were parked on the taxiway. When Gran Canaria reopened, air traffic control in Tenerife began the process of getting these planes away again as quickly as possible. As Pan Am flight 1736 was taxiing down the runway, dense fog descended on the airport, greatly reducing visibility, and the plane missed its exit off the runway. At the same time, KLM flight 4805 was approaching at take-off speed, due to a series of misinterpreted communications between air traffic control and KLM 4805. The captain thought he had been given permission to take off, the rest of the crew disagreed, but the pilot made the decision to take off. The KLM was unable to clear the Pan Am aircraft, and the planes collided, with devastating consequences. In its report into the accident, the Air Line Pilots Association highlighted the “significant human aspects and system aspects which led, step by step, toward tragic human error.” [4]

Example 2. On March 29, 2005, Martin Bromiley’s wife Elaine went into hospital in the UK for what should have been a routine sinus operation. However, while she was anaesthetized serious problems occurred, with her airway becoming obstructed. The anesthetist and his assistant tried to place a tube down her airway, but failed. Others then arrived in the theatre to help, including another anesthetist and the surgeon waiting to perform the operation. Guidelines suggested that the best course of action would have been surgical access to the airway, such as a tracheotomy, but this was not performed. Mrs. Bromiley never regained consciousness and died 13 days later. Her death was attributed to failings in teamwork, leadership and decision-making. In his independent report into the case in July 2005, Professor Michael Harmer concluded: “This was a tragic case from which many lessons can and need to be learnt. There were certainly areas where, in my opinion, the clinical practice fell below an acceptable level, but even if the management had been different, there is no way of knowing with certainty that the outcome would have been different.” [5]

The link between these two cases is that Martin Bromiley was a commercial airline pilot and he wanted his wife’s death to be investigated as an aviation crash would have been, so that lessons could be learned and similar outcomes prevented in future. Rather than taking legal action against the NHS, Mr. Bromiley set up an independent charity, the Clinical Human Factors Group, which is dedicated to working with clinical professionals and managers to make healthcare safer.

LESSONS THE PROCESS INDUSTRY CAN LEARN

The process industry also has the potential for human error to result in an accident with disastrous consequences. Therefore, it is vital for plants to closely scrutinize their operating procedures and learn how cultures within their organization could be improved.

For example, statistics show that 60% of all accidents or serious incidents happen within 30 minutes of a shift change. Thus, owners need to think about the critical handovers that happen in their plant.

shift changeOwners need to consider whether these handovers are formalized, whether they can be compromised by time pressures and if their existing procedures could be improved.

Plant owners should also think about their staff turnover. When someone comes into their organization, how long does it take them to know where to obtain the information that enables them to perform their job properly? They might need that information outside regular hours or in a hurry if something has gone wrong in the plant. Online and intelligent documentation systems are now making it significantly easier for operators to get the information they need, at the right time, in a way that’s easy to understand.

Companies and plants also need to look at the culture within their teams. Sometimes, a culture of acceptance can develop when things are not working as they should. Workers who ought to put their hand up and say ‘this isn’t right’ can feel that they are being suppressed by some of their peers. They might believe that even if they do speak up, management won’t take their views into account. A major challenge facing plants is to ensure that workers feel empowered to intervene in such circumstances rather than do nothing. The eyes and ears of our plants are the people working on them, and they must be prepared to raise issues, whether they are a site director or a scaffolder.

Training is another area where significant improvements can be made. Take, for example, the offshore industry. The cost per hour of having a person on a platform is enormous, so training for both normal operating conditions and abnormal situations is now being performed using Operator Training Solutions (OTS) that are located onshore. These simulators replicate the systems and processes installed on the platform, which means that when a worker arrives on the platform, they don’t need a long handover process. They have already been thoroughly trained not only in how to use the systems, but also the correct way of reacting to abnormal situations, should they arise. With the cost of such training and simulation tools having dropped significantly, it should become the norm for the process industry to use simulation in training operators to deal with all credible failure scenarios.

If companies can heed these cross-industry lessons and carefully consider the human factors affecting their plants, the number of accidents within the industry can be reduced and workforces can be happier, more efficient and more effective.


This email address is being protected from spambots. You need JavaScript enabled to view it. is principal industry consultant, Chemical Industries and Operational Excellence Team at Emerson Automation Solutions; This email address is being protected from spambots. You need JavaScript enabled to view it. is vice president of marketing at Emerson Automation Solutions, Europe.

[1] U.S. Department of Labor: Census of Fatal Occupational Injuries Summary, 2015.

[2] U.S. Department of Labor: Employer-reported Workplace Injuries and Illnesses, 2015.

[3] Health and Safety Executive: Reducing error and influencing behaviour.

[4] Air Line Pilots Association: Human Factors Report on the Tenerife Accident.

[5] Independent Review on the care given to Mrs. Elaine Bromiley on 29 March 2005. Prepared by Michael Harmer, MD FRCA, Professor of Anaesthetics and Intensive Care Medicine.  


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