2012 young generation network - human performance problems
TRANSCRIPT
Tel: (+44) 01492 879813 Mob: (+44) 07984 [email protected]
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Human Performance Problems
Andy Brazier
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Overview
A bit about meThe ways people failLearning from accidents.
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A bit about me
Chemical engineer16 years working as human factors consultant7 years self-employedRegistered member of the Institute of Ergonomics and Human Factors (IEHF)Associate member of the Institution of Chemical Engineers (IChemE).
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People are never 100% reliable
Our failures are predictableThey are not always preventableUnderstanding human failure allows us to manage the risks by:
Reducing consequencesImproving mitigationReducing likelihood.
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How many errors?
Human factors is impotent when your asessing tge risks in your organization
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People are fallible
People are good atDetecting small signals & perceiving patternsImprovising and using procedures flexiblyRecalling historical information when neededExercising judgement
They are not so good atPaying attention for a long timeBeing precise in physical tasksAnalysing lots of dataDoing things exactly the same each time.
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Automatic
Conscious
Skill-BasedAutomated routines with little conscious attention
Rule-Based
IF symptom X THEN cause is Y IF the cause is Y THEN do Z
Knowledge-BasedNo routines or rules available for
handling situation
Understanding Human Behaviour
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Design is a compromise
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Which button for which ring?
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Taking short cuts
Major accidents
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Fixborough
Deepwater Horizon
Piper Alpha
Buncefield
Costa Concordia
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Ship Capsizes - 32 People
die
Captain gives order for unsafe
course
No one intervenes
Safety devices failed
Not everyone is able to escape
Passengers did not know
procedure
Crew delays
declaring emergency
Captain did not co-
ordinate evacuation
Why?
Why? Why?
Ship hits rocks
Why? Why?
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Captain gives order for unsafe
course
No one intervenes
Safety devices failed
Why?
Ship hits rocks
Culture of orders
followed without question
Captain only person to ever take
decisions - no one else realised his
error
Everyone working towards same goal - no one
realised the error
Why?
System had failed and
no one realised
People over-reliant on technology - did not know what to do when it failed
People assumed technology would not allow them to
do something unsafe
Device prone to spurious
warnings - people ignored them.
Group Exercise
Watch the videoDevelop a causal tree to explain
What happenedWhy it happened
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