2012 young generation network - human performance problems

Tel: (+44) 01492 879813 Mob: (+44) 07984 284642andy@abrisk.co.ukwww.abrisk.co.uk

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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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