Week 4 Human Factors in Safety Systems

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 Case Study Report

– Due Sunday!
– There is a discussion thread you should have been using, though
it is getting late to ask any questions there now..
– It won’t be monitored after 5pm tomorrow!
– Hints:
– Make sure you read the assignment carefully
– Address all parts (there are four bullet points)

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 Goal of WHS in the workplace?

– What is the goal of managing WHS in the workplace?

– www.menti.com 6321483

– To promote safe work environments

– Develop and implement policies, plans and procedures to comply with
legislation and standards
– To encourage effective leadership and communication
– Continual improvement
– To encourage, foster and develop a positive safe work culture

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 Word cloud results

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 “Human Factors”

– What do you think “Human Factors” refers to?

– Physical or cognitive property of an individual

– Social behaviour of people

– Human interaction with technological systems

– How humans relate to the world around them

– “Ergonomics” (physical aspect)

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 Word cloud results

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 Why Consider Human Factors?

– Aim to improve the interaction between people and machines

– Improve productivity through efficient operations

– Improve safety of people/machine interactions

– Improve safety through human focused work procedures

– Originally developed from work on improving aviation safety

related to the pilot/machine interaction

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 Human-Machine Model

– Humans and machines both process information

– Inputs
• Human: sensory, touch, sound, sight, smell, heat/cold
• Machine: Levers, keyboards, switches, sensors etc.
– CPU (brain vs electronic chip)
– Outputs
• Human: Hands, feet, body, voice
• Machine: Screen display, sounds, motion, electrical signals

– Environment of the human/machine interaction

– Physical aspects
– Cognitive aspects (brain, thinking, senses)
– Organisational (workplace structure)

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 Human/Machine Interaction

– Consider a human operating a machine in an industrial

environment
– Human operator:
– Brain (mental) and body (physical)
– What are some possible issues/deficiencies that may exist in
human/machine interactions?
– Possible solutions to these deficiencies?
– Redesign the machinery
– Redesign the operating environment (light, noise etc.)
– Retrain the human
– Reselect the human
– Task redesign
– Automation?..

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 Chat comments for previous slide question
– What are some possible issues/deficiencies that may exist in human/machine interactions?

• Machine buffer/lag
• Tired
• Wrong operation
• Low fault tolerance
• Carelessness
• Machine loses control
• Short circuit
• Panic/anxiety
• Too much information, information overload
• Not operating according to regulations
• Complexity
• Ambiguous action buttons/switches
• System crash and reboot
• Unskilled operator
• Entanglement

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 Human-Machine Systems
– Large human-machine systems are difficult to analyse and
model
– Well examined human factors are important for the safe,
productive operation of these systems
– Four key factors for success:
– Personnel
– Training
– Operating procedures
– Machine design
– Important to apply human factors (capabilities & limitations) to
the design of processes and work environments to:
– Improve ease of use
– Improve reliability of process
– Improve safety by reducing operator errors and fatigue

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 Machine Interface - Risk Factors

– Lack of commonality between designs

– Substitution errors
– Inadequate separation of controls
– Coding systems (colours, switch types)
– Sensory overload

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 Muscular Skeletal Injuries

– One of the most common worker injuries is muscular skeletal

injuries/disorders
– Results in pain, loss of functionality
– Can be difficult to diagnose
– Caused by repetitive and forceful exertions
– Heavy lifting
– Overhead lifts
– Awkward work positions
– Vibrating equipment
– Need to design task and machine interface to reduce these
causes

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 Human Factors

– The Job
– The actual task, work environment, input/output design, workload, role
of procedures
– Job task needs to be designed to take into account user limitations;
physical and mental
– The Individual
– Competency, skills, attitude, risk perception
– Some can be modified through training
– Organisational factors
– Workplace culture, leadership, resources, communication
– Need to consider these factors together to produce positive
changes to workplace safety

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 Why are Human Factors Important?

– Cost of Health & Safety

– Business reputation
– Decreased productivity
– Good businesses can produce high quality goods & services,
high productivity, high standards of health and safety.
– Through the use of:
• Good technology
• Good work practices/systems
– Skilled workforce
– Well designed tasks/operations
– Individuals that are well suited to their tasks
– Comprehensive and effective safety management system

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 Human Factors & Accidents

– Human failures are the primary cause of incidents

– But most of the time is not the ‘fault’ of the human physically involved in
the incident..
– Be very wary about attributing blame!
– Need to manage human factors & failures as well as technical
and engineering processes used in safety systems
– Need to develop human error tolerant systems & prevent
human errors from occurring
– Manage the potential for human error in the initial risk
assessment process

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 Types of Human Errors

– Generally not random occurrences

– Human error:
– Action or decision that was not intended
• Slips and lapses – familiar task - wrong button, omitting a step in a
process
• Mistake – error of judgement, person doesn’t know the correct
procedure, confusion with similar process
– Violation (non compliance):
– Deliberate deviation from a rule or procedure
– Not normally malicious but may occur when trying to finish job quicker
– Often cause by bad task design

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 Managing Human Failure

– Very difficult to eliminate human failure (unless automating the

process)
– Process may contain multiple possible failure mechanisms
– Operator consultation is essential!
• Speak with the user!
– Risk assessments need to attempt to identify possible mechanisms for
human failure
– Incident investigations need to fully investigate the cause of the human
failure, not just blame “operator error”

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 Human Factors & Risk Assessments

– Identify tasks that are safety critical or have the most potential
for harm (as in any risk assessment)
– Determine the nature of the task, its procedures and the work
environment
– Involve operator in assessing risk and controls
– Identify potential opportunities for human failure
– Redesign process to eliminate possibility of human failure or
formulate control measures
– Relying on procedures and/or training is not a good solution
(recall the hierarchy of control)
– Review and evaluate effectiveness

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 Human Factors in Incident Investigations

– Accidents/incidents are often caused by active failures or

latent conditions which can lead to human error or violations
– Active failures:
• Acts or conditions that explicitly led to the failure
• Frontline staff, machine operators, control rooms
– Latent conditions:
• Work safety culture, managerial, social influences.
• “Behind the scenes”
• Often hidden until incident occurs.
• People whose tasks are often isolated from operational activities,
e.g. designers, decision makers and managers.
• Often stem from failures in Safety Management Systems

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 Examples of Latent Failures

– Poor design of plant and equipment

– Ineffective training
– Inadequate supervision
– Ineffective communication
– Inadequate risk assessments
– Inadequate resources (e.g. people and equipment) and
– Uncertainties in roles and responsibilities

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 Human Contribution to Accidents

http://www.hse.gov.uk/humanfactors/topics/core2.pdf

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 Determining the Underlying Reasons

– Job factors;
– Poor/illogical design of equipment and instruments,
– Constant disturbances and interruptions,
– Missing or unclear instructions,
– Poorly maintained equipment,
– High workload,
– Noisy and unpleasant working conditions.

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 Determining the Underlying Reasons

– Individual (person) factors:

– Low skill and/or competency levels,
– Insufficient training,
– Tired staff,
– Bored or disheartened staff,
– Individual medical problems.

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 Determining the Underlying Reasons

– Organisational and managerial factors

– Poor work planning, leading to high work pressure,
– Lack of safety systems and barriers,
– Inadequate responses to previous incidents,
– Management based on one-way communications,
– Deficient co-ordination and responsibilities,
– Poor management of health and safety,
– Poor health and safety culture.

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 Developing a positive workplace safety culture – Du
Pont video

– https://www.youtube.com/watch?v=ghGTpGzosgs 26
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 A “Just” Safety Culture

– Idea of a “Just” safety culture

– ‘Justice’, no ‘blame’
– Blame should only be assigned to those who have been reckless
or clearly negligent in their work practice
– Likely that managerial decisions might be the underlying cause
of many incidents
– Reluctance for management to dig too deeply in case they are
found to be the root cause
– Apply the “Just” culture at all levels
– Lead from top management

Source: Energy Institute Guidelines for Incident Investigation 2008 - Page 21

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 Just Culture

– Need to improve the level and quality of safety reporting

– Need to ensure that the work force is not afraid to report
issues, near misses etc.
– Need to determine when blame is necessary to be attributed
– Approximately 10% of actions contributing to bad events are
found to be judged as culpable
– Need to establish trust with workers
– Leads to a reporting culture that leads to a learning culture
– Creating and developing a “Just” culture is critical for an
effective Safety Management System

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 Just Culture Benefits

– Benefits of a Just work culture over a blame culture

– Increased reporting of safety issues
– Increased development of trust relationship
– Earlier detection of potential hazards
– More effective safety and operational management

– Bring together various sections of the workforce

collaboratively; that might otherwise not have frequent contact
and influence on decisions and policy making
– Enhances the trust relationship

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 Methods to Improve Reporting

– Changes to policy and legal framework

– Policies and procedures that encourage reporting
– Clear definition of roles and responsibilities of people
– Feedback to workers – rapid and high quality
– Professional handling of investigations and dissemination of
lessons learnt
– Education of users as to why change is important and motives
for change

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 Safety Culture

Roadmap to a Just Culture: Enhancing the Safety Culture. 2004, Global Aviation Safety Network

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 What to Expect in a Just Safety Culture

– Everyone understands hazards & risks inherent in their operations and those with
which they interface
– Personnel continuously work to identify hazards & risks
– Errors are understood, effort is made to eliminate errors
– Wilful violations are not tolerated
– Employees and management agree on what is acceptable & unacceptable
– Everyone is encouraged to report safety hazards
– Hazards and controls are tracked and reported at all levels
– Employees encouraged to develop their own safety skills & knowledge
– Safety issues are communicated openly & everyone learns from lessons gained

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 Communication

– Goal of a Safety Management System is to improve workplace

safety and is best obtained through effective communication of
safety issues
– Written instructions related to safe work practices can be very
ineffectual, although definitely required for auditing purposes
and to promote awareness
– Verbal communication by supervisors and safety management
personnel is critical
– People are more likely to recall informal, casual face to face
communication than written information they have been
“forced” to read
– Also affected by literacy standards

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 Communication

– Two stage process:

– Written information helps inform the frontline worker but does not
generally change their perception of safety issues
– Written information tends to create a safety awareness
– Verbal communication reinforces this awareness
– Source of verbal information needs to be trusted
– Awareness is an important step towards behavioural change
but by itself does not induce change
– Personal involvement by supervisors is also required to induce
change

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 Communication (cont.)

– Also need to be aware of literacy levels

– Employee and Supervisors/Managers
– Consider using graphics, pictures of people
– Less dense text
– Dot points increases chances of people reading text

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 Energy Institute’s Top Ten HF Issues

– Organisational change (and transition management)

– Staffing arrangements and workload
– Training and competence (and supervision)
– Fatigue (from shift work and overtime)
– Human factors in design:
(a) General
(b) Alarm handling
(c) Control rooms
(d) Ergonomics – design of interfaces
(e) Ergonomics – health ergonomics
– Procedures (especially safety critical procedures)
– Organisational culture (and development)
– Communications and interfaces
– Integration of human factors into risk assessment and investigations (including Safety
Management Systems)
– Managing human failure (including maintenance error)

http://www.energyinst.org/technical/human-and-organisational-factors/human-factors-top-ten

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 Summary

– Human Factors are an important aspect of any Safety

Management System
– Human/Machine interface
– Human psychology and work culture
– “Operator Error”
– Attribution of blame
– A “Just” safety culture
– Effective communication is essential

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 Next Assignments

– Safety management system plan (20%)

– Groups of 3 or 4 selected by students
– Groups to form via Canvas Monday-Wednesday next week (instruction
to come via Canvas announcement)
– Groups MUST be from the same tutorial TIME
– Week 5 tutorial will have some dedicated time for groupwork to start

– Hazard identification risk assessment task (10%)

– 90minutes During Week 6 tutorials
– More information to be provided in week 5 lecture
– Risk assessment for a given scenario
– Groups of 3-4 selected by students
– Groups MUST be from the same tutorial TIME

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 Bibliography

– Energy Institute Guidelines for Incident Investigation 2008

– NSW WHS Act 2011 No. 10.
NSW WHS Regulation 2011 No. 674.
http://www.hse.gov.uk/index.htm
Global Aviation Safety Network, Roadmap to a Just Culture: Enhancing the Safety Culture.
2004
Australia/New Zealand Standard 4801:2001, Work Health & Safety Management Systems –
Specification with guidance for use
Australia/New Zealand Standard 4804:2001, Work Health & Safety Management Systems –
General guidelines on systems, principles and supporting techniques
Australia/New Zealand Standard HB205-2004, OHS Risk Management Handbook
Australia/New Zealand Standard HB211-2001, OHS Management Systems Handbook

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