George Petrie describes how TEPUK has used human factors principles to reduce potential for human failure in the gas industry
the oil and gas industry, the importance of human failures as an
accident causation factor is well known. Historically, the focus has
been primarily on identification and prevention of technical failures
causing major accident hazard events (MAH) with less emphasis on the
role of human failures.
In order to address human failures in
potential MAHs, TOTAL E&P UK (TEPUK) has developed a process to
manage the risk of human error across their onshore and offshore assets.
This journey over the last few years has not been an easy one, but by
developing sound foundations the company has started to show significant
benefits in managing human failures in MAH scenarios.
How are we implementing change?
decided that a move to focus on Human and Organisational factors (HOF)
in process safety required a competent person, that is, a member of the
CIEHF, to be embedded in the safety engineering department rather than
within traditionally the occupational safety department.
methodology chosen was to follow the guidance produced by the HSE in
their Roadmap for safety critical task analysis. In order to implement
this, a number of in-house procedures were developed to ensure a
consistent approach was used across the company.
The first step in
the roadmap process was to identify the MAH scenarios where HOFs
influence the outcome. From a human error point of view, the definitions
and detail of MAH scenarios in the guidelines were open to a certain
amount of interpretation. In order to identify the MAH scenarios in a
robust and consistent manner, TEPUK held a series of workshops
facilitated by an experienced external risk management consultant. These
workshops involved engineers from TEPUK’s safety engineering department
who reviewed various MAH scenarios to develop and test a defined
methodology appropriate for the company.
In order to identify the
MAH scenarios at each operational site, the first step involved a
workshop covering each designated plant area. During the workshop, a
review of the site Control of Major Accident Hazards (COMAH) Report and
corresponding safety studies such as the Hazard and Operability (HAZOP)
study was the main focus of activity. The output from this process
identifies the specific involvement of people in the relevant activity
associated with the upkeep of each prevention, mitigation or control
To complete the task analysis process, it is essential to
involve internal technical support from the human factors engineer,
safety or process engineers and most importantly the supervisors,
operators and technicians who carry out the tasks.
The human error analysis actions have been followed up in number of ways, depending on severity:
Where significant risk is found as a result of human error, specific
studies are carried out to identify if further engineering controls are
Where procedural controls are required, stop/hold points
are added at the specific steps in the procedure that highlight the
hazard effect and risk control measures. This also requires a counter
signature by a second person before proceeding.
occupational safety hazard is found, a safety, health, environment and
operational integrity note is added explaining the hazard and risk
control measures at that specific point in the task.
for the performance influencing factors was developed after reviewing
guidance and it is imperative that this allows a consistent approach
when walking through the tasks on site. After completion of the new
procedure a review of training and competency is carried out. This
requires a clear link between the task, training requirements and
competency to ensure human error is minimised.
How far are we on the journey?
whole process has gained momentum at TEPUK’s onshore gas plant, with
resources being allocated to support the assessment process and to
facilitate updates to site procedures.
During the workshops, a
number of scenarios were identified where a single error could lead to a
MAH. Various operators recognised that they were not aware of the
possible scenarios following these errors. These scenarios are now the
focus of HAZOP studies and also changes to the isolation procedures to
include STOP/HOLD points and full details of the hazard effect and the
risks. The STOP/HOLD points are placed at specific task steps and
highlighted in order that operators or maintenance techs have clear
information at the appropriate step in the task rather than a generic
statement at the beginning of the procedure or mentioned in a separate
work permit. This simple step allows increased control of potential
human error as an counter signature is required by a second person prior
to the task proceeding to the next step.
As this subject is not
widely understood by people who are not human factors professionals,
TEPUK developed specific awareness training courses. Leaders attend a
two-day course facilitated by external consultants and the in-house HF
engineer, while operators/technicians attend a shorter awareness course
of approximately two hours. Feedback from this latter course has
highlighted that we need to lengthen the time allowed. These courses are
fully aligned with the safety critical task analysis process using site
based examples to help explain the principles throughout the training.
The process requires a large amount of resources and subsequent support
and investment from management, and is now progressing well across TEPUK
with plans to involve project and modification engineers.
Lessons learned and conclusions
Developing and implementing this process has been challenging and the following explain some of the learning points identified:
- Organisations need to be intelligent customers and choose HF
consultants that fulfil the competency requirements of the CIEHF.
clear strategy and common methodology is required. We found that
without a TEPUK common process, results obtained were not consistent
across the various operational sites.
- Focus on major risks. The
process is more effective when priority is given to MAH scenarios that
are deemed high risk from human error.
- Close the loop from MAH
scenarios right through to training and competency. The higher level of
detail required in documentation for high risk tasks must fully align
with the actions identified from human error analysis and be linked to
training and competency for that task.
- Integrate HF into the
business, ensuring the workforce and management have sufficient
knowledge and understanding of human and organisational factors.
- Involve the employees. The initial studies, which were not particularly successful, were conducted mainly as desktop studies.
were found to be largely ineffective in understanding how a task is
carried out. As a result, TEPUK always involve the workforce at each
step in the process. This has resulted in significant benefits being
realised both with employee buy in and their improved understanding of
TEPUK future plans, 2015 and beyond
entire process is still very much a work in progress but the
foundations have been developed. TEPUK have focused their efforts on
high risk tasks at each operational site as a priority until these have
been fully addressed. Once complete, progress will be made on those
remaining tasks identified as medium and low safety critical tasks.
benefit from implementing this approach has been the subsequent
identification of situations where risks of human error could affect the
validity of environmental permits and consents, adversely impact
operational downtime, potentially damage equipment or impact future
business continuity. Due to the business value of addressing these
issues, they will be incorporated and further developed in future plans.
By George Petrie, Lead Human Factors Engineer at TOTAL E&P UK
This article was first published in issue 538 of The Ergonomist, April 2015