Human Factors and Occupational Safety and Health

6.
1 Human factors and occupational safety and health 243
efficiency-thoroughness trade-off (ETTO) principle and human variability in de-

cision making that turns much upside down again.
In the late 1990s, rather suddenly safety culture became a buzz word in the
process industry, although at least a decade earlier the lack of it had been recognized
as contributing significantly to accident causation. The essays of Dov Zohar, James
Reason, and others on safety culture as a derivative of organizational culture have
had much effect on safety thinking. We shall learn the distinction between safety
culture, safety climate, and safety attitude and how to measure and influence these.
If there is something going wrong then quite often the management level has
been failing. Leadership is crucial, and not only have we become aware of it, but
we shall see initiatives to educate those in command of the organizations to such
an extent that they at least can ask the right process safety questions before
decisions are made. Note that most often these individuals are nontechnical people.
We shall also encounter some new features as risk registers, the ISO 55000 standard,
and involvement of top managementdin other words, aspects of corporate gover-
nance for effective process safety. Attention will be given to rules and procedures,
compliance, and work discipline. However, in the fervor to reach a state of zero ac-
cidents, the mistake can be made to avoid complacency by more rules and more
frequently checking off items at screen displays or paper. This may easily become
counterproductive. An atmosphere of safety thinking and trust on the work floor,
freedom to take action and improvise if necessary, motivates. It also might be
more productive being addressed without arousing emotion when a colleague points
to one’s error, and the right to stop the work if feeling unsafe. However, everything
has its limits and keeping the right balance is management’s challenge.
We shall conclude the chapter with a brief history of the evolution of key
performance indicators (KPIs) adapted to process safety. Explanations will
be given of why KPIs for human factors (HFs) and organizational safety culture
Copyright © 2015. Elsevier Science & Technology. All rights reserved.
indicators help so much, how the industry looks at them, and some practicalities
of their introduction. How we can further use performance indicators as weak risk
signals once we collect them, besides just watching trends, will be a topic in
Chapter 7.
6.1 HUMAN FACTORS AND OCCUPATIONAL SAFETY

AND HEALTH
Process safety and risk management must give HFs much attention and must devote
much effort to treating HFs with great care. HFs is a much broader concept than hu-
man errors. In the limited sense of ergonomics it is a multidisciplinary field of study
of designing equipment and devices optimized for the human physical and cognitive
abilities. Hence, adaptation of the machine with its screen display to human senses,
body measures, and time needed to make decisions (See Figure 6.1 for the reverse
situation of human adaptation to the machine). It can be interpreted even in a still
wider sense as human factors engineering (HFE), which comprises besides the
Pasman, Hans J.. Risk Analysis and Control for Industrial Processes - Gas, Oil and Chemicals : A System Perspective for Assessing and Avoiding
Low-Probability, High-Consequence Events, Elsevier Science & Technology, 2015. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/uamrg2-ebooks/detail.action?docID=2069956.
Created from uamrg2-ebooks on 2020-06-11 16:14:30.
244 CHAPTER 6 Human Factors, Safety Culture, Pressures, and More
FIGURE 6.1
In the old days, an operator had to be knowledgeable and also athletic!
above, task analysis, writing procedures, design of personal protection equipment

including protocols for use, training aids, simulators, communication, enhancing
team work, and system ergonomics, here all with reference to safety. System ergo-
nomics in manemachine interaction has a strong cognitive accent, as a human oper-

ator must make the right decisions based on information generated from information
technology systems and offered to him by the system in the right colors and lighting
for optimum observation. Hence, achieving a good state of affairs with HFs is a
matter of optimizing demands and requirements on the one hand against human
capacities and system performance characteristics on the other, and so minimizing
human error. Good examples can also be found in design and layout of equipment
such that effective and safe maintenance can be performed. Sound procedures for
work permits (e.g., for hot work) and confined space entry are other important items.
One distinguishes even organizational ergonomics as optimizing the socio-technical
system for sustainable high performance. To support work on methods to optimize
workplace safety and health many countries have dedicated institutes such as
NIOSH (National Institute of Occupational Safety and Health) in the US.
Viewed from the negative, inadequacies in HFs lead to errors and unsafe acts,
which can result in injury or death, both by acute or by chronic exposure, and to
6.1 Human factors and occupational safety and health 245
loss of productivity and efficiency. Therefore, HFs are also heavily connected to OSH,
entailing an impressive body of relevant regulation and (risk-based) standards on
amongst others machinery safety. There is also a large volume of literature and text-
books available on OSH topics and perhaps even more material, at least in volume,
from consultants. A known book by Daniel Della-Giustina1 contains chapters such
as Hazard Communication and Hazardous Materials Handling, Job Safety Programs,
Safety Committees, Lockout/Tagout, Confined Space Entry, Personal Protective
Equipment, Occupational Noise and Ventilation, Bloodborne Pathogen Standards,
and chapters on emergency response issues. The last few years there have been quite
a few laboratory accidents. CRC Handbook on Laboratory Safety by A. Keith Furr2
contains a wealth of information that would help to prevent these. For process industry
practice in preventing human error API 7703 provides a useful guide.
A historical review of the interesting evolution of OSH is available from Paul
Swuste et al.4,5 In the 1920se1940s (the time of Herbert W. Heinrich), recounted
in these reviews, the worker was blamed for causing the accident. In contrast to
this opinion, in the present day “just culture” came up. Just culture was a phrase first
coined by James Reason6 as one of the components of safety culture (to be treated in
Section 6.5). Pushed forward more recently by amongst others Sydney Dekker,7 just
culture attempts to propagate the creation of justice inside an organization by
learning from accidents and fair accountability. It endeavors to build an atmosphere
of trust within an organization so that safety-related information is not withheld or
swept under the carpet (“Keep your mouth shut”). Criminalization and civil liability
of an unsafe act (resulting from error, negligence, recklessness, or violation) may
keep a person from providing information and is a concern, while personal culpa-
bility in organizational accidents shall only be apportioned with care. However,
the borderline between acceptable and nonacceptable behavior must always be clear.
Just culture applied to aviation and health-care organizations is well described in
respective guidelines.8,9
In explaining the value of just culture, John Bond10 summarized Reason’s
distinction of three potential accident causation types, resulting from HF inade-
quacies as
• the personal factor: the main emphasis here is on inadequate capability, lack of
knowledge, lack of skill, stress and improper motivation, fatigue, sleep
deprivation;
• the workplace factor: this includes inadequate supervision, engineering,
purchasing, maintenance, inadequate training, and work standards;
• the organization factor: this views human error more as a consequence rather
than a cause and is indicative of latent inadequacies in the leadership or
management system.
Around the year 2000, a consortium guided by the European Process Safety Centre
accomplished a European Union (EU) project called PRISM11 dedicated to the HF.
246 CHAPTER 6 Human Factors, Safety Culture, Pressures, and More
The project was reported at the 11th International Symposium on Loss Prevention and
Safety Promotion in 2004 and covered the following topics spread over 16 papers:
• organizational and cultural issues, such as team working, and behavior-based
safety;
• optimizing human performance: task design, procedures, ergonomics, man-
machine, and humanecomputer interface;
• HFs in high demand situations: diagnosis of process upsets, cognitive (alarm)
overload, emergency response, control room layout, abnormal situation
management;
• HFs as part of the engineering design process: an application guide.
Behavior-based safety is an approach to reduce unsafe behavior in the working
place. It is a process to help perform routine tasks safely by, for example, behavioral
observation, intervention, and feedback, and further by setting improvement goals,
training and education, motivation, and coaching. UK’s Health and Safety Executive
(HSE) issued a useful guide.12 A separate activity but with the same goal is the
issuing of the Napo safety promotion videos,13 prepared by a consortium supported
by the European Commission and distributed by the EU-OSHA. Napo is the name of
the hero in the cartoons and is a normal, willing worker who finds himself in all
kinds of situations. Hopkins14 points, though, to the weakness of safe behavior pro-
grams, as these tend to shift causation to the first link in the chaindthe worker (the
sharp end)dand not to the last onedmanagement (the blunt end), where for the
sake of general prevention more gain can be obtained. Also, observations may be
biased and attitude may be more important than observed behavior.
Abnormal situation management is the operator response to deviation from
the normal course of a process, such as unexpected process parameter excursions,
runaways, leaks with emissions possibly followed by explosion or fire, unplanned
shutdowns, et cetera. Besides technical causes, it has quite a few HF aspects. We

shall return to this topic in Chapter 8, where we shall also discuss the activities of
the Abnormal Situation Management Consortium led by Honeywell in the US,
which since 1994 has been working on research to prevent and mitigate.
As the PRISM papers show, there are many detailed recommendations to be
made with regard to HFs. UK’s HSE issued two very practical HF advisory notes:
the HSE Human Factor Briefing Notes15 and the Inspectors’ Toolkit on Human Fac-
tors16 in the management of major accident hazards at lower-tier COMAH sites.
These contain suggestions for questions to be asked by inspectors on the various
HF aspects. Further, Bridges and Tew17 provided an overview of how HFs are
addressed in the US OSHA Process Safety Management standard, CCPS Risk Based
Process Safety guideline, and the Responsible CareÒ recommendations. They pub-
lished a list of practical HF items that were missing in the OSHA PSM standard.
More recently, following the 2005 BP Texas City refinery accident, for personnel
in refining and petrochemical industries in the US, the API Recommended Practice
755 on Fatigue Risk Management has been introduced. (In 2005 at the Texas City
refinery shifts worked 12 h.)
6.1 Human factors and occupational safety and health 247
In the 2005 time frame, another initiative of HSE’s Hazardous Installations

Directorate led to the effort of Bellamy, Geyer, and Wilkinson18 to develop a func-
tional model integrating HFs, SMS, and the organization. The ultimate goal was to
find in practice patterns identifying weaknesses that could initiate major accident
scenarios. Hence, the identification would generate warning signals. This work was
specifically aimed at safety in the process industries and to support inspectors and
companies. The idea has been to break down the three separate areas into a taxon-
omy of smaller components (they number nearly a thousand) and use these as
building elements to reconstruct an integrated model that can serve during both au-
dits and inspections. The product is what the authors called an archetypal warning
triangle, of which an example is reproduced here in Figure 6.2, and a sector-
specific taxonomy to be used for defining safety constraints. Four warning triangles
themes were proposed: Understanding Major Accident Prevention; Competence
for Tasks; Priorities, attention, and conflict resolution; and Assurance. The latter
means making sure operations are safe by monitoring and evaluating. The four tri-
angles can be combined to a regular tetrahedron (also called triangular pyramid).
The triangles can be made sector specific. Case histories of eight major accidents
that had occurred in various countries were used to check how warning signs were
ignored. Inputs are issues of concern/interest; outputs from the taxonomy are “def-
initions of meaningful integrations in the knowledge space” that can act as guide to
a user. The user himself must specify criteria and should have his own knowledge
resources. The paper announced that before validation of the proposed model in
practice, a workshop would be held.
FIGURE 6.2
Example of warning triangles embedded in a large one representing the theme, as developed
by Bellamy, Geyer, and Wilkinson.18 The triangle here is for Understanding Major
Accident Prevention (MAP), within the center what is necessary in MAP for Risk Control,
above what is relevant from the SMS, below left from organization, and to the right from HFs.

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6.

1 Human factors and occupational safety and health 243

efficiency-thoroughness trade-off (ETTO) principle and human variability in de-

6.1 HUMAN FACTORS AND OCCUPATIONAL SAFETY

above, task analysis, writing procedures, design of personal protection equipment

nomics in manemachine interaction has a strong cognitive accent, as a human oper-

shutdowns, et cetera. Besides technical causes, it has quite a few HF aspects. We

In the 2005 time frame, another initiative of HSE’s Hazardous Installations

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