SEPTEMBER

INFO SHEET 2020

Understanding and managing

human factors in the wells sector
We often hear statistics like ‘80% of accidents are caused by human error’
in newspapers, presentations and training courses. It makes us think that
incidents are caused by people, but is that true?

When we look at the detail of these incidents we find that there are many contributing factors in the workplace.
Problematic tasks, unclear procedures, difficult equipment, workload, resourcing and training – these difficulties often
lead to mistakes and workarounds, which eventually become incidents. What’s more, all of these are conditions that
leaders have the potential to influence. Leaders can make decisions to change and improve systems and make procedures
and tasks resistant to error, especially if they have the support of the workforce.

Human Factors, Human Performance and Crew Resource Management are terms often used interchangeably. Within this Information Sheet, the term ‘Human Factors’ is used
in its broadest context and incorporates the concepts of Human Performance and Crew Resources Management.
 Understanding and managing human factors in the wells sector
To help us, we can be clear about how we
think about human factors:
• People interact with each other, plants and processes as
part of a complex system. Human beings are essential in
maintaining our barriers and safeguards. They can, and
often do, “save the day”.
• We understand and accept that people will make mistakes,
but these are typically due to underlying conditions and
systems. People’s actions are rarely malicious and usually
make sense to them at the time. Since human error will
never be eliminated entirely, we try to make sure that our
most critical tasks and barriers are resistant to error.
• Understanding how mistakes happen can help us prevent or
cope with them. We use what we learn to design plants, tools
and activities to reduce mistakes and better manage risk.
• Finally, we know that leaders help shape the conditions
that influence what people do. It matters how leaders
respond when things go wrong.”
From IOGP Report 453 - Safety Leadership in Practice:
A Guide for managers
The nature of wells activities
Wells activities, perhaps more so than in any other sector
of the Exploration and Production (E&P) industry, places a
greater reliance on the skills and judgement of individuals
and teams to perform safety critical functions appropriately.
We work hard to ensure our personnel are capable of
performing the duties required of them, but we also need
to take care that the environment within which they work
maximises their ability to operate in a safe and efficient
manner, by designing equipment, tasks and processes to be
“safe”, even when someone makes a mistake.
By their very nature, operations across the well life cycle -
from exploration drilling to well decommissioning - expose
personnel to new and evolving hazards which often have to
be dealt with in real time, with a time constrained analysis
and decision-making process. People may find themselves
in situations where they have to make decisions that are key
to preventing or mitigating a major accident, in stressful
and adverse environments.
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What the experts say about
“80% human error”
When the 80 percent human error is
broken down further, it reveals that
the majority of errors associated with
events come from latent organisational
weaknesses (mostly the result of human
and organisation actions in the past)
whereas about 30 percent are caused by
the individual worker who last touched the
equipment or process.
Human Errors
70% Organisation
Events 80%
Weaknesses
Human Error
30% Individual
20%
Mistakes
Equipment
Failures
To be successful, we have to make it as easy as possible for
people to succeed in their tasks. The processes, systems
and hardware we rely on, are not always suited to the
dynamics present within many types of well operations. An
appreciation for human factors helps to tune tasks, systems
and processes to be more helpful in the hands of the people
who have to use them.
Further, well operations are often conducted in working
environments that are constantly evolving. Over a year,
a drilling rig, a workover hoist, or intervention unit can
operate in a number of different locations, each with
its own logistical and operational challenges. When the
location or client changes, the personnel and organisation
required to deliver the operation may also change. Yet, the
consequences of a failure are such that it is essential that
all these different elements work together seamlessly from
the start of the operation if the risk of a well control incident
occurring is to be minimised or its consequences mitigated.
 Understanding and managing human factors in the wells sector

Managing the Inevitable

A Subsea Engineer was running a BOP on a marine riser when he accidentally activated the Emergency Disconnect
Sequence (EDS). The BOP separated from the riser and sank to the seabed. The Engineer had intended to press the
Pilot Operated Check Valve override button, which had similar labelling and protection to the EDS button.

Considering human factors in the design stage could have eliminated the potential for similar looking buttons that
could be pressed in error.

The continuous improvement cycle, which forms an
important element within the HSE Management System,
is particularly challenging to embed within a dynamic
environment where Human Factors play a critical role.
An analysis of the well control incidents submitted to IOGP
indicates that there were few instances of spontaneous
equipment failure, but a prevalence of problems with
supervision, condition-monitoring, procedural problems and
mistakes in reaction to a deteriorating situation, all of which
have some element of human factors associated with them.
The aim of this document is to provide the reader with
a basic understanding of what human factors are, why
they are critically important and how organisations can
approach their management. Its focus is on well operations
conducted within the E&P industry whether onshore or
offshore.

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 Understanding and managing human factors in the wells sector

What do we mean by human factors?

Whilst many industries have improved safety and
effectiveness by improving technical and engineering
controls and mitigations, there is no escaping the fact
that human beings are an essential part of making these
operations successful and safe.
Other advanced and developing industries have realised
that procedural and engineering controls only work when
they are designed with people in mind. That means taking
account of the capabilities of normal human variability.
In ‘human factors’ we try to understand how teams interact
with the equipment they use, the systems and tasks they
are required to work with and the interfaces they have with
their colleagues.
Top 10 human factor issues
(Step Change information compiled from interactions
with UK HSE inspectors dealing with Major Hazard Sites)
1. Organisational change and transition management
2. Demanning and staffing levels
3. Training, competence and supervision
4. Fatigue from shiftwork and overtime
5. Alarm handling
6. Compliance with safety critical procedures
7. Safety culture/blame culture
8. Communications, e.g., shift handover
9. Ergonomics
10. Maintenance errors

It covers a large range of issues, the majority of which may • Communication issues: Are there common
not be directly within the control of the individual. languages? Are channels open and two-way between
leaders, workforce, operating companies and
There are some broad categories which human factors
contractor companies?
traditionally focuses on:
• Risk Management: Do the risk assessments consider
• Hardware: Is the equipment designed to be easy
the potential for human errors to occur and means of
to operate and maintain? Is the doghouse layout
preventing, detecting and recovering from them?
(ergonomic design) such that it provides the drillers
• Competence: Are key personnel trained and practiced in
with the information they need to respond to a
the critical situations that they may find themselves in?
scenario in an efficient and effective manner?
• Operating Systems and Procedures: Are they The above list shows some of the issues associated with
designed with the user in mind? Do they address the each of the main categories; there are many more.
potential for human error and ways to prevent, detect
Fundamentally, human behaviour is influenced by a wide
and recover from an error?
range of factors, such as fatigue, time pressure, distractions,
• Leadership: Do leaders promote a positive and
or poor design. One aim of Human factors is to identify and
proactive attitude towards HSE related issues? Do they
manage these influences. People make the most of poor
encourage personnel to report negative issues? Do
design, poor shift systems, production pressures and other
they spend time with the workforce to understand the
problems to get the job done despite these challenges, but at
problems being faced?
some point they are likely to be tripped up by them. People are
• Working patterns: Do the shift working patterns cause
flexible and generally come to work to do a good job. Working
fatigue? Are there enough people of the right skills
with people who understand the work and where the difficult
to carry out tasks that are critical to safe and reliable
issues are can go a long way to reducing human error, but
operation?
working with a Human Factor specialist can make it easier.

Simple Ergonomics
During a coiled tubing operation, the operator was required to monitor two screens on opposite sides of the cabin
while recording information in the log. As a result the operator missed a build up of excess load on the unit. If the
ergonomics of this situation had been considered, screens could have been positioned to allow the operator to see
both at the same time, and spot the problem emerging.

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 Understanding and managing human factors in the wells sector
The importance of proactively addressing human factors
IOGP receives and analyses Well Control Incidents from
around the world and uses the results to direct activities
towards areas which will benefit the industry. Human
factors opportunities feature prominently in many of the
incidents submitted to IOGP. In particular:
Problems with Procedures
Nearly every incident reviewed by IOGP involved a
procedural issue, whether it was the absence of written
procedures, inadequate procedures, or not following
established procedures. More detailed analyses of such
incidents often identify human factors as one of the causes:
the procedure was too difficult to follow, or it was common
practice to not use a procedure.
Crews are frequently blamed for not following procedures
after an incident, ignoring the fact that in a dynamic
operation, such as well construction, operational execution
never happens exactly as per the procedure. Acknowledging
the limitations inherent to procedures is an important
element when analyzing human factors in well operations.
5
“A procedure is the mirror of the theoretical
and practical knowledge of the operation of
a process, valid in a certain moment. There is,
usually, a gap between the procedure and the reality.”
(Human and Organisational Factors in Nuclear Plants,
European Commission, 2007).
Risk Assessment
Whilst in the majority of cases some form of risk
assessment appeared to have been carried out, there were
indications that these frequently missed hazards or risks,
or that adequate controls had not been put in place. This
was particularly evident in nonroutine operations. After an
incident, it might seem odd that people didn’t foresee the
hazards, but we have to remind ourselves that we have the
benefit of hindsight. The reality of risk assessment is that
we ask people to predict risks and hazards based on what
they know, have experienced or think likely to happen. This
is hard to do and no risk assessment can account for all
eventualities in a complex system.
 Understanding and managing human factors in the wells sector
If the possibility of an error exists it may only be a
matter of time before that error surfaces. By proactively
addressing human factors, we aim to reduce the
likelihood of an error occurring, or when an error is
made, to quickly and safely detect and rectify it.
As well as risk assessments conducted before a task,
crews are constantly identifying and assessing changes in
the operational conditions, understanding the additional
risks from these changes and stopping and considering
control measures. That is how high performance crews
practice situational awareness.
Responding to weak signals
In hindsight, it appears that early or weak indicators were
believed to be insignificant, or were explained by convincing
but incorrect explanations. In reality, people are constantly
trying to make sense of multiple weak signals and bits of
information. This can lead to things which later turn out to
be important being dismissed. It is made harder by the fact
they cannot see what is happening downhole and several
plausible explanations can all satisfy the data streams
(anecdotal indicators) they are fed-back. Reacting to weak
signals by seeking concrete evidence to support or rule out
a problem is an important skill.
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What analyses of the incidents tells us is that unless
Human Factor issues are managed, then the likelihood
of an incident occurring is heightened. This has been
recognised for some time in sectors such as nuclear,
aviation and medicine, where significant efforts have been
made to understand and address human factors. In fact,
many of the approaches developed in these industries have
been introduced to some extent within sectors of the E&P
industry.
In the types of environments that may be present on a well
operations site, where the actions of people are critical to
maintaining a safe operation, organisations cannot rely
solely on common good practice to manage the Human
Factor issues specific to their facilities, their culture and
their people. A proactive and structured approach to
understanding and addressing human factors is required.
In an environment where major accidents are possible,
addressing human factors is vital to long-term survival.
Even for organisations working in environments where
there is no possibility of a major incident arising, there
is value in proactively addressing human factors. Making
systems, tasks and tools easier and more intuitive to use
without error leads to reduced risk, improved productivity
and reduction in serious injuries.
 Understanding and managing human factors in the wells sector

Getting the culture you want

The Role of Leaders

Report 453 says:
“…the culture of any organisation is a complex and
unpredictable mixture of leadership, employee
involvement and motivation, workforce and national
values, beliefs, assumptions, business pressures and
practices, to name a few.
This might give us the impression that culture is an
immovable object, something which is the outcome of
so many complex variables that it’s almost impossible
to influence. However, research has revealed that
leadership has an especially high influence on
workplace cultures...
Leaders have a major role in shaping the culture of the
organisation. By ‘Leaders’ we are not only thinking about
people at the top of the organisation’s management
structure, but also the rig managers, the OIMs, those
in charge of the drill floor activities and those who
supervise activities. How they act and the messages they
communicate can have a significant influence on the
culture of an organisation
Does your behaviour as a leader support the proactive
and early reporting of problem areas?

This means that how we lead has a significant impact

and potential to give us the culture that we want.
Unfortunately, it also means that some of the things
we do as leaders can unwittingly lead to a culture
that we don’t want. In other words, we get the culture
we deserve.”
The ‘safety culture” of an organisation’ can influence
people to act in a particular manner. For example, if an
organisation, through its actions or poor communication
appears to be placing the requirement to deliver improved
drilling performance above safety, then people, when forced
to make a choice between one or the other, may choose to
take risk in order to be productive. Equally, if nobody uses
procedures at a site – for whatever reason – it should not
be surprising to find that the behaviour of an individual
follows that trend. Our question then becomes: What is it
about these procedures which means they are not valued?
The answer may be a combination of accuracy, availability,
usefulness, expectations, or something else.
Having the appropriate technical skills is only one part of
being a good leader in our industry. Another, equally critical
aspect of effective leaders is their behaviour in supporting
a safe working environment for their team. Do they make
themselves available in the field? Do they respond with care
for their people and curiosity to the underlying issues when
things go wrong? Do they listen to the workforce, as well as
setting expectations? Are they active in identifying fatigue
or stress in their work parties? Does the example they set
promote a positive safety culture, or a culture of ‘getting
the job done at any cost?’ Do they “Walk the talk”? Training
in certain aspects of human factors can equip receptive
leaders with the skills that create a positive safety culture.
It is worth remembering that, while it requires considerable
effort for an organisation to develop and maintain a good
HSE culture; it is extremely easy for an individual at a
senior level within the organisation to quickly undermine it.

Although there are many culture survey tools available,

their value is questionable. They produce large amounts
of information, but can be labour intensive and difficult
to extract actionable information from the results. Since
we know that leadership shapes culture, it helps to read
cultural surveys as an indication of leadership, not the
people being surveyed

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 Understanding and managing human factors in the wells sector

Competence and human factors

Safe operations rely on having trained and experienced

(competent) personnel who are provided with error-tolerant
Competence and human factors
equipment, processes, time and adequate resources
necessary to perform their duties. On its own, Competence is not a protection against
error. Even the best trained, experienced and
Different groups may require different skills. Leaders
dedicated workers make mistakes. These mistakes
require technical and people management skills. Engineers
are made more likely by the influence of Performance
need to understand how their designs can increase or
Shaping Factors such as:
reduce likelihood of error. Teams managing high risk
• Excessive workload
activities may require particular nontechnical skills,
• Undue pressure (real or perceived)
such as communication, decision-making and situational
awareness skills taught in Crew Resource Management. • Inappropriate supervision
• Poor communication
When something goes wrong because someone has made a • Fatigue
decision or taken an action that seems unwise in hindsight,
• Stress
it can be tempting to see competence as a root cause.
• Poor ergonomics
The challenge in all situations is to dig down below the • Poor procedures
human error or competence issue to understand the
context that influenced people to do what they did. The
purpose is to stop anyone else falling into the same trap,
not to “fix” the person involved.

In many of the well control incidents the industry

experiences, an activity has been carried out in a manner
that might appear not to meet competency requirements,
whether in the office (the design of the well did not account
for shallow gas) or the rig (cement log was not correctly
run). However, things which appear to be competence
failures can also be mistakes. People have to perform these
tasks in complex, unpredictable conditions and even the
best, most competent and dedicated are subject to normal
human variability.

Care needs to be taken when assigning the causes of

an incident to a lack of competence. A person being
assigned a task for which he is not competent is usually an
organisational failure; the organisation did not interview,
train, or resource to the right level. Even where an
individual is clearly competent to perform an activity, but
fails to do so, it is essential to explore the situation they
found themselves and the factors that were the context for
Photography courtesy of BP p.l.c.

them doing what they did.

Tools are available to assist organisation in identifying the

Human Factor aspects of any incident or failure (see Useful
References and Resources on page 11).

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 Understanding and managing human factors in the wells sector
Crew Resource Management
Competence management, specifically the training and
certification component of it, has traditionally focused on the
technical aspects of the activity: how to design the well, how
to operate drilling equipment, how to run coiled tubing and
so on. However, while being competent to perform an activity
is essential, experience from other industries, particularly
aviation and healthcare, has shown that further benefits can be
realized by providing teams with training on ‘nontechnical skills’.
Crew Resource Management (CRM) relates to “the
cognitive, social and personal resource skills that
complement technical skills and contribute to safe and
efficient task performance”, (Flin and O’Connor, 2008). It
focuses on providing the whole crew with the skills and
confidence to identify, communicate and address issues
before they become incidents.
Training in this area is likely to focus on one or more of the
following non-technical skills:
• Situational Awareness: developing and maintaining a
dynamic awareness of the situation and the risks present
during a well operation, based on gathering information
from multiple sources from the task environment,
understanding what the information means and using
it to think ahead about what may happen next.
• Decision Making: The ability to reach a judgement or
choose an appropriate option to meet the needs of an
assessed or anticipated situation.
• Communication: The exchange (transmission and
reception) of information, ideas and beliefs, by verbal
and non-verbal methods.
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Photography courtesy of BP p.l.c.
• Teamwork: The ability to work effectively and
interdependently in groups of two or more to achieve
a shared goal.
• Leadership/Supervision: The ability to successfully
influence others to achieve a shared goal by providing
guidance, direction, coordination and support and
generating an environment in which candid feedback is
expected and rewarded (Lopez et al, 2020).
• Awareness of performance shaping factors:
Understanding how a team’s performance and general
wellbeing can be affected by excessive workload, undue
pressure, inappropriate supervision, poor communication,
fatigue, stress, poor ergonomics and poor procedures.
In an environment where people may have not worked together,
be unfamiliar with the hardware and systems on the rig and, as
a result, be uncomfortable raising any safety concerns they may
have, CRM can help teams to work in dynamic conditions, and
recognize and respond to emerging situations. Using simulation
tools can help crews improve their competencies while
managing unexpected, critical operational situations.
Empowering and mobilising the
whole team
We value people speaking up when something looks odd,
or a situation worries them. It can be hard to raise these
things if we think other people have already seen it, or
regard it as normal. Empower and recognize people who
speak-up no matter what the circumstances.
 Understanding and managing human factors in the wells sector
Getting started
The application of human factors is an activity all
organisations have engaged in to some degree.
To make a start it can be helpful to assign a champion who can
learn more about the topic, help inform others in the company
and start thinking about how the company performs in some
of the human factors issues discussed - investigations,
critical tasks, etc. This person then acts as an informed
buyer of human factors specialist support, if necessary.
Supervision, ergonomic design, stakeholder involvement
in the development of procedures, shiftwork and fatigue
management are all examples of initiatives aimed at
addressing a particular human factors element. Much can be
achieved by simply working with those that have to do the work
and understanding and eliminating the difficulties they face.
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Who is responsible for managing Human Factor issues
within your organisation?
A system for addressing human factors concerns is
necessary for an organisation to be confident that it
has taken adequate actions to prevent human factors
contributing to the next incident.
There are many resources and organisations that
can support companies addressing human factors
issues whether at the corporate level or on the rig site.
Recognizing the need to address these issues, within a
dynamic environment such as a well operation, represents
the first important step.
 Understanding and managing human factors in the wells sector
Useful References and Resources
IOGP Reports
IOGP Report 452 - Shaping Safety Culture through Leadership
IOGP Report 453 - Safety Leadership in Practice: A Guide for
Managers
IOGP Report 476 - Recommendations for the enhancement of
well control training
IOGP Report 501 - Crew Resource Management for Well
Operations Teams
IOGP Report 502 - Guidelines for implementing Well
Operations Crew Resource Management training
IOGP Report 621 - Demystifying Human Factors: Building
confidence in human factors investigation
All of these IOGP Reports are available from the
IOGP Bookstore (https://www.iogp.org/bookstore)
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Other Resources
Flin R and O’Connor P. Safety at the Sharp End. Boca Raton:
CRC Press, 2008.
Lopez JC et al. “Applying Behavior Engineering to
Procedural Adherence.” Society of Petroleum Engineers
International Conference and Exhibition on Health, Safety,
Environment, and Sustainability, 17 - 19 Mar 2020 Bogotá,
Colombia (postponed). SPE-199396-MS.
Step Change in Safety Human Factors Resources:
https://www.stepchangeinsafety.net/workgroups/human-
factors/
Energy Institute: Human and Organisation Factor Resources:
https://publishing.energyinst.org/topics/human-and-
organisational-factors
UK Health and Safety Executive: Human Factors and
Ergonomics: https://www.hse.gov.uk/humanfactors/
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