Review of Human Factors in Queensland Mining incidents The HFACS-MI project Trudy Tilbury, Safety and Health.

Slides:



Advertisements
Similar presentations
Managing a clinical incident
Advertisements

HSE & Edinburgh University working together to manage Biological Safety Dr Matthew Penrose HSE Biological Agents Unit.
Nursing Diagnosis: Definition
The Safety Analysis Methodology EHEST Conference 13 October 2008 Cascais, Portugal.
HWB boards and Co-production Clenton Farquharson.
Accident and Incident Investigation
Business Partnership Model Aligning HR Service with organisation strategy.
AssessmentAssurance Evaluation Policy development Public Health Action Cycle.
Home Insurance Charts show annual (yearly) fees. Fees are based on replacement value (not market value). For HOUSES use Homeowners chart. vs. For APARTMENTS.
ROSIS - Working Towards Safer Healthcare Delivery
MASTERS INDUCTION USING A CASE STUDY. LEARNING OBJECTIVES FOR THIS SESSION Understand the use of case studies in teaching business strategy Provide a.
 Session One (8am – 3pm) 1. Course Introduction 2. Content Review (8 taxonomies)  Session Two (8am – 3pm) 1. Test Taking Skills 2. Critical Thinking.
Learning Outcomes Contrast different approaches which can be used within the discipline system Suggest how these approaches can be avoided by the business.
Business Critical Rules March 2015
HSE’s Ageing and Life Extension Key Programme (KP4) and Human Factors
Event Review Using HFACS (Template)
Human Factors Analysis and Classification System (HFACS)
Incident Investigation : An Advance Approach By: Shakir Imran Fauji Fertilizer Company Limited Fauji Fertilizer Company Limited Mirpur Mathelo.
Pamela Simpson MCSP Moving And Handling Consultant.
IMS Training on Management Standards ISO 9001, ISO 14001, and OHSAS Prepared by SL, 18/01/2011.
Introduction to Root Cause Analysis Understanding the Causes of Events
24 October 2002 ICAO NAM/CAR/SAM RUNWAY SAFETY/INCURSION CONFERENCE 1 Retrospective Human Factors Analysis of US Runway Incursions (Focus: Air Traffic.
HSE Management System - TRIPOD Presented By: Naman Shah Pakistan Refinery Limited Incident Investigation and Analysis.
SHE Code 26: Safe use of Lifting Equipment and Lifting Accessories Safety, Health and Environment (SHE) Group.
Thames Water Behavioural Safety Briefing 1½ hour.
Matthew Wyman and Sarah Longwell, Keele University
The benefits of positive leadership and an effective worker engagement programme Martin Worthington SHEQ Director.
Torkel Soma 25. August 2010 Can safety culture be measured? DNV Solutions DNV contact person:
Occupational Health and Safety
Error Management OGHFA 1_HP_06_VIS_Error Management 1.
George Firican ICAO EUR/NAT Regional Officer Almaty, 5 to 9 September 2005 SAFETY MANAGEMENT SYSTEMS.
SAFETY.
TOOL BOX TALKS OHS Risk Management. Definitions Hazard – anything with the potential to cause harm to a person or damage to property Risk – the actual.
Worker Focused Safety Program Violence in the Workplace Worker Training Module 5.
Operations Defining Operations What about Quality Planning your Operations Laws and Regulations Health & Safety Regulations.
Margin Management. PAGE 2 Margin Management Plant Shutdowns 1.Late 1990’s – numerous “surprise” long-term plant shutdowns 2.Shutdowns resulted when a.
IOSH Humber Group – 2 nd February 2010 Managing Change & Maintaining Competency Wayne Currie.
Duty and responsibility -- Make EVERY DAY a TRAINING DAY….so that… EVERYONE GOES HOME! Firefighter Life Safety Initiatives.
Hazard Identification
Positivity Campaign. Establish the Problem Include at least five pieces of evidence. Facts Data Expert Opinions Testimonials Focus on convincing your.
Of XX Cybersecurity in Government Contracting, Acquisition and Procurement Nicholas R. Schacht ©2015 PubKLearning. All rights reserved.1 KnowCyber improves.
TSQM Overall Merged Data Analysis by Industry Analysis by Company Size July 10, 2006 Vicki Deng.
Human insight ISIM – The Big Picture A TSB tool to derive safety knowledge from accident data Context Information.
The difference between blame and accountability Denise Chaffer Director of Safety and Learning NHSLA.
SafeMARINERTM Helping Companies Get to Zero
Imperial Oil Resources D.J.Fennell Strategies for Understanding and Addressing Risk Tolerance Factor # 2 Familiarity with the Task “Complacency”
Business Simulation – providing a bridge between academic studies and the “Real World” Mike Ashwell Teesside University Business School.
Human Factors in Accident Investigation
Presented by:. Foresight Training Aims of the session Background and introduction to Foresight Training Foresight in action: Interactive workshop.
Development, Validation, Implementation and Enhancement for a Voluntary Protection Programs Center of Excellence (VPP CX) Capability for the Department.
Department of Defense Voluntary Protection Programs Center of Excellence Development, Validation, Implementation and Enhancement for a Voluntary Protection.
Department of Defense Voluntary Protection Programs Center of Excellence Development, Validation, Implementation and Enhancement for a Voluntary Protection.
Risk Management 101. Definition of adventure? An experience with uncertain outcomes Key information may be missing, vague or unknown Life as an adventure.
Department of Defense Voluntary Protection Programs Center of Excellence Development, Validation, Implementation and Enhancement for a Voluntary Protection.
Medicines adherence Implementing NICE guidance 2009 NICE clinical guideline 76.
Organisational Issues Helen Jones Human Factors Consultant DNV.
Health and Safety Executive Health and Safety Executive Working at Height & Ladders.
PST Human Factors Jan Shaw Manchester Royal Infirmary CMFT.
Toolbox presentation: Approaches to hazard identification.
TOOL BOX TALKS WHS Risk Management. Definitions Hazard – anything with the potential to cause harm to a person or damage to property Risk – the actual.
What is HSE Competence Assurance?
Event Review Using HFACS (Template)
2006 Senior Falls Prevention
Human Error Analysis of Commercial Aviation Accidents: Application of the Human Factors Analysis and Classification System (HFACS) Douglas A. Wiegmann,
Quarry Operator and Contractor Code of Conduct
Risk Tolerance Factor # 4 Voluntary Actions and Being in Control
Behavioural Skills for Business
Event Review Using HFACS (Template)
Review process to assess whether or not a Leading Practice
Presentation transcript:

Review of Human Factors in Queensland Mining incidents The HFACS-MI project Trudy Tilbury, Safety and Health

Points covered today What is human factors and why use it in Mining Introduction to HFACS-MI Main findings from HFACS-MI Analysis QME strategy Questions

A general definition of Human Factors “Human factors is the multi- disciplinary science that applies knowledge about the capabilities and limitations of human performance to all aspects of the design, manufacture, operation, and maintenance of equipment and systems”. (ATSB, adapted)

Human Factors = evidence on people Focus is on what people can and can’t do in the real world of work rather than a design/ engineering view of people Some systems, and the equipment used in them, are developed without information on the end users, or based on (sometimes) outdated standards

Human Factors gaps Most safety management systems do not address human error, for example: Ignoring potential human error/human factors completely - especially in risk assessments. Using training as a control without understanding that training will not have an effect on skill based (autopilot) errors or violations (adapted from HSE, Human Factors)

Introduction to HFACS-MI

HFACS is a ‘taxonomy’ or classification system looking at errors (unsafe acts), unsafe leadership and organisational factors HFACS-MI (developed by Clemson University specifically for use in Queensland Mining) is based on the work of James Reason The lowest level of errors (unsafe acts that happen directly before an incident) are skill based, decision and perceptual errors

HFACS-MI

Human error in the HFACS-MI model A very common error is a ‘routine disruption error’ or autopilot error (skill based error in the Reason or HFACS model) These errors happen when we’re on autopilot and we miss something (like a turn off for home). These errors are made by those who are fully competent or ‘unconsciously competent’

Human error in the HFACS model Another common error is a “decision error” These errors are the ones where you have a plan, but take the wrong action usually because you don’t have all of the information or knowledge, or because of previous experience.

Human error in the HFACS model Key point from HFACS model and Reason Error at lower levels can be influenced or caused by decisions and ‘latent’ errors within the organisation or system. It is important to trace these errors back to the actual root cause.

Errors influenced by higher levels Li and Harris, 2006

HFACS-MI RESULTS HFACS-MI analysis of Unsafe Acts for 500+ Qld Mining incidents from 2004

Data used in analysis

Unsafe Acts 95% of cases identified at least 1 unsafe act Skill-based Errors most identified (50%) Perceptual Errors and Violations represent <10% of codes identified

Skill-based Errors (consciously competent, routine disruption) Attention failures most identified (32%) Occur when operators are focused on multiple things at once. Technique errors refer to how things are done (24%) PPE/Tool/Equipment errors (14%)

Decision Errors Procedural errors (29%): Incorrect application, applying incorrect procedure, lack of knowledge on correct procedure Situational assessment (22%): Identification of hazards Risk assessment (19%): using appropriate risk assessments, JSA, Take 5, etc.

Where could HFACS-MI ‘fit’ in mining?

Incompatible controls

HFACS-MI Strategy HFACS is a ‘taxonomy’ or classification system, not an investigation tool or system Primary focus for the QME working group is to translate HFACS-MI findings into current systems, including investigations Primary focus for QME Ergonomist is to improve understanding of human factors and human error via website, seminars

Using human factors principles in mining investigations

Butchers Hill New equipment No formal lockout/tagout Human factors issues (additional to safety) Communication Design End of shift on a hot day

Improving awareness of human factors

Questions? Trudy Tilbury A/Senior Principal Ergonomist/Principal Human Factors Advisor