The Offshore Management of Human Factors Inspection Guide Open Government Status Fully Open Publication Date 26 March 2021 Review Date 26 March 2024 Review History Date Changes

Target Audience

OSDR Inspectors / ED Offshore Inspectors / ED Specialist Inspectors

Contents

Summary.......................................................................................................................................... 3 Introduction ...................................................................................................................................... 4 Human Factors ................................................................................................................................ 4 Relevant Legislation ......................................................................................................................... 5 Action ............................................................................................................................................... 7 Background ...................................................................................................................................... 7 Other relevant Inspection Guides..................................................................................................... 7 Specialist Advice .............................................................................................................................. 8 Organisation..................................................................................................................................... 9 Targeting ...................................................................................................................................... 9 Timing........................................................................................................................................... 9 Resources .................................................................................................................................... 9 Recording and Reporting.............................................................................................................. 9 Appendix 1 - Pre-visit Information Request .................................................................................... 10 Appendix 2 - Sample Inspection Agenda ....................................................................................... 11 CM9: 2021/ Owner: ED4.6 Page 1 of 39

Appendix 3 – Inspection Questions and Success Criteria .............................................................. 12 Appendix 4 Application of EMM and Duty Holder Performance Assessment ................................ 35 Appendix 5 References / Further Reading ..................................................................................... 37 Appendix 6 - Glossary .................................................................................................................... 39

Summary

This inspection guide (IG) outlines an approach to inspecting the management of human factors (HF) in the United Kingdom Continental Shelf (UKCS) offshore oil and gas sector. The guide focuses on the key areas that should be considered when inspecting this topic. It also sets out the criteria against which dutyholder performance will be rated. Reference is made to technical standards and guidance that inspectors will use to form an opinion of legal compliance.

Dutyholders should be able to demonstrate how HF is accounted for in the assessment and management of major accidents. HF should be integrated throughout the safety management system to ensure a systematic approach is adopted for managing the human element of major accident hazard risk across the entire lifecycle of the installation.

It is recognised that HF is a broad topic area and that dutyholders do not have access to infinite resources, therefore it is important that a targeted, risk orientated approach based on good practice is taken when addressing HF topics.

Technical competence in HF is a crucial enabler for human factors integration and will be evaluated throughout inspections. Dutyholders may choose to draw on external expertise and/or appoint an internal resource to support and drive HF integration and studies. As a minimum dutyholders should look to maintain intelligent customer capability to ensure resources, scopes of work and deliverables are appropriate.

Due to the broad nature of HF topics, it is likely that inspectors across Energy Division (ED) will be required to address elements associated with managing HF, for example, risk assessment, safety critical tasks, safe staffing levels, procedures and alarm management. Consulting with this IG and directly with the Human Factors Team will ensure that human factors elements are appropriately addressed through inspection, investigation and subsequent enforcement action.

Introduction

The purpose of this IG is to provide information and guidance to Offshore Safety Directive Regulator (OSDR) inspectors to support the delivery of consistent and effective inspection of dutyholders arrangements to comply with HSE’s human factors inspection requirements.

This IG is written to complement the Human Factors Roadmap for the Management of Major Accident Hazards, and highlights key areas for inspection areas which contribute to the management of human factors risk based on research, lessons learnt from previous incidents, published industry standards and good practice guidance. It provides a framework against which inspectors can judge compliance by identifying benchmark standards and examples of good practice for each inspection topic in order to support the assignment of performance ratings and determine what enforcement action should be taken with respect to legislative breaches.

Human Factors

HF is an integrated discipline which applies psychological and physiological principles to the engineering and design of products, processes and systems with the goal of managing the risk of human error, optimising human reliability, enhancing safety, improving comfort and supporting productivity.

The management of HF is an essential element of major accident hazard (MAH) management in the offshore oil and gas industry and forms a key component of regulatory activity.

The primary goal of HF, is to reduce the likelihood and consequences of human failure where it could lead to, or fail to mitigate, a MAH, or lead to the degradation of a safety barrier in place to prevent a MAH.

The Assessment Principles for Offshore Safety Cases (APOSC) sets of the fundamental principles associated with managing HF.

Principle 8 requires that ‘risk evaluation should consider people as both a key element in safe operation and as a potential cause of major accidents and their escalation’, that dutyholders take account of human and organisational factors in their major accident risk evaluation, that “safety and environmentally critical tasks should be analysed”, that ‘human performance problems should

be systematically evaluated, and “the depth of analysis should be appropriate to the severity of the consequences of failure of the task”.

Principle 10 requires dutyholders to keep risks and possible further risk reduction measures under review, taking into consideration advances in technology and knowledge. This includes advances in HF good practice.

Principle 13 requires dutyholders to take into account HF principles alongside sounds engineering and management when deciding on what is reasonably practicable.

Relevant Legislation

Offshore Installations (Offshore Safety Directive) (Safety Case etc) Regulations 2015

Regulation 8 Safety and environmental management system This regulation requires dutyholders to establish a safety and environmental management system which must include a description of the organisational arrangements for the control of major hazards. These arrangements should take account of HF, inclusive of the identification, analysis and control of safety and environmentally critical tasks, and occupational factors which could affect a person's ability to reliably perform such tasks e.g. multi-tasking, long working hours.

Regulation 16 Management and control of major accident hazards This regulation requires dutyholders to include in their safety case a sufficient demonstration that all hazards with the potential to cause a major accident have been identified, all major accident risks have been evaluated, their likelihood and consequences assessed. The major accident risk evaluation should take account of HF through the analysis of safety and environmentally critical tasks and systematic evaluation of human performance problems which could affect a person's ability to reliably perform such tasks.

Regulation 20 Safety case for dismantling fixed installation This regulation requires dutyholders, when revising and preparing their safety case for decommissioning, to take account of human and organisational factors associated with dismantling activities such as the introduction of personnel to the platform who may be unfamiliar with established safety rules and expectations.

Offshore Installations (Prevention of Fire and Explosion, and Emergency Response) Regulations 1995

Regulation 5 Assessment This regulation requires dutyholders to assess major accident hazards arising from fire and explosion and events which may require evacuation, escape and rescue, and identify appropriate arrangements for dealing with them. These assessments should consider the implications of human failure associated with the operation, management or function of any protective / preventative arrangements.

Regulation 9 Prevention of fire and explosion This regulation requires dutyholders to take appropriate measures to prevent fire and explosion. Where people must perform tasks which are associated with this regulation, human and organisational factors issues should be taken into account in the design of procedures and systems.

Regulation 12 Control of emergencies This Regulation requires dutyholders to have appropriate control measures to limit escalation of an emergency. Where equipment is used to control the extent of an emergency the design of such equipment should take HF into account, including ergonomic factors with respect to its operation in an emergency.

Management of Health and Safety at Work Regulations 1999

Regulation 3 Risk assessment This regulation requires dutyholders to carry out a suitable and sufficient assessment of the risks to the health and safety of employees to which they are exposed while they are at work. This includes the risk of human failure.

Regulation 5 Health and safety arrangements This regulation requires dutyholders to implement arrangements for the effective planning, organisation, control, monitoring and review of preventative and protective measures. This includes measures associated with the management of human and organisational factors.

Other legislation

Provision and Use of Work Equipment Regulations 1998

These regulations cover a range of relevant areas related to ergonomics such as the design factors (operating positions, working heights and reach distances), information and instruction and training. See L22 for Guidance on safe use of work equipment

Offshore Installations and Pipeline Works (Management and Administration) Regulations

These regulations cover a range of relevant areas related to HF such as communications, permit to work and instructions. See L70 for guidance on the regulations.

Action Inspectors should review relevant documentation (see Appendix 1 Pre-visit Information Request) prior to the installation visit and test compliance during the installation visit against the ‘success criteria’ given in Appendix 3).

By the conclusion of the inspection it should be possible to

• determine the appropriate performance rating • determine the initial enforcement expectation • consider how and when the issues raised during an inspection are to be closed out

Background This IG has been developed to • consolidate HSE approved codes of practices and guidance, international and national standards and relevant industry body guidance into a single IG to determine legal compliance with HF topics areas

• meet the guiding principles of HSE’s Enforcement Policy Statement

• proportionate • targeted • consistent • transparent • accountable

• Support the Industry Hydrocarbon Release Plan, which includes HF, by providing a clear framework for which OSDR inspectors can carry out HF inspections.

Other relevant Inspection Guides It should be noted that, due to the nature of HF as a discipline, there is naturally a degree of cross over to many other specialist areas, particularly to safety and environmental management (SEMS), topics but also to all engineering disciplines.

As such users of this guide should be mindful of other IGs, notably • Loss of Containment, particularly appendices: 2C (procedures), 2D (competence), 2E (handovers) and 2F (supervision). Topic 3.I Alarm Management of this guide also covers instrumented protective systems. • Control of Work and Operational Risk Assessment IGs, which overlap particularly with inspection topics in this IG for example, Appendix 1 – 3.A - Analysis of Safety and Environmentally Critical Tasks (SECTs), 3.B Management of Procedures for Safety and Environmentally Criticality Tasks, and 3.E Safety Critical Communications

Specialist Advice Specialist advice should be sought from the Human Factors Team (ED 4.6) in the following circumstances

1. Where inspectors identify issues in the assessment and/or management of safety and environmentally critical tasks which require enforcement action. Examples include • a failure to undertake safety critical task analysis of a task deemed to be safety critical • deficiencies in procedure design and use • training and competence or • the design of working environments, equipment and control systems, and human machine interfaces (HMI)

2. Where inspectors identify occupational or organisational factors which may have a significant impact on an individual’s ability to perform safety and environmentally critical tasks which may require further inspection. Examples include • safe staffing levels and workload • fatigue and shift design • supervision and • safety culture

3. Where inspectors identify significant organisational or technical change which has the potential to impact on safety and environmentally critical tasks e.g. • change of dutyholder • outsourcing/insourcing • organisational re-structures

4. Where inspectors making early enquiries into incidents identify that human and organisational factors may have contributed to the event.

Organisation

Targeting It is essential to make sure that dutyholders are robust in their management of HF. Inspections should be planned within the timescales set out by ED divisional management, and should be targeted at dutyholders identified as having the greatest risk gaps.

Timing Inspections should be undertaken as part of the agreed Intervention Plan, or as determined by the Energy Division Senior Leadership Team (EDSLT).

Resources The ED4.6 HF team own this IG and take the topic lead on inspecting HF. Resource for inspections against this IG will come from ED4.6 supported by inspection management team (IMT) inspectors, and other specialist teams as appropriate.

Recording and Reporting The dutyholder performance ratings should be entered on the Inspection Rating (IRF) Tab of the relevant installation Intervention Plan Service Order. Findings should be recorded in the post inspection report and letter.

Appendix 1 - Pre-visit Information Request

When preparing for a HF inspection, inspectors may request a range of information, including policies and procedures, risk assessments, human factors studies, records and key performance indicator data. Table 1 below outlines examples of information that may be requested.

Table 1 Examples of information that may be requested

Topics Information Request Analysis of safety and environmentally Safety critical task analysis procedure critical tasks safety critical task analysis reports

Procedures Procedure for procedures

Example procedures

Training and competence Training and competence procedure

Training and competence standard

Training and competence records of individuals/teams

Fatigue risk management Fatigue risk management procedure

Working hours records

Safety critical communications Shift/crew change handover procedure

Permit to work procedure

Control room and equipment design Human factors/ergonomic studies

Alarm management Alarm management philosophy

Alarm performance data

Safe staffing and workload Staffing level philosophy / Offshore organisational chart

Safe staffing level / Workload studies

Management of organisational change Management of organisational change procedure Human factors in projects Human factors engineering standards

Human factors integration plan

Appendix 2 - Sample Inspection Agenda Advance Information Request Information Human Factors Requested by • procedure for safety and environmentally critical task analysis • safety critical task analysis reports / process hazards analysis • design and management of procedures standard • training and competence standard • alarm management procedure • fatigue risk management procedure

Anticipated Schedule and Personnel Requirements Add detail as required – include timing and personnel requirements where possible

Onshore Human Factors i. implementation status of safety and environmentally critical task analysis on the installation (methodology, schedule, resources, management of actions) ii. inspection of 1 to 2 safety and environmentally critical tasks with appropriate technical authority, including the relevant procedure and training and competence standard iii. implementation status of human factors good practice in procedures for safety and environmentally critical tasks iv. implementation status of human factors good practice in training and competence management for safety and environmentally critical tasks v. implementation status of fatigue risk management system Offshore Human Factors i. inspection of 1 to 2 safety and environmentally critical tasks, including relevant procedures and training and competence standards, monitoring and supervision. This will include detailed task walk-through-talk-through ii. inspect the status of any actions arising from the safety and environmentally critical task analysis iii. inspection of working time records iv. discussion with personnel in safety and environmentally critical roles about fatigue risk management practices Note: Use of a camera is requested while on board. Please arrange permits, as required

Appendix 3 – Inspection Questions and Success Criteria

3.A - Analysis of Safety and Environmentally Critical Tasks (SECTs)

SECTs are tasks which contribute to both the risk and management of major accident and environmental hazard scenarios. These tasks include those associated with the prevention, detection, control and mitigation of these scenarios, and therefore play a significant role of achieving continued safe operations.

Safety and environmentally critical tasks should be considered throughout the lifecycle of the installation, during design, operations, modifications and decommissioning. Where safety and environmentally critical tasks are undertaken, they should be analysed using human factors good practice to demonstrate that they can be performed reliably when required. Safety and environmentally critical tasks should be considered within a wider hierarchal risk management approach, recognising that even most well motivated, highly experienced people can make errors and mistakes.

When inspecting this topic factors to be considered should include

• the range of tasks that have been identified • how tasks have been prioritised • the method and depth of analysis used to identify human failure and performance influencing factors • control measures used to reduce the risk of human failure

Inspection Questions

1. Is there a formal process for managing safety and environmentally critical task analysis?

Success Criteria

• a formal process is established for identifying and analysing safety critical tasks. This process aligns with industry good practice • this process should be integrated into the broader system of risk assessment of major accident hazards e.g. HAZOP, HAZID, PHA • the process identifies periodic review criteria e.g. incident, engineering design/modifications, degradation of equipment (level control, safety systems) • qualitative analysis is the expected standard of analysis, if quantitative analysis is used, it should be underpinned by a qualitative analysis

2. Has a full range of tasks been identified for the installation?

Success Criteria

• tasks should be identified using a range of methods such as HAZOPs, HAZIDs, operating and maintenance procedures and system walkthroughs, and consider a full range of tasks e.g. operations, maintenance, marine, drilling and emergency response • reliance purely on existing procedures to identify tasks is not sufficient as this does could miss tasks which may not be covered by a procedure

• tasks may be prioritised based on certain task characteristics such as complexity, frequency, consequences of human failures

3. What human factors methods have been used to analyse tasks?

Success Criteria

• a risk-based approach should be adopted when determining what tasks to analyse, in what order and to what depth • use of a formal task analysis method to describe task e.g. task goals, steps, and the interactions between the people, plant and equipment • use of formal human failure guidewords/taxonomy to identify a full range of human failures • an analysis of the consequences of human failure including any recovery opportunities • an analysis of performance influencing factors which may make failure more likely • the outputs of the analysis should be formally recorded

4. What is the output of the analysis?

Success Criteria

• the analysis and recommended actions should be formally recorded • human failures that present a significant risk to safety are subject to error reduction measures o error reduction measures may include: elimination of the task, redesign of the task or working environment, improvements to training of staff, procedural support, or placing additional barriers in the system to prevent the consequences of errors e.g. fail-safe, error-tolerant designs o the hierarchy of control is applied when addressing human failure (e.g. by eliminating