REPORT OCTOBER 621 2018

Demystifying Human Factors: Building confidence in human factors investigation

understand facilitate

Acknowledgements This report was authored by the Human Factors Subcommittee, a component of IOGP’s Safety Committee.

Photography used with permission courtesy of © Hybrid Images/iStockphoto and © Maersk Oil - Photographer Morten Larsen (Front cover)

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REPORT OCTOBER 621 2018

Demystifying Human Factors: Building confidence in human factors investigation

Revision history

VERSION DATE AMENDMENTS

1.0 October 2018 First release

Contents

Scope 5

Foreword 6

1. How to use this document 8 1.2 Why understanding human performance matters 8 1.3 What are ‘Human Factors?’ 9 1.4 How do human factors relate to incidents? 9 1.5 Introducing the worked example 10

2. The roles of investigators and clients 11 2.1 What the investigation is trying to do 12 2.2 The role of the investigator 13 2.3 The role of the client 14 2.4 Maintaining independence 16 2.5 When you might need more help 16

3. HF in each stage of an investigation 17 3.1 Preparation stage 18 3.2 Evidence gathering 20 3.3 Analysis 29 3.4 Findings and recommendations 34 3.5 Reporting 37

4. Implementation 40

Appendix 43

References 44

Scope

The oil and gas industry is committed to learning from operating experiences and incidents, and using that information to prevent harm to people and the environment. An important part of learning from incidents is to understand the role that people play. Investigation presents a unique opportunity to understand the systems and conditions that lead ordinary people into complex situations, or provoke simple errors.

The field of Human Factors (HF) can seem mysterious and complicated. Even those with training and tools to address HF in investigations can be reluctant to put them to use, believing that it is something that only experts can do. This document aims to ‘demystify’ human factors and help those involved in the investigation process gain confidence by successfully incorporating human factors into investigations.

Foreword

This document does not assume any pre-existing training in human factors investigation. It will be helpful whether your company has extensive processes, tools and resources, or nothing at all. The advice in this guide will help those involved in investigation create the conditions for human factors to surface, and become more comfortable using human factors to explain how the event occurred. This guide was written with two audiences in mind: • Those that lead and participate in the investigation process – the investigator • Those that receive and act on the recommendations produced by investigations – the client

Let’s also talk a bit about what the guide is not about.

For a start, the document is not intended to be a game-changer. It does not seek to spell out new theories or push the boundaries of what can be done with HF. There is a lot of excellent writing and research out there that is doing just that. Instead, the guide simply tries to explain some important aspects of HF in a reassuring and helpful way that gives confidence to those involved in the investigation process so that they can use HF to learn and improve.

The document is also not intended to provide an investigation process or methodology. We have assumed a basic series of investigation steps only as a way of structuring the guide. The guide is intended to compliment investigation methods in use within your own organisation.

The guide is organised in three parts, so that you can select the appropriate advice, depending on where you are in the investigation process, and what your role is.

This document has three main sections 1) Roles, in which we look at the role of the investigator, and the investigation client, in understanding human factors as part of an investigation 2) The investigation, in which we look stage-by-stage at an investigation, and what can be done at each stage to maximise human factor learning 3) Implementation, in which we look at some ways that you can improve the implementation of some of the ideas in this document

Throughout the document we will use a number of icons:

Translate Jargon This icon will show when there is a commonly used human factor term that describes what is being talked about in the text. You don’t need to remember it, but it may help you if you hear people using the term.

Worked example A single worked example will run throughout the document. This icon shows when we are returning to that example.

Key points Brings out a small number of key points that will be particularly useful to you in this section.

1. How to use this document

There are a number of ways we suggest using this document: • Understand your role. Whether you are an investigator or a client, it is helpful for you to understand what the role is for both parties. • Overview the stages before an investigation. • During an investigation, revisit the appropriate stage for advice. • After an investigation, use the stages to consider how you might approach things differently. • Consider how you can embed this advice in your organisation using the Implementation section.

1.2 Why understanding human performance matters People interact with each other, plants, and process as part of a complex system. Human beings are essential in maintaining our barriers and safeguards. They can, and often do, “save the day”.

But we also know that people will make mistakes. Their actions are rarely malicious and usually make sense to them at the time. We know that mistakes are typically due to underlying conditions and systems. 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 why mistakes happen can help us prevent or cope with them. Investigation is central to understanding why people did what they did. We use what we learn from investigation 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. This document will demonstrate how leaders can educate others about human factors roles in incidents.

Human error/Mistakes: Simply put, terms that describe the natural variability of human beings, i.e., “we’re all human”. In Human Factors these terms can describe a range of different human failure mechanisms, including forgetting, misperceiving, or accidentally or intentionally taking the wrong action or decision. The important thing to remember is that when an investigation discovers human error or mistakes contributed to the chain of events, the inquiry does not stop there. The team keeps searching for the conditions and systems that made them likely to happen.

1.3 What are ‘Human Factors?’ ‘Human Factors’ are simply those things that can influence what people do.

They may include factors relating to the job people do (e.g., time available or control panel design) personnel factors (e.g., fatigue, capability) and organisational factors (roles, manning levels). This list of factors is often referred to as “Performance Shaping Factors”.

If a behaviour was causal or contributory to the incident, Human Factors analysis can help the investigator understand why human performance suffered, and help develop meaningful recommendations to reduce that risk in the future.

1.4 How do human factors relate to incidents? People are involved in all of our barriers and safeguards. People design, operate, and maintain engineered barriers. They also perform tasks, checks and monitoring that we rely on to prevent, detect, and respond to risk events. We rely on humans in every aspect of our business: • Engineers and planners in project design • Crafts in construction • Operators in the control of processes • Maintenance technicians in maintaining the kit • Inspectors in checking the kit • Managers and leaders who oversee and influence the conditions for all of the above actions

If people do not perform as anticipated, it can have a negative effect on the outcome, including causing or contributing to an incident. Human performance can directly affect the effectiveness of a barrier that relies on a human to sense, decide, and/or act to make it work.

Performance shaping factors: Also known as “preconditions”, or Performance Influencing Factors (PIFs),these are the characteristics of the job, the individual, and the organisation that influence human performance. Addressing these factors reduces the likelihood of all types of human failure. For examples of PSFs, see appendix A.

Behaviour: In human factors, this simply refers to an observable action, or the thing that somebody did or did not do. It is not associated with “good” or “bad” behaviour”.

1.5 Introducing the worked example Throughout this document, you will see the magnifying glass icon ( ), where we apply what we have been discussing to the worked example. This is the first description of the example.

First contact Imagine that you have had a call from a site. There has been a spill of oil from a vessel. The person on the telephone is keen to tell you what happened. “The early indications are that an operator was draining water out of a vessel, which had a layer of oil floating on the water. The operator was supposed to watch the drain and close the valve as soon as traces of oil appeared, but they wandered off to do something else. While they were away the water layer drained out and the oil layer began to drain out. The spill was discovered by another operator.”

Vessel Vessel

Oil

Water Oil

Open Open drain drain valve valve

“The operator was supposed to “But the operator did not watch watch the drain, and close the valve the drain, and oil flowed through when traces of oil appeared” the valve and caused a spill”

2. The roles of investigators and clients

In this document we have referred to two roles which are central to uncovering the human factors that underlie an incident: • The Investigator, who leads or is part of a team that examines the incident to understand its causes and contributory factors • The Client, who receives the investigation’s results or acts on its findings. This is likely to be a manager or leader

As well as being part of an incident story, human factors can also influence your investigation. We are all human, and investigators and clients can be subject to biases and judgments that can lead to unhelpful conclusions in an investigation.

Why do you think the operator left the valve unattended? The chances are that the first explanations you thought of were that the operator was not competent, forgetful, or maybe even lazy. Vessel It is a normal human reaction to assume that the reasons for a person’s actions Oil are due to a personal characteristic or personality. However, studies show that Water in most instances, people’s actions and decisions are due to external factors. For Open drain instance, the operator may have been valve told to leave the drain and do another job, they may have been doing the task the way everybody did it, or they may have “The operator was supposed to “ accidentally closed an identical valve. watch the drain, and close the valve th when traces of oil appeared” If we automatically assume that the operator was at fault, we miss the very high chance that there were external factors which can lead others into the same situation.

As investigators and clients we may tend to: • Assume peoples behaviours result from their personality or character, rather than the systems or conditions they work in (Fundamental Attribution Error) • Believe that we would have acted differently in the same circumstances (Overconfidence Bias) • Over-rely on what we know now, to make judgements about what people knew then (Hindsight Bias) • Only search for and accept evidence to confirm what we already believed (Confirmation Bias)

As an investigator or client you need to be particularly cautious not to jump to conclusions. Keep an open mind and evaluate a wide range of possible explanations to avoid bias.

2.1 What the investigation is trying to do In any investigation we want to understand the conditions that influenced the event, in order to change them so that we can avoid that event happening again, as well as any other that could be made more likely by the same circumstances.

The goal of human factors (HF) in investigation is to understand what influenced the behaviours that were causal or contributory to the incident. Plants, tools, and activities can be designed to reduce mistakes and manage risk better.

Understanding what underlies the actions and decisions of individuals, teams, or leaders can seem difficult, but it needn’t be. Simply put, we are looking to understand the context in which people did what they did. What aspects of plant or job design might have influenced people? What were the underlying organisation conditions and systems? What motivations might have influenced them? What earlier decisions or actions laid the foundations for what happened?

This presents us with the best chance of helping anybody who finds themselves in a similar situation in the future.

Fundamental Attribution Error (FAE): The natural tendency to ‘attribute’ a person’s behaviour to their personal characteristics (e.g.,“this is just the operator being lazy and not paying attention”). Unfortunately incident data suggests the reverse – that the majority of behaviours are due to external factors (the systems and conditions people work with).

Overconfidence bias: The tendency for us to believe that we would handle a situation differently. The majority of drivers believe themselves to be “above average” – which can’t be true!

Hindsight bias: The tendency to assume that things that we know now were available to people at the time of the event, e.g., “they must have known there was oil in the vessel”

Confirmation bias: The tendency to search for and accept only evidence that supports your initial assumptions about what happened, e.g., “we found evidence to support our original theory”

2.2 The role of the investigator Investigators carry out the inquiry that establishes the facts involved in an incident, gather evidence to support their conclusions, and make recommendations for action by the client. How the investigator goes about this can lead to the human factors becoming visible, or being hidden from the investigator.

Do Don’t

• Always put yourself in the position • You are not being asked to psychoanalyse of the person whose behaviour individuals. HF analysis is not about you’re analysing. It’s easy to apply getting to the psychological definition. It your ‘hindsight bias’ when looking at is about understanding why the individual behaviours, applying what you know behaved as they did at the time. from the investigation, which often is more than what the individual(s) involved knew at the time of the incident (“local rationality”). Remember, we want to understand why this person did what they did (right or wrong), so we can make recommendations that will help others perform better. • This may mean physically putting yourself • Never raise the subject of blame or in the same location or situation (in a discipline with those involved, even if safe way). Visit the accident site, see the you are trying to be reassuring. Telling actual field conditions, distances, noises/ someone that you are “not trying to lighting/heat. Get as close as possible to establish blame” can actually lead a the “work as done”. person to worry about blame.

Local Rationality: The idea that during the events leading up to accidents, people are acting in a way that makes sense to them at the time. All of their knowledge, training, experience, organizational culture, and input from the environment combine to influence the decisions made and the actions taken.

Work As Imagined/Work As Done: Procedures, rules, permits and expectations are all part of how leaders, engineers and task designers imagine the work is going to be conducted, under ideal circumstances – this is Work as Imagined. Work As Done is how work actually happens, in the cold and rain, with equipment that doesn’t work as expected and rules and procedures that are ambiguous. A vital part of investigating human factors is about getting as close as possible to how work actually happens.

Do Don’t

• Consider all reasonable possibilities • Don’t focus on the last person to touch and use evidence to support including or the equipment. The underlying conditions excluding them. that led to the incident may have existed for some time. • Focus efforts on preventing anyone • Don’t give “human error” as the root else getting into the same situation by cause. Human error is not the