A7 HUMAN FACTORS Flashcards

Question

7.3 PIPER ALPHA How it happened and what course of actions were taken to prevent recurrence, Lessons learned.

Answer 1

Piper Alpha Facts: Fire Explosion knocked out fire proof - not Blast proof - walls Control room damaged in 1st blast Initial fire could have been extinguished Fire pumps were set to manual Lifeboats all in one location and could not be reached from accommodation block Other platforms did not shutdown instead continued pumping hydrocarbons to Piper Alpha, increasing the fire Piper Alpha Failures: Permit to Work System -two permits issued for same task Platform layout Delayed decision making Lack of training Active fire system set from Auto to Manual Passive fire protection Lifeboats Communications/Shift Handover

Answer 2

Ineffective communications come about from a variety of causes (only four required) Some information is missed or missing Unnecessary information is included, causing confusion Information is inaccurate or misleading The quality of information is poor Information is not understood (either by transmitter or receiver) Information is not carried forward over successive shifts

Answer 3

The most problems in communications occur: During plant maintenance, when it runs across more than one shift. In areas where safety systems may be over-ridden (e.g. Fire deluge system switched to manual). During deviations from normal work working, such as breakdowns, or lack of spares. When members of the team have been absent from work for long periods. If handover takes place between experienced and inexperienced staff.

Answer 4

Individual - characteristics of the individual Job - characteristics of the job or task being performed Organisation - characteristics of the organisation

Answer 5

``` Safety culture of the organisation Leadership Resources Work Patterns Communication Policies and procedures Setting standards, lead by example, aims & objectives Commitment and leadership from mgmt (aka positive leadership) Levels of supervision Peer group pressure Consultation and worker involvement Training ``` Poor work planning, lack of a safety system, poor management, poor culture, one way communication

Answer 6

``` Task inc unrealistic timescales Workload inc lack of breaks Piecemeal work Environment - noisy dark Displays and controls Procedures Job interest/repetitive nature of the job ``` Physical match and mental match, missing and unclear instructions, poorly maintained equipment, high workload.

Answer 7

Competence - knowledge, experience, training and ability Skills Personality Attributes Risk Perception- the way a person interprets information detected by the senses. Attitude - how they think and feel about it, change attitudes by education and training, high impact interventions, enforcement and consultation, and involvement in the decision-making process Motivation - the thing that is making a person do what they do. Tired staff, nored staff, medical problems, low skill

Answer 8

``` Hazard is not detected by human senses Person with some sensory impairment Illness Stress Fatigue Drugs and alcohol Previous experiences Training and education ```

Answer 9

- Management Commitment and Leadership - Competent Staff - Effective Communication

Answer 10

- behave safely - involvement in day-to-day H&S, e.g. by attending H&S meetings - Taking part in safety tours and audits - Promote changes to improve safety - Enforce company safety rules

Answer 11

``` Sufficient training Knowledge Experience Other abilities or skills - to carry out work safely and without risk to health ```

Answer 12

Understanding of H&S implications of day-to-day decisions | Understand the risks of the tasks they manage, even if they cannot complete the task

Answer 13

``` Verbal communication Written communication Graphic communication Broadcasting methods Co-operation and Consultation ```

Answer 14

``` Language barrier Jargon not understood Strong accent or dialect Background noise Ambiguous message Recipient may miss information Recipient may forget information No written record as proof Poor transmission quality if by telephone or PA system ```

Answer 15

``` Personsal Quick Direct Allows for check of understanding Allows for feedback Exchange of views Tone, facial expression and body language add to message ```

Answer 16

``` Indirect Takes time to write May contain jargon and abbreviations Impersonal Ambiguous Message not read by recipient Recipient unable to read Immediate feedback unavailable Questions cannot be asked Recipient may have impaired vision ```

Answer 17

Permanent record Reference Can be written carefully to avoid jargon, abbreviations and ambiguity Distribution relatively cheap

Answer 18

``` Only convey simple messages Expensive to but or produce May not be looked at Symbols or pictograms may be unknown to recipient Immediate feedback unavailable Questions cannot be asked Recipient may have impaired vision ```

Answer 19

``` Eye-catching Visual Quick to interpret No language barrier Jargon-free Conveys a message to a wide audience ```

Answer 20

Buncefield Incident Causes: A fill level gauge and high fill level alarm failed Fuel storage tank overfilled Fuel leaked out of the vents at the top of the storage tank into the bund This resulted in a Vapour Cloud The vapour cloud flowed offsite Ignition leading to the vapour cloud explosion took place at a pump house Buncefield Lessons learned: Need for back-up systems/processes for safety critical devices Bunds/containment walls to be designed to withstand heat/explosion Importance of coordinated response & emergency planning Business/Disaster interruption and or recovery plan Dealing with media after the incident.

Answer 21

Errors - Not intended - SLIPS - LAPSES - MISTAKES - skill based - not intended Violations - deliberate - routine (normal) - Situational (job pressure) - Exceptional (benefits outweigh the risk)

Answer 22

Careful consideration of human factors at work can reduce the number of accidents and cases of occupational ill health. Efficient and effective workforce.

Answer 23

They have an immediate consequence and are usually made by front line people ( drivers, machine operators)

Answer 24

Are made by people who's tasks are removed in time and space from operational activities (designers decision makers and managers). Latent failures are usually hidden with an organisation until they are triggered by an event likely to have serious consequences (ineffective training, supervision, communication, poor design of plant)

Answer 25

Reducing errors are more likely to occur under certain circumstances WORK ENVIRONMENT STRESSORS - eg extremes of heat, noise, poor lighting EXTREME TASK DEMANDS - eg high workload, repetitive, distractions, interruptions (kegworth SOCIAL & ORGANISATIONAL STRESSORS - inadequate training, fatigue, family problems, ill health, drugs and alcohol EQUIPMENT STRESSORS - - poorly designed displays & controls< inaccurate & confusing instructions & procedures

Answer 26

1) addressing the conditions and reducing the stressors which increase the frequency of errors 2) designing plant and equipment to prevent slips and lapses or increase choice of detecting them 3) make certain that arrangements for training are effective 4) designing jobs to avoid the need for tasks which involve very complex decisions, diagnosis or calculations eg write procedures 5) ensuring proper supervision for inexperienced staff and independent checking 6) check job aids are clear, concise and up to date (instructions) 7) consider the possibility of human error in incident investigations 8) monitoring that measures taken to reduce error are effective

A7 HUMAN FACTORS Flashcards

(73 cards)