Who are we? The lecture. Human and organizational factors in accident and incident investigation. What are they and how can we find them?

Transkript

1 Human and organizational factors in accident and incident investigation What are they and how can we find them? Lena Kecklund Uppsala Universitet April 4th 2011 Who are we? Consultancy and research in risk prevention concerning the interaction between HuMans (M) Technologies (T) Organisations (O) 2 The lecture Human and organisational factors, what are they? The MTO concept Why is it important? t? How can it be applied in accident and incident investigations? Examples Discussion 3 1

2 MTO design for humans and useability! 4 Humans MTO influences on human behavior Technology Kowledge Organisation Design Goals Rules and practices Education and training Housekeeping Communicaton Psychology Physiology Technology and equipment Work environment Attitudes and values 5 MTO a system safety view HuMans Technologies Organisations MTO >M + T+ O 6 2

3 Human factors, Ergonomics, HuMans Technology Organisation (MTO) Systematic application of knowledge on human behaviour to optimize the interaction between Humans, Technologies and Organisations To apply knowledge on human behaviour and a system safety view 7 MTO/Human factors An example: All the people issues we need to consider to assure the lifelong safety and effectiveness of a system or organisation Understanding Human Factors v1.0r,rssb,uk, 2006 Three Mile Island M + T 9 3

4 Tjernobyl M + T + O 10 Fukushima M + T + O + O?

5 Discussion Which MTO problems can you find in the next slide? How must humans adapt? What can go wrong? Why accidents occur (Reasons Swiss cheese model) Organisation Rules and procedures Planning Training Communication Housekeeping Maintenance Technologies Design Equipment Tools Work environment HuMans Competence Knowledge of task Motivation Work satisfaction ACCIDENT 15 5

6 What is wrong and why? Summary What MTO is about System safety view Knowledge on human behaviour Methods and tools 18 6

7 Texas City 2005 Discussion based on the film Film sequence approx 15 min Discuss What happened? What were the causes? Look for M, T och O 19 Human and organisational factors in accident investigation 20 Why do accidents and errors occur? Latent failures (in different parts of the system) creates error/producing conditions Unsafe acts och circumstances Problems in the interaction beteeween Man Technologies and Organisation Lack of protection; barriers/defences or existing defences being broken OFTEN COMBINATIONS IN WELL DEFENDED SYSTEMS 7

8 Organisational accident causation model Laws Procurement Goals and demand Organisation Manag- ment Culture Information Resources Society Company Workplace Error- producing conditions? Person/ Group Right or wrong? Errors and violations Barriers Accident An example from the medical domain Laws Procurement Goals and demand Organisation Manag- ment Culture Information Resources Society Company Workplace Error- producing conditions? Person/ Group Right or wrong? Errors and violations Barriers Accident Legislation: Secrets acts Medical journal not available on a 24 h basis for all involved in treatment Staff on nightshift duty do not have full information Risk of No barriers making wrong prescription Society Law Regulators Norms Norms Resource allocation Demands made in procurements 8

9 Company Management system Quality control systems Staffing Shift schedules/work hours Training/Knowledge Rules, procedures, work practices Responsabilities Culture Technical resources Designed for usability? Gives right support for the task? Gives feedback? Person Knowledge Experience and skill Motivation Alertness Stress Workload Attitudes 9

10 Situational factors Time pressures Staffing too short High workload Examples Accidents in all areas of industry Nuclear; TMI, Chernobyl Oil; Piper Alpha Sea; Zebrugge, Estonia Railways; Clapham Junction, Kings Cross fire, Paddington, Åsta Medical; Radiotherapy accidents Examples of causes or errorproducing factors Time pressure Sleepiness/work hours Poor ergonomics High vigilance and mental demands Poor training Problems with rules and procedures (many varieties) 10

11 Examples of causes or errorproducing factors Work environment untidy work place Problems in communication High workload and stress Problems in planning and control Inadequate allocation of resources Management System goals incompatible with safety How to perform an accident investigation? Parts of the analysis Data collection Analyse: Events Deviations Causes Barriers Consequences Make recommendations/suggest safety enhancing measures 32 How to apply the MTO view in an investigation Understand the peoples actions in relation to the circumstances and the situation Understanding based on knowledge from the behavioural sciences Understand the relation to managment and organisation Understand the relation to regulators and society 33 11

12 Example: Investigation of incident 34 Exempel: Tillbud med TP 101 Styrning; ledning; uppföljning Rutiner & regler Verktyg & procedurer saknas Litar inte på mätare Bränsle slut i huvudtank Flygning planeras Färdplanering beaktar inte meterologiska förhållanden Flygning med tyngre last & under längre tid än planerat Piloter tror att bränslemätare visar fel Motorstopp på en motor Landning med en motor Verktyg, procedurer & kompetens Utrustning: Bränslemätare ej reparerad Två motorer 35 Uppgift: Grundorsaksanalys Anna arbetar i en livsmedelsbutik Hon ska en tidig morgon med truck köra in en pall med tvättmedel från lastkajen till butiken Leveransen ska köras in i butiken med truck. De brukar vara två men kollegan är sjuk det går influensa på arbetsplatsen Anna måste väja för en kollega som kommit i vägen, kör på ett föremål & trucken välter Anna skadar armen 36 12

13 Datainsamling Hur och vad skulle ni vilja samla in? Uppgift Händelseanalys Vad hände och i vilken ordning? Avvikelseanalys Vilka avvikelser fanns mot normala förhållanden? Orsaksanalys Vad berodde avvikelserna på? Barriäranalys Vilka barriärer fanns, vilka brast och vilka saknades? Konsekvensanalys Vad hände och vad skulle kunna ha hänt? Rekommendationer/åtgärder Vilka åtgärder skulle ni vilja vidta och hur skulle dessa genomföras? 37 Exempel: Orsaks- och händelseanalys Ordning & reda? Ovan att köra truck Kollega sjuk Personal i truckens körväg Svårt att väja; trångt? Ordning & reda? Kör in lastpall i butik Kör truck ensam Kollega i vägen Väjning Kör på föremål Truck välter; skadad arm 38 MTO-analys Grundorsak Grundorsak Bidragande faktor Direktorsak Direktorsak Direktorsak Händelse 1 Händelse 2 Händelse 3 Händelse 4 Händelse 5 Konsekvens Barriär Barriär Barriär 39 13

14 The Columbia Accident Investigation Board In our view, the NASA organizational culture had as much to do with this accident as the foam. Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of an institution. n At the most basic level, l organizational culture defines the assumptions that employees make as they carry out their work. It is a powerful force that can persist through reorganizations and the change of key personnel. It can be a positive and negative force. Columbia Space Shuttle,2003 Olyckan och påverkande förhållanden Isolering lossnade vid återinträde i jordatmosfären Kultur och förhållningssätt i organisationen som påverkade säkerheten negativt hade utvecklats, t ex Tidigare tillbud hade inte bedömts som tillräckligt allvarliga Förlitade sig på tidigare framgångar satte mindre tilltro till nya bedömningar och beräkningar Organisationens utformning förhindrade effektiv kommunikation av viktig säkerhetsinformation Bristande samordning i ledningsfunktioner mellan olika delprojekt Informell lednings och beslutsstruktur som inte följde de regler som fanns i organisationen 14

15 MTO Säkerhet in accident investigations Investigations where we have particpiated

16

17 49 Brand i t banevagn i Rinkeby (Publicerad 22 februari 2007 kl 10:01)»Det var vid halv tio tiden på torsdagsmorgonen som tunnelbanestationen i Rinkeby fylldes med kraftig rök. Samtliga passagerare evakuerades och Rinkeby torg spärrades av. Dessutom fick flera lokaler och en skola utrymmas.«

18

19

20 Conclusion Human and organisational factors are always important Look for the causal chain Apply the system safety view Use knowledge on human and organisational behaviour 58 20