IA8 Flashcards
A worker has been seriously injured after being
struck by material transported using an overhead
crane.
Outline
the types of human failure which
may have contributed to the ac cident
AND in EACH case give examples
relevant to the scenario to illustrate your
answer.
The types of human failure could have included skill based errors, mistakes and
violations.
Skill based errors
could include:
ü
slips of action where a f amiliar task or action was not carried out as planned such
as operat ing the wrong switch or control
ü
lapse of memory where a step in the action sequence was missed, for instance
commencing the lifting operation out of sequence when other employees were not
prepared.
Mistakes
are generally errors of judgement which could be
ü
rule based involving the application of the wrong rule such as lifting instead of
lowering, or crossing the path of the lifting operation
ü
knowledge based such as
-
an unfamiliar situatio n
-
a situation w here no rules had been applied
-
arriving at a wrong conclusion when, for instance, the crane driver was
undertaking a particular lifting operation for the first time
-
the injured person being unaware that the lifting operation was taking place
Violations
or a deliberate failure to follow rules could include:
ü
not sounding the siren when the lifting operation was taking place
ü
intentionally walking close to the lifting operation.
A more detailed response could differentiate between
routine (a n ormal way of working) working),
situational (due to a specific situation, such as time and exceptional (rare and
generally occurring when something has gone wrong) violations.
Outline a range of factors relating to the individual which influence behaviour in the workplace AND give an example in EACH case.
Factors relating to an individual that might influence his/her behaviour in the workplace
include (amongst others):
ü
motivation
ü
personality involving individual traits and preferences
ü
aptitude perhaps in volving innate skills such as the possession of special
awareness
ü
experience, education and intelligence
ü
training involving the development of cognitive and physical skills
ü
perception of risk and disability
Give
the meaning of the term
motivation
Motivation is a driving force or incentive which persuades people to behave in a certain
way and to do something willingly.
Outline with an example in EACH case, how workers can be motivated to behave in a positive way.
A prime factor in motivating workers to behave in a positive way is the attitude of
management, who should show commitment, lead by example, involve and communicate
wit h the workers and give them praise, recognition and encouragement where this is
appropriate.
Other motivational factors include job satisfaction where sufficient time is allowed to carry
out a particular activity, where the right equipment is available an d the working environment
including welfare facilities is to a good standard, and where there is positive peer pressure
to attain certain goals.
Reward and incentive schemes, together with safety campaigns, have a part to play and
individuals are inclined to react more positively when they are told what particular desired
behaviour is expected of them, and when this is facilitated in such a way as to make it easy
to attain.
Finally, in certain cases, discipline may prove to be a powerful motivational tool
Outline
the meaning of ‘skill based’,
‘rule based’ AND ‘k nowledge based’
behaviour.
‘Skill
based’ behaviour involves a low level, pre programmed sequence of act ions
where employees carry out routine operations, often as though they were on ‘automatic
pilot’.
‘Rule
based’ behaviour involves actions based on recognising patterns or situations
and then selecting actions based on a learned set of rules.
‘Knowledge
based’ behaviour is involved at the higher problem solving level, when
there are no set rules and a decision on the appropriate action to be taken is based on
knowledge of the system.
With reference to practical exampl es or actual incidents, explain how EACH of these types of operating behaviour can give rise to human error AND in EACH case, explain how human error can be prevented.
For ‘
skill based’ behaviour errors may arise if:
ü
a similar routine is incorrectly selected
ü
there is interruption or inattention causing a stage in the operation to be omitted or
repeated
ü
checks are not carried out to verify that the correct routine has been selected.
Preventive measures
could include:
ü
designing routines and controls so that they are distinct from each other
ü
using feedback signals to warn when the wrong course of action is being taken
ü
allowing adequate work breaks or job rotation to maintain attention
ü
introducing training, competence assessment and a high level of supervision.
For
‘rule based’ behaviour, errors may occur if:
ü
the diagnosis is based only on previous experience
ü
sufficient training has not been given to enable employees to make an accurate diagnosis
ü
there is a tendency to apply the usual rule or solution even if it is inappropriate
ü
there is simply a failure to remember the rule that should be applied.
Preventive measures
include:
ü
clear presentation of information
ü
logical and easy to follow rule sets
ü
systems designed to highlight infrequent or unusual even ts
ü
provision of training and competence assessment.
Examples
(if properly explained) could have included the Kegworth air crash or Piper
For
‘knowledge based’ behaviour, errors may occur if:
ü
there is a lack of knowledge or inadequate understanding of the system
ü
there is insufficient time to carry out a proper diagnosis
ü
the problem is not properly thought through or evidence is ignored.
Preventive measures
include:
ü
training, particularly in risk and hazard assessment
ü
the provision of adequate resou rces in terms of information and time
ü
the use of supervision and checking systems such as group or peer review.
‘Perception’ may be defined as the process by
which people interpret information that they take
in through their senses.
Outline
a range of factors that may
affect how people perceive hazards i n
the workplace.
There are many factors that can affect the way that hazards are perceived in the
workplace such as:
ü
sensory impairment or health status
ü
intelligence and/or m ental capability
ü
the effect of drugs or alcohol
ü
inattention and boredom
ü
the nature of the hazard which may not be readily detectable
ü
environmental factors that may distract or confuse such as noise or poor lighting
ü
interference by the use of personal prote ctive equipment
ü
the effect of inadequate or ambiguous information and training
ü
the presence or absence of previous experience of, or exposure to the hazard
ü
the effect of expectation following exposure to similar situations
ü
sensory overload, work pressures, stress and fatigue and the pressure exerted
by peer groups.
Outline the desirable design features of controls AND displays on a control panel for a complex industrial process aimed at reducing the likelihood of human error.
Desirable design features of controls
include:
ü
Keeping their number to a minimum whilst ensuring a sufficient number to control the state of
operation.
ü
A change of system state should only occur after operating a control, and should require a positive
action of the control with immediate feedback to the user.
ü
A system restart should again only occur after operating a control after a deliberate or non intentional
stop.
ü
A stop function should be easy to activate and override s tart and adjust controls.
ü
All controls should be visible, positioned and ordered logically so as to follow the process and be
within easy reach of the operator while labelling, shape or colour can be put to effective use to ensure
controls are easily iden tified.
ü
The type of control should be appropriate to the degree of control required, for example a lever may
be more appropriate than a knob.
ü
Recognised conventions should be followed such as up for off, green for on and clockwise to
increase.
ü
Controls positioned next to their respective displays are also desirable.
Desirable design features for displays
include:
ü
They should be clearly visible and labelled and show steady state.
ü
They should also clearly indicate change, match expectations and attract th e appropriate sense such
as flashing to draw visual attention.
ü
It is important to use the appropriate type of display for the reading, ie analogue or digital, and ensure
that all dials are in a similar position for “normal” operation.
ü
Markings on dials a nd the application of different colours can be used to indicate abnormal situations.
ü
Additional design features include shielding bulbs from strong ambient light, shielding glass dials
from glare, and placing displays against a panel of neutral colour.
ü
Di splays should be kept to a minimum and safety critical displays should be separated from other
displays.
In rel
ation to behaviour in the
workplace, outline what is meant by
the term ‘attitude’.
‘
Attitude’ is a predisposition to act in a certain way which may be determined by
ancestry, personal experience or training.
Outline the meaning and relevance of the following terms in the context of controlling human error in the workplace. (i) ‘ergonomics’ 2 marks (ii) ‘anthropometry’ 2 marks (iii) ‘task analysis’
In the context of controlling human error in the workplace acceptable outlines would
have been similar to the following:
(i)
Ergonomics
the design of equipment, task a nd environment to take account
of human limitations and capabilities.
(ii)
Anthropometry
the collection of data on human physical dimensions which
can then be applied to equipment design.
(iii)
Task analysis
the breaking down of tasks into successive ly more detailed
actions which allows an analysis of the scope for human error with each action.
Excluding ergonomic issues, outline ways in which human reliability in the workplace may be improved. In your answer, consider ‘individual’, ‘job’ and ‘organisational’
‘Individual’
improvements would involve:
ü
careful selection taking into account skills, qualifications and aptitude
ü
the provision of appropriate training both at the induction stage and to meet
subsequent job specific needs
ü
the consideration of the special needs of those who may be more vulnerable
ü
monitoring personal safety performance
ü
using workplace incentive schemes and assessing job satisfaction
ü
providing health s urveillance and a counselling service for those suffering from the
effects of stress.
Job improvements would include:
ü
the introduction of task analysis for critical tasks
ü
the design of work patterns and shift organisation to minimise stress and fatigue
ü
the u se of job rotation to minimise monotony
ü
the introduction of good communication arrangements between individuals, shifts
and groups
ü
using a sufficient number of personnel to avoid constant time pressures.
‘
Organisational improvements would include:
ü
the d evelopment of a positive health and safety culture with the provision of good
leadership example and commitment
ü
the introduction of effective health and safety management systems
ü
maximising employee involvement in health and safety issues
ü
ensuring effectiv e arrangements for employee consultation
ü
the introduction of procedures for change management
ü
the provision of an adequate level of supervision.
Outline
ways in whi ch workers can be
motivated to work safely
A prime factor in motivating workers to behave in a positive way is the attitude of
management, who should show commitment, lead by example, involve and communicate
with the workers and give them prai se, recognition and encouragement where this is
appropriate.
Other motivational factors include job satisfaction where sufficient time is allowed to carry
out a particular activity, where the right equipment is available and the working environment
includ ing welfare facilities is to a good standard, and where there is positive peer pressure
to attain certain goals.
Reward and incentive schemes, together with safety campaigns, have a part to play and
individuals are inclined to react more positively when t hey are told what particular desired
behaviour is expected of them, and when this is facilitated in such a way as to make it easy
to attain.
Finally, in certain cases, discipline may prove to be a powerful motivational tool.
In order to reduce the likelihood of human error, outline the desirable design features of: (a controls 12 marks (b displays 8 marks on a control panel for a complex industrial process.
(a Design features of controls to be outlined include: ü sufficient numbers of controls but kept to a minimum to avoid confusion ü positive action of controls ü visibility of con trols ü stop function priority ü clear identification of controls. (b Design features of displays to be outlined include: ü displays being visible and labelled ü displays being appropriate for the reading (analogue or digital) ü displays should be shielded from g lare ü safety critical displays should be separated from other displays.
Outline
content of typical behavioural
change programmes
The content to be outlined should include:
ü
who would be involved, for example behavioural safety champions and supervisors
ü
the tra ining requirements to change behaviours
ü
management commitment, including praise, support and promotion of the programme
ü
how the desired and undesired behaviour and trends will be measured and monitored
ü
how communication and feedback will be carried out.
A train driver has passed a stop signal resulting in a collision
with a nother train. Investigation of the incident concluded that
the driver had seen the overhead signal but had not perceived
the overhead signal correctly.
There had been a number of previous similar incidents at the
signal, although the driver was not aware o f this.
The driver concerned was inexperienced and had not received
information and training associated with that route. The signal
was difficult to see being partly obscured by a bridge and
affected by strong sunlight. In addition, the arrangement of the
lights on the signal was a non typical formation. The driver had
approached the signal with no expectation from previous
signals that it would be on ‘stop’.
(a
Give
practical reasons why the driver may not
have perceived the signal correctly.
7
marks
(b
Outline
the steps that could be taken to help
reduce the likelihood of a recurrence of this
incident.
(a
Practical reasons include:
ü
failure of the driver to distinguish colour
ü
the driver’s vision may have been affected by sunlight
ü
the drive r may have been distracted
ü
the driver’s view of the signal could have been blocked by the
bridge
(b
Steps to be outlined include:
ü
selection and recruitment of drivers based on capability
ü
training and competence development
ü
health surveillance to ensure drivers are fit and able to distinguish
colours
ü
monitoring of the driver’s environment to ensure distractions are
minimised
ü
review of signal formations and visibility
ü
provision of information to drivers about previous incidents at
particular locations.
