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... are less likely. Under stressful workloads people tend to drop safety issues first so a good operational guideline defines employees working time as 85 % working and 15 % thinking. Process Maturity Safer operations come from evolving processes that learn from past iterations. This is demonstrated in Fig. 3 where the feedback obtained from reviews and audits flows back into the organisations accumulated knowledge base. This then allows improvement of subsequent design processes V it has evolved.
It is beneficial to study processes applied to similar cases, as the experience gained here can advance maturity. Mature processes should be targeted, as they are stable, reliable and well understood. This reduces the chances of latent errors flowing through into operation. 5. 1. 4 Competent Staff The intelligence and background of staff should be carefully considered. In the context of monitoring type roles in high risk sites it may not be wise to resource the most intelligent subjects, such as those with PhDs. On first sight this seems the logical process, but such subjects are likely to possess inquisitive minds seeking experimentation. This can be detrimental to operational safety as seen in the Chernobyl nuclear explosion.
Possibly a wiser move is to employ not less intelligent, but certainly more steadily- minded operators who are more likely to be content in the monitoring role. A culture where staff are trained to the whys of actions as well as how to should be encouraged. In case of emergency they are more likely to take appropriate action due to better understanding of the system. Training can be structured to force operators to contemplate the whys directly using questions on mock scenarios and suggested actions. A safety conscious culture should result in more stringent operators. Using classes on analysing past disasters and some horrific personal accounts are likely to penetrate most peoples conscience.
To ensure knowledge and attitude doesnt relax over time refresher courses should be implemented. 5. 1. 5 Emergency Procedures Emergency Procedures are an essential safety precaution. Firstly these procedures should be defined and catered for in the design stages. Referencing the Piper Alpha emergency evacuation one of the main flaws was the extensive time required to set up the rescue platform (up to 45 minutes) in difficult conditions of smoke and heat from the raging fire V clearly a design issue. Once effective procedures are defined regular drills need to be run to ensure actions become second nature, especially in high-risk scenarios.
Generous time for such drills needs to be scheduled by the management so that reviews can be conducted and problems resolved. Management also needs to be trained up to give strong leadership in crisis situations. This can be achieved by realistic drills and simulations where managers can be monitored by external bodies in their effectiveness. A combination of analysing theoretical scenarios and participating in full-scale drills would be most beneficial. 5. 1. 6 Monitoring and Audits of Safety The situation now is hopefully we have safely designed systems with effective operating and emergency procedures.
However, there is a need to ensure that the system procedures are being operated as intended in a safety conscious manner. This is where audits and monitoring are utilised. As discussed in Ironies of Automation if the automation is efficient then operators can become complacent, becoming less stringent with a more relaxed attitude towards safety, as their trust in the system grows. Using simple audits operator records can be checked to see if plausible events/ values are being recorded in the logbooks.
If not, management needs to address issues of why this has occurred. One possible reason may be job time pressure, where these often seen remedial tasks are the first to be rushed or bodged. In addition to audits more technical methods can be applied such as monitoring trends in the output of the system. For example, if attributes of the system output are on a gradual change this may be indicative of changes within the system, possibly dangerous ones such as increasing tolerances in machining parts. 5. 2 Systems View of Processes A systems approach stands back and looks at the whole system lifecycle.
A critical issue in ensuring safety is to ensure there are enough resources, correctly directed to work the problem. A trend in the past was a complete misuse of resources depicted by the following model. The left pyramid represents the time and effort expanded to reduce errors for the sector described on the left. The right pyramid represents the suggested importance of each sector.
Fig 5 V Resource Importance model A simple model that demonstrates the mismatch of effort expanded to minimise error in each sector versus the relative importance. This balance needs to addressed and corrected at the very top level within an organisation. A common and modern process in systems engineering is that of concurrent engineering where the lifecycle stages overlap to reduce time to production. However, I see another advantage as allowing faster feedback of knowledge such as between prototyping and design. This links again into developing process maturity and subsequently safer systems with fewer surprises.
As I have experienced an important aspect of ensuring safe systems is to maintain tractability between requirements and the final product. This way all safety aspects identified in requirements are sure to be satisfied, not getting lost in the process. This an I. T. issue and is achieved by cross-referencing on computer systems. A strategy I believe governance would find worth employing the resources to implement in high-risk systems such as military aircraft. 6.
Conclusions A common theme throughout has been the importance of knowledge, the accumulation of and dispersion to the people in the systems that need it. In accumulating knowledge, and feeding back into the processes, this constantly reduces the unknowns in a system improving process maturity. Mature processes improve understanding, reducing the risks of accidents, but only if processes exist within the system to disseminate knowledge to all parties who require it. Organisations should also be governed to ensure human factors and the role of humans is designed as an integral part of the system. Ideally, this would avoid highly automated scenarios where the human is isolated both physically and mentally from the system. Enforcing this design philosophy should facilitate humans better equipped to deal with emergency situations.
Apparent in the many case studies browsed was a lack of safety culture. This culture should be targeted at the top of the management structure so it flows down and infests itself in all personnel. However, managements can become isolated and believe their safety influence is minimal such is their physical isolation from the plant. Difficult to resolve such scenarios, a possible solution is external audits funded by the government to flag up such lax managements. I believe a systems approach is an excellent way to tackle the design of high-risk plants. This ensures all system requirements are traced through and satisfied by final design including mock-up human factors rigs where required.
However, this process is mainly used for design and manufacture acceptance to a customer so additional processes would be required for operation/ maintenance etc. As stated in the introduction I believe the fallible nature of humans makes it impossible to say no disasters will occur in the future. The ubiquitous theme in my discussions has revolved around the humans role in systems. To minimise the risks in future with increasingly sophisticated technology one principle should be applied above all; integrating humans into the system. 7. Bibliography In addition to material from the HUC 109 System Ergonomics lecture notes the following sources were used.
Books Reason, J. (1990) Human Error. (London: Cambridge University Press) Klotz T (2001) An engineer's view of human error 3 rd ed. (London: Institute of Chemical Engineers) Main Websites web 3 / 12 / 01 Famous Engineering Disasters web 22 / 11 / 01 Piper Alpha Disaster web 23 / 11 / 01 Ironies of Automation
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Research essay sample on High Risk Human Error
