• Analysis of a process following a number of hazardous incidents

    2010 - Steel

    The client was experiencing a number of recurring hazardous incidents, and the high level team set up to investigate were struggling to determine the precise cause or come up with practical means of reducing the risk.  Working with a cross section of personnel from several departments involved in the activity including contractors, Andy facilitated a workshop where the whole process was mapped out.  This identified approximately 20 stages, 45 variables and a further 30 factors that may influence human behaviour and performance.  From this Andy was able to show that the problem was more complex than had been realised and that the solutions that had been tried to reduce the risk were unlikely to be effective or reliable.  As a result, the client fundamentally changed their view of the situations and their method of dealing with it.

  • Analysis of an accident

    2011 - Gas

    A fire had occurred and an employee had been burnt.  The company had carried out their own investigation but asked Andy to give them his opinion.  Using causal trees and applying his knowledge of human factors he was able to ask some searching questions that highlighted organisational and management weaknesses.  As a result the client developed a new engineering standard for the equipment being used at the time of the accident; and reviewed training and audit programs.

  • Assessment of the human errors in accidents

    2004 - Chemical manufacture

    The client was concerned that they were experiencing frequent incidents where human error was a cause. However, they did not understand why those errors were occurring and so did not know what to do to prevent them. Andy led a small team in assisting the client in analysing past incidents and suggesting preventative strategies. This required him to train his colleagues in the techniques to be used. The project started by assessing a selection of past incidents in order to identify if there were any recurrent themes. As well as his in depth knowledge of human factors, Andy able to provide a systematic approach to this assessment. From this, a number of error prone tasks were selected for further analysis. The error prone tasks were assessed using the 'Human Factors Assessment of safety critical tasks' methodology described in HSE report OTO 99:092. During workshops attended by site personnel, error prone tasks were assessed using Hierarchical Task Analysis (HTA) and Predictive Human Error Analysis (PHEA). From this, error reduction strategies were proposed.

  • Evaluation of site emergency response arrangements

    2006 - Steel manufacture

    The client had experienced an incident that caused significant plant upset and had the potential to be a COMAH (major hazard) accident. Andy was asked to investigate how the incident had been responded to by the plants affected and the wider site, and to evaluate whether the emergency management systems were adequate for the nature of hazards present.

    Talking to key people involved and reviewing logs from the incident, Andy developed a comprehensive timeline of the incident; and assessed the communications and decision making processes that had been employed. From this he identified a number of apparent shortcomings. He then compared the existing emergency management system and procedures with documented good practices from HSE and others and was able to identify the root causes of weaknesses in the system, particularly regarding command and control. He recommended that the existing system could be restructured and simplified, and that this would significantly improve the way it works in practice.

  • Fitness for service review

    2010 - Gas

    The client had recently experienced a significant incident, that came following a number of operational problems.  Prior to restarting the affected unit a fitness for service review was carried out to ensure that all known problems had been recognised and rectified.  Andy was asked to lead the human factors element of the review, which involved a review of incidents, task and error analysis of critical tasks and a formal HAZID assessment.  The result was a thorough documentation of the known issues and risks associated with the unit based on past experience, and a list of actions and recommendations.  The main finding was that the vast majority of issues were related to the unit's design, and relatively few were related to the softer human factors issues.

  • Human factors analysis of systems for evacuation, escape and rescue

    2007 - Gas, offshore

    Following a major incident on an offshore platform the client identified a number of human errors that had occurred during evacuation, escape and rescue.

    Andy was asked to carry out a human factors analysis of the systems in place, taking into account the events that occurred during this incident. He visited the platform in order to observe arrangements and talk to key personnel. He then completed a task and error analysis. From this Andy made a number of recommendations for improving procedures, training and equipment arrangements.

  • Supporting the analysis of an incident that involved errors by a control room operator

    2011 - Gas

    The client had experienced an incident. Although the consequences had been relatively minor it was recognised that a number of failures had occurred, including errors by the control room operator, that could indicate deep set human factors problems. Because of his knowledge of the site, Andy was asked to assist in the analysis of the incident. He was able to point towards systemic weaknesses that had contributed to the errors. Also, he was able to show that warning signs had been visible for some time prior to the incident, but people had not appreciated their significance. The client is using the findings from the incident, including Andy's report, to develop plans to improve the management of human factors across the business.

  • Task analysis of a maintenance task performed on a low pressure gas system where it is not practicable to prove isolation integrity

    2010 - Steel

    The plant studied in this project uses low pressure gas.  The high proportion of impurities in the gas meant that pipework required regular dismantling and cleaning.  However, because the gas was of such low pressure it was difficult to prove isolation and as a result the plant had experienced a number of gas releases and fires over the years.  Andy was asked to carry out a task and error analysis of the task in order to identify if there were any further actions that could be carried in preparing the plant for maintenance that would reduce the risk.  Working with the contractors who performed the task, along with the client's maintenance team Andy was able to identify three potential options that would reduce the risk of gas release.  All were considered practical and plans were immediately put in place to run trials of the new methods.  This was a particularly project because the client's technical experts had reviewed the situation a number of times in the past and had been unable to come up with any suggestions for improvement.