Human Factors in Procedures

This topic is about selecting, designing, and managing safety critical procedures in a way that assists human reliability. It limits the risk of unreliable or dangerous performance of safety-critical tasks and ensures the activity is performed the same way each time, ensuring a safe outcome. Safety critical procedures should be an output of safety critical task analysis.

A number of major incidents have cited poor procedures as a cause or contributory factor. Therefore, when carrying out critical tasks, and with the procedure as one of the last barriers, it is vital to ensure the risk of human error is identified and necessary mitigations or controls included in procedure design. Likewise, findings from investigations should address specific failures or weaknesses in procedures.

Operating procedures should reflect ‘work as done’ and not ‘work as imagined’, i.e. they should reflect the sequence, circumstances, constraints and operating environment in which the task is carried out. To ensure the relevant format and content of procedures is suitable, involve the users in writing, reviewing and managing the content. They know best what will support them during a task and what level of information is appropriate. Too much detail can be just as challenging as not enough! Users should consider what format and level of content is proportionate to the risks associated with carrying out the task – sometimes an annotated diagram is more effective than rows of text. Critical steps in tasks should be clear to ensure sufficient attention is paid to that section of the task. Additionally, the frequency of a task will determine how much detail is needed.

Procedures can then demonstrate an agreed safe and consistent way of carrying out critical tasks and improve operating integrity. If procedures are developed and maintained by users, with independent review and approval, this capably supports training and competence in specific tasks.

"Harbour Energy has a robust process for conducting safety critical task analysis resulting in safety critical procedures that are developed with users. We carry out awareness sessions with personnel to explain why consistent use of safety critical procedures minimises the risk of working outwith operational parameters and ensures the task sequence is performed consistently.

"Our crews are fully involved in the development and review of our safety critical procedures and operational integrity issues have been addressed as a result of their feedback. This ensures the safety of people and plant and reduces the potential for a major accident. It also highlights where engineering controls need to be considered to reduce human intervention.

"Tantamount to this is continued collaboration with frontline personnel to ensure the procedures are accurate, fit-for-purpose and allow more efficient and safe execution of safety critical tasks. By carrying out safety critical task analysis and ultimately updating our safety critical operating procedures, it has created ‘ownership’ by our asset personnel and helped with procedural compliance. It has invited challenge to certain aspects of procedures and highlighted safe innovations in the way tasks are carried out. This is vital in legacy assets where equipment has been updated since original design."

Regulator Guide - Offshore

• A formal process is in place for managing procedures which includes criteria for periodic review.
• The design of procedures should be in line with good practice for layout/format etc.
• End users should be involved in writing procedures to ensure they accurately reflect tasks.
• There should be clear expectations for how procedures are used, e.g. sign-offs.
• End users should understand which procedures are safety critical.
• End users should feel that procedures provide good support to tasks and they should feel involved in maintaining procedures.

Onshore COMAH

• Established, and is implementing, a clear written standard for developing and managing COMAH-critical procedures (based on relevant good practice).
• Established clear links between procedures and local MAH scenarios.
• Used on-plant task analysis to inform the step-by-step content of COMAH-critical procedures - they define the agreed way of carrying out relevant tasks in a safe manner. Critical steps are clearly identified and appropriate warning information is given.
• Established a framework to optimise usability of procedures e.g. accessible, level of detail appropriate, style, language and layout are consistent etc.
• Developed arrangements to ensure day-to-day compliance with COMAH-critical procedures, including effective supervision.
• Established a structured framework to train and assess personnel in new or updated procedures.