Improving Maintenance Reducing Human Error

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Improving Maintenance - Reducing Human Error
Steve Mason Principal Human Factors Consultant
Health, Safety Engineering Consultants Limited
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A maintenance operator who is motivated, well
trained, under no time pressure, given the
correct information, and working with equipment
which has been designed to be maintenance
friendly, will likely complete all specified
maintenance work to a high standard.
HSEC Ltd
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Human Error in Maintenance
From James Reason
SLIPS LASPES fail to achieve what is wanted
MISTAKES achieved intended action - but action
proved to be wrong
VIOLATION achieved intended action - knowingly in
breach of safety rules and procedures
HSEC Ltd
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Reducing Human Error in Maintenance
SLIPS LASPES Improve DESIGN
MISTAKES Improve TRAINING
VIOLATION Improve SAFETY CULTURE
HSEC Ltd
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Addressing Violations
DIRECT MOTIVES

• Making Life Easier
• Getting the Work Done on Time

BEHAVIOUR MODIFIERS

• Poor Understanding of Consequences
• Poor Attitudes of Supervisor/Manager

HSEC Ltd
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The Human Factors in Reliability Group - HFRG
Is a forum of individuals from industry,
regulatory and academic institutions with an
interest and expertise in human factors
associated with reliability

• Foster Collaboration
• Support Research
• Dissemination of Information

HSEC Ltd
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IMPROVING MAINTENANCE - A Guide to Reducing
Human Error
HSE Books ISBN 0 - 7176 - 1818 - 8
Steve Mason HSEC Ltd Jon Berman Greenstreet
Berman Ltd Greg Gibson Nuclear Industry
HSEC Ltd
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HFRG Report on Improving Maintenance
Utility to Most Industries Solution Orientated
Approach Used by Non-Human Factor Specialists
Practical Advice Methodology to help Managers
Engineers involved in the management of
maintenance performance of people quality of
maintenance activity
HSEC Ltd
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Report Structure

• Maintenance Risks
• Human Performance in Maintenance
• Assessment Method
• Maintenance Management Issues
• Copies of Blank Work Sheets

HSEC Ltd
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Structure Based on HSG(65)

• Policy Organisation

• Policy
• Resource Allocation
• Roles, Responsibility Accountability
• Formal Communication
• Management of Change
• Organisational Learning

HSEC Ltd
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Structure Based on HSG(65)

• Procedures Permits
• Work Design
• Shift Handovers
• Individual Capabilities
• Competence
• Teamwork
• Supervisory Effectiveness
• Plant Equipment Design
• Environmental Factors

• Planning Implementation

HSEC Ltd
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Structure Based on HSG(65)

• Measuring Performance, Audit Review

• Routine Checking of Maintenance Performance
• Review of Maintenance Performance

HSEC Ltd
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Assessment Method

• Stage One Identify Areas of Concern
• Physical Location of the Work
• Type of Work (eg Routine/Breakdown or
  Electrical/Mechanical etc)
• The Main Consequences (eg Plant Reliability,
  Safety to the Public, Safety to Employees etc)

HSEC Ltd
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Assessment Method
Stage Two Application of QUESTIONNAIRE
and/or INCIDENT ANALYSIS
HSEC Ltd
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Extract from a completed incident review score
sheet
Score
Management issue
Underlying causes
1
2
Procedures and permits (contents)
11
Procedures contain technical errors
Procedures contain inadequate information on
task requirements
2
15
Permits- to- work not completed correctly
0
Errors in procedures and permits not reported
2
HSEC Ltd
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Extract from a completed questionnaire
How much do you think the listed factors
contribute to the following identified
maintenance problem employee safety during
routine maintenance?
No contribution Small contribution Medium
contribution Major contribution
A
B
C
D
F
Factor
A B C D
Procedures that are needlessly too detailed
or complicated
F13
F14
Procedures that contain technical errors
F15
Clarity of instructions in procedures / manuals
HSEC Ltd
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Assessment Method

• Stage Three Analysis of Results
• Identify Priority Areas for Improvement
• Guidelines Recommendations Section

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Comparison of top 4 rankings
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Comparison of top 6 rankings
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Comparison of average ranks
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HSEC Ltd Human Factors Assessment Tool

• Very quick to apply
• Summarises both positive negative features
• Discussion material on negative features
• Short long terms action suggestions
• Action plan

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SUMMARY

• Human Error is a key factor in Offshore
  Maintenance
• HFRG approach specifically designed for
  non-human factor specialists
• Solution led
• HFRG authors would welcome feedback from users

HSEC Ltd
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HSEC Ltd