Fatigue Workshop Human Factors in Process Safety

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Fatigue WorkshopHuman Factors in Process Safety

• Presented by Bill Gall, Kingsley Management Ltd
• At EPSC Conference 5th -6th October 2006

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Workshop Facilitator

• Bill Gall, CPsychol, MErgS, MEI
• 28 years HF experience
• Manufacturing
• Consultancy
• Health and Safety Executive
• Kingsley Management since 2002
• IP/EI Working Group

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Fatigue Overview

• Fatigue is an HSE top ten issue
• Under-reported problem?
• Primary or secondary cause of incidents?

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The Fatigue Problem

• Fatigue has been recognised around the world as
  a contributor to many accidents involving means
  of transport. There have been many incidences
  where fatigue has been suspected of contributing
  to or causing transportation and industrial
  accidents however, that connection was difficult
  to justify IMO

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The Fatigue Problem

• 29 of UK drivers felt close to falling asleep
  while driving
• A quarter of New York drivers reported having
  fallen asleep at the wheel
• 10 of almost 68,000 serious road crashes in good
  conditions affecting only one vehicle were
  related to fatigue in France
• HSE survey workforce identified fatigue due to
  shift work and stress about work as the factors
  most affecting their health in the offshore
  environment
• Quote We do far too much time offshore to be in
  good condition (mind and body)Im coming to the
  end of my trip and Im very tired. Ive lost lots
  of sleep due to shiftwork
• Fatigue cited in
• Exxon Valdes
• Chernobyl/Three Mile Island
• Challenger space shuttle
• Many marine accidents

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Fatigue Definition

• a combination of symptoms including impaired
  performance (loss of attentiveness, slower
  reaction times, impaired judgement, poorer
  performance on skilled control tasks and
  increased probability of falling asleep) and
  subjective feelings of drowsiness or tiredness.
  Australian Transport Safety Bureau
• a result of prolonged mental or physical
  exertion it can affect people's performance and
  impair their mental alertness, which leads to
  dangerous errors. HSE

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Energy Institute Guide

• HSE guidance Managing Shiftwork
• Duties under law, risks of shiftwork, systems to
  control fatigue, legal duties, risk assessment,
  risk reduction, checking and review
• Energy Institute guidance
• Stand-alone, specific topics, guidance and tools,
  case studies
• based on, research material, case studies
  problems/solutions, most relevant process
  industry guidance
• Objective is to allow organisations to
• Recognise fatigue causing conditions
• Take effective remedial action

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Factors Affecting Alertness

• Long Hours
• Shift Work/Night Working
• Shift Patterns
• Poor Quality of Sleep
• Sleep Apnoea
• Sleep Deficit
• Unstimulating (boring) Work
• Warm, Dark, Comfortable Environment
• Chemical Substances

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Specific Offshore and Driving Issues

• Offshore
• Environment for sleep, travel
• Shift Patterns 12 hr, rotating
• Driving
• Largest risk
• Effective Countermeasures sleep, caffeine,
• Ineffective Countermeasures fresh air, radio
  on, rest without sleep

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Effects of Fatigue

• Short Term Effects
• Impaired concentration
• Irritability
• Poor judgement
• Reduced hand-eye coordination
• Reduced visual perception
• Reduced vigilance
• Slower reaction times
• Cardiovascular disorders

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Effects of Fatigue

• Possible Long Term Effects
• Cardiovascular disorders
• Gastrointestinal disorders
• Childbirth problems - miscarriage, low birth
  weight and premature delivery

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Effects of Fatigue

• Short Term Effects can result in poor performance
  leading to
• Reduced quality/quantity of output
• Incidents/accidents
• Inability to respond to off-normal conditions
• Long Term Effects
• Impaired health

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Alertness Fatigue Guide

• How to explore the issue
• Incident Investigation
• Risk Assessment
• Survey methods informal interviews and
  discussion, questionnaires
• Toolkits e.g. HSE Fatigue and Risk Index
  Calculator, sleepiness scales

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Alertness Fatigue Guide

• A note on questionnaires
• Questions will mostly of two types
• Those seeking objective information from
  individuals concerning their experiences of
  fatigue
• Those seeking subjective information relating
  mainly to underlying causes of fatigue
• Supplement with follow up questions if so,
  why?, list these, consider multiple choice
• Purely factual information about shift patterns
  etc from other sources, for example, HR dept

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Alertness Fatigue Guide

• Guide provides sample questions
• Aim is to find out whether fatigue is a problem
• What systems deficiencies and cultural factors
  contribute to this

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Alertness Fatigue Guide

• Solutions focused on
• Shift design and scheduling
• Work environment
• Management procedures
• Education of workforce and managers
• Additional factors (ageing, exercise)
• Innovation sleep contracts

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Exercise - Task

• Two types of syndicate
• Risk assessment
• Accident investigation
• Purpose
• Use formal techniques one proactive one
  reactive to identify problems and solutions

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Hazard Identification
Accident Investigation Risk Assessment
What went wrong and exposed people to the hazard? What could go wrong that could expose people to the hazard?
What were the immediate causes? What would be the immediate causes? (What human failures error/violation)?
What were the underlying causes? What would be the underlying causes? (Influencing factors)
What in our protection systems failed and led to exposure to this hazard? What deficiencies in our systems could fail and lead to exposure to this hazard? (Inadequate procedures lack of barriers)
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Exercise - Findings

• Mate had been awake for 19hrs 25mins. Last sleep
  was poor quality
• Alcohol consumption exacerbated this failed
  breath test
• Wheelhouse environment was conducive to sleep
• Zero tolerance drug policy contravened
• Excess hours overtime not evenly spread
• Short off duty periods and master and mate did
  not take opportunities for rest
• Company had not provided guidance on hours of
  work
• Industry guidance not followed for regulated
  hours of work and rest
• Lone watchkeeping common at night poor
  practice against industry guidance
• Lack of properly used watch alarm as per guidance

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Exercise - Recommendations

• Introduce specific instructions and guidelines on
  hours of work and rest
• Consider employing additional watch-
  keeper/lookout
• Consider fitting watch alarm to all vessels

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Sleep Contracts

• Separate EI study and report
• Employers and employees formally document how
  they will
• identify and report fatigue risk
• respond to reports of fatigue problems
• record, review and address reports of fatigue
  risk

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Sleep Contracts
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Workshop Conclusions

• Fatigue is a top 10 issue
• Research shows underlying causes
• Effects short term/long term
• Safety is key concern
• HSE cross-industry guide on shiftwork
• EI petroleum industry guide with basic tools

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Fatigue WorkshopHuman Factors in Process Safety

• Presented by Bill Gall, Kingsley Management Ltd
• At EPSC Conference 5th -6th October 2006