Safety Leadership: Reducing catastrophic incident potential via enhanced human performance reliability
Editor’s Note: Achieving and sustaining an injury-free workplace demands strong leadership. In this monthly column, experts from global consulting firm DEKRA Organizational Safety and Reliability share their point of view on what leaders need to know to guide their organizations to safety excellence.
Faced with increasing demands, changing technology and dynamic environments, many organizations I work with across the energy sector continue to have incidents. Are they just unlucky?
The answer is “no.” Typically, updated work systems and processes that maximize human performance reliability are needed.
Updating organizational factors that impact human performance strengthens existing focus on leadership development, peer-to-peer feedback, exposure reduction, and culture characterized by engagement and psychological safety.
To protect from catastrophic incidents that put lives at risk and significantly damage organizational reputation in the market, a holistic approach to safe work is necessary to ensure consistently safe and controlled operations.
Take, for example, the following incidents:
- On an offshore installation, an assistant driller on a dual-activity rig released from the vertical pipe handler a 40-foot joint of 16-inch casing that fell across the entire drill floor. Nobody was hurt, but definite potential for serious injury and fatality was there.
- Two floormen on a land-based rig fell 20 feet when breaking a connection with the pumps left on. Both men survived but were seriously injured.
- On a drill ship, joints of casing were being lifted to and from the pipe bay area. When landing a joint of casing, it swung and crushed the rigger between the load and another joint of casing in the pipe bay, resulting in a fatality.
- When making up a connection using manual tongs, the tongs slipped while being torqued and flew across the drill floor, crushing a floorman between the tongs and rail and resulting in a fatality.
- An electrician working on top of an elevator on a semi-submersible offshore rig was crushed to death when the elevator started to ascend and could not be stopped.
These are real incidents still occurring across the oil and gas industry. They happen to great organizations with strong cultures, capable leaders and people who had no intention of causing an incident.
So, what’s driving these catastrophic incidents?
The fact is simple and obvious: People make mistakes. Telling people to stop making errors or leadership applying discipline won’t improve performance error. What it takes is creating increased consistency through understanding critical decision-making and evaluating the design of key work tasks to ensure latent error potential is mitigated.
What we know about human design that informs task and process design is:
- We spend quite a bit of time working on “autopilot,” during which habitual actions, instead of conscious actions, can lead to a serious injury with just the slightest change in our working environment.
- Our visual system is designed to notice important things. If something isn’t deemed important at the time, or there are other demands on our attention, we naturally miss important items within our visual field.
- Lack of high-quality sleep leads to cognitive fatigue. The risk is that we are much less likely to perceive and react to changes in the moment.
- Our memories are designed to recall general information to help us avoid obvious danger. We often misremember things, including recalling required or completed steps, in work processes.
- We make more mistakes when our work is designed to have us multitask.
Each of these directly impacts performance errors that continue to result in catastrophic incidents across the oil and gas industry. They create direct exposure in hazardous work tasks, as they impact decision-making that can result in action not conducive to reliable performance.
Layers of protection your organization should consider to further reduce potential for catastrophic incidents through improved human performance reliability include:
- Creating clear alignment on prioritization of competing organizational targets and objectives.
- Creating brain-aligned standard operating procedures and documents in which design and content are developed in a way that highlights critical steps and prompts specific actions that reduce potential for critical error.
- Creating specific lines of inquiry related to human performance and human-machine interface to understand how errors might occur/or have occurred post-incident.
- Deploying a structured technique for hazard identification (going from looking to seeing and mitigating hazards).
- Creating prompts that move people out of the default “autopilot” (fast brain) during safety-critical transitions within work tasks.
- Training frontline team members to understand the causes of performance errors and co-develop the techniques and system changes necessary to control for them.
It’s a good idea for safety governance teams to create a safety learning team dedicated to reviewing all safety critical work tasks to ensure they meet current standards around risk acceptance and are designed with consideration for the points above. Proactively reviewing these key tasks will support prevention of catastrophic injuries; save lives; and promote intentional, reliable operational execution for years to come.
Let’s make 2021 a year where the human side of safety is further integrated into the way we design our work.
This article represents the views of the authors and should not be construed as a National Safety Council endorsement.
Matt Hargrove is a principal consultant working in the brain-centric reliability practice within DEKRA’s Organizational Safety & Reliability division (dekra.us/osr). To learn more about brain-centric reliability, go to dekra.us/en/organizational-safety-reliability/brain-centric-reliability.
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