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LECTURE 10
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HUMAN FACTOR HUMAN PERFORMANCE
HDB 2123 Workplace Safety in
Malaysia
COURSE SYNOPSIS
Introduction
Definition of workplace & the purpose of creating a safe workplace
Knowing about workplace hazards
Workplace safety issues in Malaysia
Malaysian legislation for securing OSH & welfare of people at workplace
HIRARC guidelines developed by DOSH
Human Factor
Providing and maintaining safe machines & systems for employees
Organizing the safe use of dangerous goods & hazardous chemicals
Managing & controlling hazards
Internal
Internal
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We are what we repeatedly do. Excellence, then, is not
an act but a habit.
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Aristotle
Greek philosopher (384 BC 322 BC)
Human Performance
Accomplishment of a task in accordance with agreed upon
standards of accuracy, completeness, and efficiency.
http://www.businessdictionary.com
All aspects of human action relevant to the safe operation of a
hazardous installation, in all phases of the installation from
conception and design, through operation, maintenance,
decommissioning and shutdown.
http://www.oecdsafetyindicators.org
Internal
Human performance is behaviour and results - series of
behaviours executed to accomplish specific results
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Human Performance
Human Behaviour is both:
Observable
Internal
Measurable
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Human Behaviour is a function of :
Forces that drive
human behaviour
Antecedents
(trigger behaviour)
Activators (what
needs to be done)
Behaviour
Competencies (how it
needs to be done)
Consequences (what
happens if it is done)
(human performance)
Consequences
(either reinforce or punish behaviour)
Definitions:
Internal
Antecedent: Activators-
person, place, thing or event
that happens before a
behaviour takes place that
encourages you to perform
that behaviour.
Activators only set the stage
for behaviour or
performance - they dont
control it.
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Behaviour: Any directly measurable thing that a
person does, including speaking, acting, and
performing physical functions.
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Consequences: Events that follow behaviors.
Consequences increase or decrease the probability that
the behaviors will occur again in the future.
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Behavioural Model
Antecedents
Behaviours
B = f (C)
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Consequences
Principles of Human Performance
Human fallibility - a permanent
feature.
Error is normala natural part of being human. No amount of
counseling, training, or motivation can alter a person's fallibility.
Considerable forethought is necessary before depending on
human beings for compensatory action or as the only defense
against a plant upset or personal injury.
Internal
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Principles of Human Performance
E.g. predicting that a person writing a personal cheque
at the beginning of a new year stands a good chance of
incorrectly recording the previous year, - similar
prediction can be done in the context of work at the
job site.
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Recognizing error traps and actively communicating
these to others permits the managing of such
situations proactively and prevent errors.
Principles of Human Performance
Organizations are characterized by goal-directed
behaviour, consequently, managers develop
processes and values to direct the behaviour of
the individuals in the organization.
The organization is simply the sum of the ways
work is divided into distinct jobs and then
coordinated to run operations safely and reliably.
Consequently, management is in the business of
directing peoples behaviour.
Internal
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Principles of Human Performance
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Behaviour is influenced by its consequences,
what happens to workers when they exhibit
certain behaviours is an important factor in
improving human performance.
Most behaviour is reinforced by the
consequences the individual experiences when
the behaviour occurs.
Principles of Human Performance
Events can be avoided reactively and proactively.
Learning from our mistakes and the mistakes of others is
reactive.
Anticipating how an event or error can be prevented is
proactive, and proactive methods provide a more costeffective means of preventing accident/incident and
problems from developing.
Internal
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To err is human
Accept that humans can and will fail
Human Nature
Different mental,
emotional, social,
physical, and
biological
characteristics that
define human
tendencies,
capabilities, and
limitations.
Internal
Vulnerable to
external working
conditions that may
test the limitations increases our
chances to err.
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Basic Tenets of Human Nature
Everyone makes mistakes
Errors are often beyond our conscious control
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Systems that depend on perfect human
performance are fatally flawed.
Internal
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Why people do things?
There are only 2 reasons that people do things
They do something intentionally
a deliberate act or decision [like a
procedural shortcut or failure to follow a
rule].
1)
They do something unintentionally
Genuine errors (slips, lapses and mistakes)
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2)
Intentional or Unintentional
Internal
crossing a barrier
into an unsafe area;
misreading a level
gauge;
operating the wrong
valve;
cancelling a
nuisance alarm
without checking it
out.
Intentional
Unintentional
Unintentional
Intentional
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Human Failures
Recall
Human failures
Intended actions
Violation - Intended consequences
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When the person decided
to act without complying
with a known rule or
procedure
Unintended actions
Errors - Unintended consequences
Mistakes
Lapses
When the
person
does what
they
meant to,
but should
have done
something
else
When the
person
forgets to
do
something
Slips
When the
person
does
something,
but not
what they
meant to
do
Preconditions for Unsafe Acts
The Human Factors
Analysis and Classification
SystemHFACS
U.S. Dept Of Transport
(Federal Aviation Administration)
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Types of Unsafe Acts
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The Human Factors
Analysis and Classification
SystemHFACS
U.S. DOT (FAA)
Categories of Unsafe Supervision
The Human Factors
Analysis and Classification
SystemHFACS
U.S. DOT (FAA)
Internal
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A theory of human error
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Human Error
rarely contributes
to accidents in
terms of a single
distinct and
obvious error.
Internal
Human errors
can/do occur
regularly.
It is the
combination of
many factors
extrinsic and
intrinsic, which
when they
coincide produce
tragic results.
James Reasons Swiss Cheese Model
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The Swiss cheese model of how defenses, barriers, and
safeguards may be penetrated by an accident trajectory
No single barrier is foolproof!
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Reason, J. BMJ 2000;320:768-770
Reasons Model (Swiss cheese)
Defences
Occurrence
Inadequate
Productive
Activities
Limited Window of
Occurrence Opportunity
U n s afe A ct s
Preconditions
P sych o l o g ic al
P recu rso rs o f U n safe
A ct s
Line Management
D e fi cie n ci es
Active Failures &
Latent Unsafe Conditions
DecisionMakers
F al l ib l e D ec isi o n s
Active Failures
Latent Unsafe Conditions
Latent Unsafe Conditions
Latent Unsafe Conditions
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Decision Makers
First layer - Decision Maker or Management
o being human, make Fallible Decisions often based on
making money and not Safety.
Management Decisions set up Latent Conditions - system
condition (policy or decision) that lays dormant until an active
failure normally brings it to light. E.g. management decides to
not buy equipment in order to save money.
Seem like good ideas at the time
May lay dormant for a long time
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Set the scen e for the Active Failure
to occur
Line Management
Second layer Line Mgmt
Error in interpreting
what it is that
management really
wants done.
Are decisions made
based on what they
think the
management really
wants
Internal
Line
Management
Latent
Conditions
Decisions
Are there but are
not recognized as
potentially
dangerous. May
also lay dormant
for a long time
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Preconditions
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The Preconditions are the Bad Influence that interfere
with the personnel judgment/performance to enable the
Active Failure to occur.
Often, there will be more than one of these working together
to make a large hole for the error to occur.
1. Lack of Communication
7. Lack of Resources
2. Complacency
8. Pressure
3. Lack of Knowledge
9. Lack of Assertiveness
4. Distraction
10. Stress
5. Lack of Teamwork
11. Lack of Awareness
6. Fatigue
12. Norms
Productive Activities
are the actions that involved unsafe
acts which resulted in Active Failures
The guilty party is the person who
makes the mistake that results in a
human error
It will be an action or lack of action that
results in the error
It is the RESULT but NOT the CAUSE
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Defences
or Safety Net
A check list is a common Safety Net as is
training of any kind but specially human
factors.
Last chance to prevent the accident from
occurring
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a regulation, policy, practice or procedure
designed to stop the Chain of Events.
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Optimising Human Performance
.. and to enhance the last layer of the Swiss Cheese
Model - Defence
Through:
Procedures
Procedure will ensure the task
is performed correctly
Training helps acquire skills,
knowledge and attitudes to make
people competent in the health and
safety aspects of their works.
Incorporation of Human
Factors in the design process
We cannot change the Human Condition but we can change the
conditions in which humans work.
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James Reason
Automation ?
http://www.nytimes.com/2016/07/11/business/fatal-tesla-crash-draws-in-transportation-safety-board.html?_r=0
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