WHY DO PEOPLE DO WHAT THEY DO? - INFLUENCING THE HUMAN FACTORS IN ACCIDENTS AT WORK

摘要

This paper describes a project initiated by BP, and later adopted by other hazardous industries, which developed and implemented human factors analytical methods to help incident investigators analyse behaviour, and put in place more effective recommendations/behavioural measures to prevent a similar accident happening again. The project was initiated to address shortcomings with existing root-cause analysis methodologies, which were good at establishing "what" happened, but not so successful in establishing "why" people did what they did, and how to prevent a recurrence. Two methods to analyse human behaviour were developed; one for intentional violations, and another for unintentional human errors. These were trialled; peer-reviewed by industry, regulatory & academic experts; then modified and used to train 200 investigators with varied levels of experience in four companies. In one of these companies, their existing root-cause analysis model was linked to a model of safety culture, allowing a series of incidents to be trended to identify underlying weaknesses in the safety culture. Case studies are presented to illustrate the benefits obtained, including a violation which led to an environmental release, and a human error near-miss concerning spillage of hydrocarbons. In addition, some of the difficulties and challenges involved in implementing such a project will be described. It is anticipated that the methods and experiences described will be of interest to other process industry organisations, who wish to deepen their understanding of how to apply human factors analytical techniques to improve performance.