We have all heard the term before, but what exactly did OSHA and EPA really mean when they stated that “human factors” must be part of a Process Hazards Analysis (PHA)? In the USA, we can look to OSHA’s PSM Compliance Directive, CPL 02-045, to get an idea of what we should consider “human factors” when doing our PHA(s).
Such factors may include a review of operator/process and operator/equipment interface, the number of tasks operators must perform and the frequency, the evaluation of extended or unusual work schedules, the clarity and simplicity of control displays, automatic instrumentation versus manual procedures, operator feedback, clarity of signs and codes, etc.)
But this is really just scratching the surface of what “human factors” is really about. For more on this topic and an excellent (and FREE) video…
It still amazes me how some businesses like to incorporate “human factors” into incident investigations yet have failed to incorporate “human factors” into their risk analysis of the workplace! In other words, we are oftentimes quick to point out “human factors” as causes of an accident, but rarely have we done enough in our analysis to identify deficiencies BEFORE the accident! To get a better understanding of “human factors” and how they play a role in industrial safety, especially process safety, I want to share a video. When watching the video, does anyone think “human factors” did not play a role in causing the incident, as well as in the response to the incident? This was gasoline, a highly flammable liquid, which may not be obvious, considering how the workers handled this significant spill. When viewing the video, watch the time elapse in the upper right corner and the responses of several worker(s). Pay particular attention to the lack of controlling ignition sources, the lack of using the emergency shutdown system, the lack of respect of the highly flammable liquid, etc. We need to ask ourselves, “Could this happen here”?
MANY THANKS to our safety friends across the pond and the UK’s Health and Safety Executive (HSE) for sharing this video with us.
Here are a few quick observations that still amaze me:
1) Did you see the “helpful” terminal workers arrive when the driver was having problems? At two minutes, notice the size of the spill increasing as they stand there and do NOTHING!
2) Well over 3 minutes into this spill, the two terminal workers stand there, observing the spill continuing to increase, NO driver around and yet do NOTHING!
3) The driver returns, RUNNING, and trips into the pool of gasoline as he looks back at the two workers, STILL STANDING there doing nothing!
4) Three minutes and 40 seconds into the video, we now have gasoline gushing from the top of the tanker and bottom of the tanker, and the driver is asking the two terminal workers why they did nothing
5) Five minutes into the spill, begin counting the number of times workers actually walk thru, ride thru, and drive thru the gasoline spill!
6) NINE MINUTES into the spill: someone uses a REMOTE SHUTDOWN to stop the flow of gasoline to the truck – NINE MINUTES to activate the ESD!!!
7) At 13 minutes, notice the gasoline still sitting in the top of the trailer, flashing off and creating flammable vapors which are 2-3 times heavier than air – COUNT the number of workers who decide the begin the investigation BEFORE clean-up of the spill!!!!
8) At 17 minutes, take notice of the vehicle traffic in very close proximity to the spill. Also take notice of the wind direction, as evident by the workers “safety vest” blowing in the wind. One saving grace here was that it appeared to be a stiff wind!!!
9) Notice the effort to clean up the spill was to WASH DOWN the area with water (gasoline floats on water!) and the fact that NO effort was made to remove the spilled gasoline from the top of the tanker! You can still see the wind ripples as the investigation begins!!!
10) I am JUST GUESSING here, but I am willing to bet a burger and a beer that the workers in the green FRC’s were truck rack terminal employees and the workers in the red FRC’s were the emergency response team personnel? Did either group respond to the situation appropriately?
11) At 1 hour and 15 minutes the tanker is pulled out of the loading bay and watch at the rear of the tanker, more fuel spills from the top of the tanker and yet they allow the truck out of the containment basin.
I ENCOURAGE ALL to use this video in some safety discussions, ESPECIALLY if your facility loads flammable liquids. I love to use it in my Behavior Based Safety Observation training and my BBSP Gauge R&R Exercises. Gather about 20 workers, give them paper and a pen, and ask them to write down every unsafe act and condition they observe during the video. Compare their reports; if everyone in the room has received the same level of training then the reports should be very similar. If we have large variations in the reports, then we have issues with “human factors” in our own facility! Don’t be discouraged, though; use this as a “teachable moment,” and never forget that as long as humans are on the job, there will ALWAYS be “human factors” to deal with!
Click Here to access the Health and Safety Executive’s OUTSTANDING section on “Human Factors”.