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Where to Focus Resources: Using Human Performance Reliability to Identify Weaknesses in Internal Controls

December 9, 2014 - Kestrel Management

A forklift collides with a liquid propylene line resulting in a release and vapor cloud explosion; 16 workers are injured, the unit receives heavy damage, and a nearby school is evacuated. A refinery explosion kills 15 people and injures 180. A train derails, despite warnings of washed out tracks due to severe weather conditions, leading to a $36 million settlement. What’s the common theme?

Controlling Risks

Each of these events was caused, in part, by human error. Human error is a significant source of risk within any organization, one that plays a large role in unintended and sometimes catastrophic events, such as those listed above.

To help manage those risks, companies employ a variety of controls organized into a management system, including:

  • Culture, leadership, and policies
  • Risk identification and assessment
  • Planning and budgeting
  • Procedures and practices
  • Personnel selection, training, and supervision
  • Monitoring, auditing, and verification

Using Human Factor DataHPR_Accident_Causation

Even with controls in place, accidents—both personal and process safety—still occur when there is a failure in one or more of those controls. This can promote a desire to focus resources on only those controls that seem to contribute to accidents, but management systems are complex. One facility can have up to 2,500 procedures alone. Given that, how does a company know where to focus resources?

Using human factor data helps to evaluate risk controls and identify those areas needing improvement. The Human Factors Analysis and Classification System (HFACS) describes the categories of barriers and identifies the system weaknesses or failures, which may ultimately result in an incident.

The HFACS hierarchy includes the following:

HFACS_hierarchy

Linking Human Factors to Company-Specific Controls

Current methods of incident investigation and cause analysis do not go broad enough in examining failures and do not specifically explore the characteristics and contributing factors to human error.

Human Performance Reliability (HPR) is an investigation process based on HFACS. HPR links human factor data to company-specific controls (i.e., policy, procedures, work instructions) and helps the company systematically identify active failures and contributing factors. HPR outputs ultimately help organizations to identify patterns, trends, and gaps in existing barriers. (Read more about the HPR approach.)

HPR enhances the connection between human factor details, operational controls, and other system elements. Opportunities are identified to strengthen safeguards and defenses for reducing risk, preventing incidents, and improving overall system reliability.

The HPR Review

The HPR Review is the process for evaluating the human factors that may contribute to incidents. It involves the following steps:

  • Designate and train a site-level HPR Team. Not all incidents undergo an HPR Review. This team sets the HPR Review threshold, which may be adjusted over time.
  • Establish the HPR Profile. The Profile creates a standard set of data that will be used to conduct the HPR Review.
  • Set up HFIT™. Kestrel’s software will allow the team to compile an inventory of site-specific controls (e.g., work instructions, SOPs, checklists) and load the list of controls into HFIT™.
  • Conduct the HPR Review. Using the HPR Profile, the HPR Team collectively answers the HPR questions to assess the incident, loads responses into HFIT™, and links them to specific controls. Not all questions will be applicable to every incident.

Outputs of the review include:

  • Behavioral and contributing factors
  • Existing and/or non-existing controls
  • Determination of significance (random chance or systemic factor)
  • Prioritized list by likelihood of systemic factors

Individual incident review and summary reports provide information for making immediate local improvements. Multiple reviews provide enough data to enable general assumptions. Aggregated reviews, then, provide the data required to analyze for patterns and trends. Finally, the application of inferential statistics determines significance and provides prioritization.

Through this data and analysis, HPR helps companies determine where to focus efforts and resources by:

  • Identifying which procedures are contributing to incidents
  • Helping to remove the “gut feel” of where help is needed
  • Distinguishing the specific human factors that are related to each of the identified procedures

Submitted by: A.W. Armstrong

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