Welcome to this introductory training course on Human Factors Analysis for the Oil and Gas Industry. This course will equip you with the knowledge to identify and analyze human factors contributing to incidents, unsafe observations, and near-misses, drawing on the structured approach of the Human Factors Analysis and Classification System. Module 1: Understanding Human Factors in Safety **1.1 What are Human Factors?** Human factors refer to the interrelationship between humans, the tools and equipment they use, and the environment in which they work. In the context of safety, human factors analysis helps us understand **why individuals or teams act the way they do** and how their actions are influenced by broader systemic issues. **1.2 Why is Human Factors Analysis Critical in the Oil and Gas Industry?** * **Human error remains a leading cause of mishaps** in many high-risk industries, including oil and gas. * Incidents and near-misses are rarely attributable to a single cause or just an individual's failure. Instead, they are often the **end result of a series of latent failures** and/or hazardous conditions influenced by flaws in the safety management system. These flaws can relate to training, resource support, policy, procedures, and/or supervisory functions. * Understanding these underlying causes, rather than just blaming the individual, leads to more effective prevention strategies and enhanced operational readiness. **1.3 Active Failures vs. Latent Failures/Conditions** The HFACS draws upon established concepts to categorize mishap causes: * **Active Failures**: These are the **last actions or inactions of the operator that were the immediate cause of the mishap**. They are most closely tied to the incident and are committed by the person directly involved. * *Oil & Gas Example*: An operator mistakenly opens the wrong valve, leading to a spill. * **Latent Failures or Latent Conditions**: These are **hazardous conditions that exist within the chain of command or elsewhere in the organization** which affected the sequence of events leading up to the active failure. They may lie dormant or undetected for extended periods before manifesting as a mishap. * *Oil & Gas Example*: An outdated procedure for valve operation that was not updated after a system upgrade. *** ### Module 2: Applying the HFACS for Incident Analysis The HFACS provides a structured, data-driven approach to analyzing human error. It involves a four-step process: **Step 1: Determine all factors that caused the mishap** This step involves piecing together the sequence of events to understand "what happened" and then identifying all anomalous events and the layers of conditions that allowed them to occur. This is achieved by applying a cause-and-effect mapping process to determine "why the mishap occurred or why the individual failed". As safety personnel, you should ask the following questions to assess human factor causes: * "What was the active failure committed by the mishap person/operator to cause the mishap?" [7a] * "Did the mishap person/operator have any physical or mental conditions that negatively influenced his/her performance?" [7b] * "Did conditions in the operating environment negatively influence the mishap person’s performance?" [7c] * "Was there a gap in either unit or institutional training that negatively influenced the mishap person’s performance?" [7d] * "Was the mishap person’s performance influenced by one or more supervisor’s/leader’s decisions, directives, actions or inactions within the command?" [8e] * "Was there a breakdown in communication among team members that negatively influenced the mishap person’s performance?" [8f] * "Did a lack of resource support negatively influence decisions or actions of the mishap person’s supervisory chain and the mishap person’s performance?" [8g] * "Did a lack of effective written standards negatively influence decisions or actions of the mishap person’s supervisory chain and the mishap person’s performance?" [8h] #### 2.1 Identifying Unsafe Acts (Active Failures) Unsafe Acts are the actions or inactions of the operator that directly result in human error or an unsafe situation. They are divided into two main categories: Errors and Known Deviations. **A. Errors (Unknown and/or Unintended Deviations)** Errors occur when the individual's mental or physical activities fail to achieve their intended outcome. They are classified as either Performance-Based errors or Judgment and Decision-Making errors. * **Performance/Skill Based Errors**: These errors occur during the execution of routine or highly practiced tasks. * **AE101 Unintended Activation or Deactivation**: An individual inadvertently activates or deactivates equipment. * *Oil & Gas Example*: A technician accidentally hits an emergency shutdown button while reaching for another control on a pipeline manifold. * **AE102 Procedure or Checklist Not Followed Correctly**: The individual did not follow the correct procedure, checklist, technical manual, or Standard Operating Procedure (SOP). * *Oil & Gas Example*: A maintenance worker omits a crucial step in the lockout/tagout procedure for a compressor during maintenance, leading to an accidental startup. * **AE104 Over-Controlled/Under-Controlled Aircraft/Vehicle/Vessel or System**: The individual inappropriately reacted to conditions by either over- or under-controlling a system. * *Oil & Gas Example*: A driller applies too much pressure or too little during a critical drilling operation, causing equipment damage or loss of well control. * **AE107 Rushed or Delayed a Necessary Action**: The individual performed a correct action too quickly or too slowly. * *Oil & Gas Example*: An operator delays activating a flare system during an overpressure event, exacerbating the situation. * **AE108 Misinterpreted/Misread Instrument**: The individual misread, misinterpreted, or failed to recognize the significance of an accurate instrument reading. * *Oil & Gas Example*: A control room operator misreads a pressure gauge on a storage tank, leading to overfilling. * **Judgment and Decision-Making Errors **: These errors occur when an individual pursues an inappropriate course of action after failing to accurately assess a situation. They are unknown deviations during diagnostic or problem-solving tasks requiring conscious effort. * **AE201 Inadequate Real-Time Risk Assessment/Action**: The individual selected or proceeded with the wrong course of action based on an ineffective real-time assessment of immediate hazards. * *Oil & Gas Example*: An offshore worker decides to bypass using a required safety harness for a quick task at height, misjudging the immediate risk. * **AE202 Ineffective Task Prioritization**: The individual did not effectively organize and accomplish required tasks. * *Oil & Gas Example*: A control room operator fails to prioritize a critical gas leak alarm over a minor equipment malfunction alarm during a busy shift. * **AE205 Ignored a Caution/Warning**: The individual disregarded an accurately perceived and understood caution or warning. * *Oil & Gas Example*: A technician ignores an audible alarm indicating high H2S levels, believing it to be a false alarm due to prior similar incidents. * **AE207 Misjudged/Misperceived Changing Environment**: An individual misperceived or misjudged operational conditions such as road/sea conditions, separation, or clearance. * *Oil & Gas Example*: A crane operator misjudges the wind speed and direction while lifting heavy equipment on an offshore platform, leading to loss of control. **B. Known Deviations ** Known Deviations are **known, intended, and deliberate deviations** from standards, rules, regulations, instructions, or procedures, where the negative outcome was unintended. * **Performed Known Deviation (Work-Around)**: The individual disregarded published policy/guidance/procedure to pursue what they believed was the best course of action based on available information for a real-time risk decision. * *Oil & Gas Example*: A pipeline technician uses an unapproved "work-around" to repair a small leak faster, believing it's the most efficient way given limited resources and time, despite bypassing safety protocols. * **AD002 Commits Widespread/Routine Known Deviation (Normalization of Deviance)**: The individual violated a published standard based on unofficial, accepted unit or community practices that are routine or widespread. * *Oil & Gas Example*: On a drilling rig, it's common practice for workers to routinely operate certain equipment slightly above its rated capacity because it saves time, and disciplinary action has never been consistently applied. * **Extreme Lack of Discipline (Indiscipline)**: The individual was trained to standard, knows the standard, but elected not to follow it without cause or need. * *Oil & Gas Example*: A worker intentionally disables a safety interlock on a piece of machinery simply because it's inconvenient to follow the full safety procedure, despite knowing the risks. #### 2.2 Identifying Preconditions to Unsafe Acts Preconditions are conditions affecting the performance or actions of the individual that resulted in unsafe acts, stemming from individual lifestyle behaviors, supervisor/leader influences, organizational influences, or a combination. At least one precondition will accompany each unsafe act. **A. Mental Awareness Conditions ** These involve failures in attention management that negatively affected the individual's perception and/or performance. * **Inattention**: The individual did not maintain readiness or alertness to properly act upon available information. * *Oil & Gas Example*: A control room operator on a long, uneventful night shift becomes inattentive and misses a critical trend indicating a developing problem in the process. * **Fixation (Channelized Attention)**: The individual focused all conscious attention on a limited number of cues to the exclusion of others. * *Oil & Gas Example*: A worker troubleshooting a pump failure becomes so fixated on a specific part of the pump that they fail to notice a rising liquid level in an adjacent tank. * **Task Saturation**: The quantity of information an individual was processing exceeded their mental resources in the amount of time available. * *Oil & Gas Example*: An operator dealing with multiple simultaneous alarms during an upset condition becomes overwhelmed, leading to errors in responding to the most critical issues. * **PC106 Distraction/Interruption**: The individual had an interruption or inappropriate redirection of attention. * *Oil & Gas Example*: A technician performing a delicate repair is interrupted by a non-urgent radio call, causing them to forget a step in the procedure. * **Change Blindness/Inaccurate Expectation**: An individual’s expectations contributed to not perceiving a change or to false interpretation of perceived stimuli. * *Oil & Gas Example*: An inspection team overlooks a corroded pipe section because they expect the piping in that area to be relatively new and therefore not problematic. **B. State of Mind Conditions ** These relate to psychosocial problems, life stressors, personality traits, or misplaced motivation. * ** Life Stressors/Emotional State**: The individual's emotional state and/or life circumstances degraded performance. * *Oil & Gas Example*: An engineer experiencing severe family issues is distracted and makes a calculation error in a design review. * ** Overconfidence**: The individual unreasonably overvalued or overestimated their own capability, or the capability of equipment. * *Oil & Gas Example*: An experienced rig supervisor, feeling invincible, performs a lifting operation without checking the load weight, confident in their ability to "eyeball" it. * ** Pressing, Haste, Motivation**: The individual's motivation to complete a task was misplaced, or they knowingly pressed themselves and/or equipment beyond reasonable capabilities. * *Oil & Gas Example*: A crew rushes a well completion operation to meet a tight deadline for production, leading to the omission of a critical safety check. **C. Adverse Physiological Conditions ** These occur when an individual experienced a physiological condition that compromised performance. ** Substance Effects**: Use of authorized or unauthorized substances negatively affected performance. * *Oil & Gas Example*: A worker uses over-the-counter medication that causes drowsiness, leading to slow reaction times during an emergency. * ** Physical Illness/Injury**: Pre-existing or operationally-related medical conditions negatively affected performance. * *Oil & Gas Example*: A worker experiencing dehydration from working in extreme heat makes a mistake due to impaired cognitive function. * ** Fatigue**: Acute or chronic sleep deprivation or circadian rhythm disruption negatively affected physical and/or mental performance. * *Oil & Gas Example*: An offshore platform worker on a 14-hour shift, after several consecutive nights of poor sleep, makes a critical error during a complex system restart. * ** Spatial Disorientation**: The individual failed to sense correctly a position, motion, or attitude of themselves or equipment, leading to misjudgment. * *Oil & Gas Example*: A diver working in murky water misjudges their depth or orientation relative to the pipeline, leading to an unsafe maneuver. **D. Environmental Conditions ** These include both the physical and technological environment that affected individual or team performance. * **Physical Environment **: Conditions in the immediate physical surroundings. * **Environmental Conditions Affected Vision**: Conditions like fog, rain, or dust impeded clear viewing/vision. * *Oil & Gas Example*: Dense fog on an offshore rig severely limits visibility for a helicopter landing, leading to a near-miss. * ** Temperature Affected Performance**: Ambient/workspace temperature negatively affected performance. * *Oil & Gas Example*: Extreme heat in a refinery's processing unit causes workers to suffer from heat stress, affecting their concentration and physical dexterity. * ** Noise Interference**: Unexpected sound not directly related to task information negatively affected performance. * *Oil & Gas Example*: Excessive noise from a nearby compressor station prevents a maintenance crew from hearing critical verbal warnings during a hazardous operation. * ** Terrain Feature Affected Performance**: Encountered known yet unanticipated or unseen/unknown terrain hazards. * *Oil & Gas Example*: A driver operating a vehicle on an access road fails to notice a large, hidden pothole due to overgrown vegetation, causing an accident. * **Technological Environment **: Workspace design conditions or automation affecting individual actions. * ** Instrumentation and Warning System Issues**: Instrument or warning system elements negatively affected performance. * *Oil & Gas Example*: A faulty gas detector on a platform gives intermittent false alarms, leading to "alarm fatigue" where operators eventually ignore a real warning. * ** Automated System Created a Hazardous Condition**: Design, function, reliability, or other aspects of automated systems negatively affected performance. * *Oil & Gas Example*: An automated well control system malfunctions due to a software glitch, causing an unintended pressure surge in the wellbore. **E. Team Coordination/Communication Condition (PP100)** Refers to verbal or non-verbal interactions among crews/teams involved in task preparation and/or execution. * ** Ineffective Team Resource Management**: Crew/team members failed to maintain an accurate and shared understanding of the evolving task or manage task distribution. * *Oil & Gas Example*: During a critical well intervention, miscommunication between the drilling supervisor and the subsea engineer leads to uncoordinated actions. * ** Task/Mission Planning and/or Briefing Inadequate**: An individual, crew, or team failed to complete all preparatory tasks associated with planning or effective briefing. * *Oil & Gas Example*: A pre-shift safety briefing on an oil rig omits critical information about a recent equipment malfunction, leaving the next shift unaware of a potential hazard. **F. Training Conditions ** When formal or informal instruction, skill development, or knowledge limits the individual's capability or performance. * ** Untrained Operator/Worker**: The individual did not receive adequate/sufficient training for a specific task. * *Oil & Gas Example*: A newly hired worker is assigned to operate complex refinery equipment without having received specific "on-the-job" training for that particular system. * ** Knowledge Retention**: The mishap person did not remember information from training and/or previous experience necessary to complete a task safely. * *Oil & Gas Example*: An experienced safety officer fails to recall a specific emergency response protocol during a mock drill, despite having received training on it years ago. * Lack of Currency**: An individual’s familiarity with a specific task or process was not current or was limited by infrequent performance. * *Oil & Gas Example*: An offshore medic, who is trained but rarely performs advanced life support procedures, struggles to effectively manage a severe injury due to lack of recent practice. * ** Lack of Job/Work Related Safety Training**: An individual had not received required or effective safety training related to job hazards or changes in processes/equipment. * *Oil & Gas Example*: A maintenance team is not provided with specific safety training for a new type of high-pressure cleaning equipment they are about to use. #### 2.3 Identifying Ineffective Supervision/Leadership (Latent Failures) This tier encapsulates longstanding actions or inactions, methods, or directives of any supervisory/leadership personnel within the unit that created hazardous practices or conditions. This includes everyone from the immediate supervisor to the commanding officer. **A. Ineffective Unit Safety Culture ** Occurs when the unspoken or unofficial rules, values, attitudes, beliefs, and customs of small unit leaders or their higher organization negatively affected adherence to safety standards. * **SC101 Unit Safety Culture**: Explicit or implicit actions, statements, attitudes, or values of supervisors/leaders fostered an environment where demands or pressures resulted in hazardous conditions or unsafe acts. * *Oil & Gas Example*: On a particular rig, the management consistently minimizes near-miss reports, fostering a belief among the crew that reporting incidents is not truly valued. * **SC102 Pace of OPTEMPO/Workload**: The pace of primary duties, additional duties, training, or other workload-inducing conditions created hazardous conditions. * *Oil & Gas Example*: A drilling team is consistently pushed to meet aggressive production targets, leading supervisors to implicitly encourage or allow shortcuts to be taken. **B. Supervisory Known Deviation (SD000)** Factors when a supervisor/leader willfully disregarded instructions, guidance, policies, rules, or SOPs. * **SD001 Failure to Enforce Published Rules/Guidance**: A supervisor/leader failed to ensure personnel adhered to published rules or knowingly allowed untrained individuals to perform tasks. * *Oil & Gas Example*: A supervisor observes workers on a platform not wearing their required personal protective equipment (PPE) but chooses not to enforce the rule. * **SD002 Allowed Unwritten Practices to Become Standard (Normalization of Deviance)**: A supervisor/leader chronically condoned the use of unwritten/unofficial procedures by subordinates. * *Oil & Gas Example*: The shift supervisor on a refinery consistently allows operators to bypass a specific safety interlock because "it's quicker" and "everyone does it," turning a deviation into an accepted practice. * **SD003 Directed Individual to Circumvent Existing Regulations, Rules, or Procedures**: A leader/supervisor directed a subordinate to circumvent existing procedures. * *Oil & Gas Example*: A drilling manager, facing pressure to complete a well, explicitly tells a junior driller to skip a non-critical but required safety test to save time. **C. Ineffective Supervision (SI000)** Supervisory/leadership personnel failed to properly identify and assess hazards, mitigate risks, ensure personnel are effectively trained, and/or provide effective guidance and oversight. * **SI001 Ineffective Supervisory or Command Oversight**: The availability, competency, quality, or timeliness of supervisor/leader oversight did not meet task or mission demands. * *Oil & Gas Example*: A maintenance supervisor fails to conduct a pre-work inspection of rigging equipment before a heavy lift, assuming the crew had checked it. * **SI003 Failed to Provide Effective Training**: Supervisors/leaders failed to provide effective training to ensure personnel competency and proficiency for a specific task. * *Oil & Gas Example*: A site manager does not ensure that new technicians are adequately trained on the specific emergency response procedures for handling a gas leak unique to their facility. * **SI007 Failed to Identify or Correct Hazardous Practices, Conditions or Guidance**: Any supervisor/leader failed to identify or correct known hazardous conditions or unsafe work practices. * *Oil & Gas Example*: A supervisor notices a corroded walkway on an offshore platform but fails to report it or take immediate action to barricade the area. * **SI008 Tasked Individual(s) with Lack of Experience, Currency or Proficiency**: A supervisor/leader inadvertently tasked an individual or team whose fluency or expertise did not match skills required for safe execution. * *Oil & Gas Example*: A supervisor assigns a relatively inexperienced worker to a complex and high-risk repair on a subsea pipeline, unaware of the worker's limited proficiency in that specific task. **D. Ineffective Planning and Coordination (SP000)** Factors when unit leadership failed to effectively utilize risk management processes to assess hazards and develop effective controls. * **SP006 Ineffective Deliberate Risk Assessment**: Supervision/leadership did not effectively apply DoD risk management procedures during planning. * *Oil & Gas Example*: During the planning phase for a major well intervention, the leadership's risk assessment overlooks potential environmental impacts of a chemical spill. * **SP010 Unit Failure to Provide Sufficient Manning/Staffing**: Unit/ship or installation planning processes failed to meet staffing demands or continuity of operations. * *Oil & Gas Example*: A refinery operates with a reduced staff on a holiday weekend, leading to an excessive workload on the remaining operators and delaying their response to an alarm. * **SP011 Unit Failure to Provide Sufficient Equipment or Supplies**: Unit/ship or installation level leaders failed to ensure personnel received all necessary equipment and/or supplies to implement risk control measures. * *Oil & Gas Example*: A confined space entry team is dispatched without fully functional ventilation equipment because the unit failed to ensure its availability. #### 2.4 Identifying Organizational Influences (Latent Failures) These are fallible processes of higher-level organizations that directly affect unit leader/supervisory practices or conditions and actions of operators. They can include major command, service, or DoD-level policies, oversight, acquisition processes, resource management, and formal training programs. **A. Organizational Climate/Culture (OC000)** Where the unspoken or unofficial rules, values, attitudes, beliefs, and customs of organizational level leadership negatively affected lower-level working environments or practices. * **OC001 Organizational Culture (attitude/actions) Created Increased Risk**: Explicit or implicit actions, statements, or attitudes at an organizational level facilitated an environment where demands or pressures existed, resulting in hazardous conditions or unsafe acts throughout subordinate units. * *Oil & Gas Example*: The corporate headquarters prioritizes cost-cutting above all else, putting immense pressure on regional managers to reduce budgets, which indirectly leads to less safety training or deferred maintenance. **B. Organizational Policy, Procedures, or Process Issues (OP000)** Flaws in an organization's safety management system (standards, policies, procedural guidance, doctrine, processes, or governance/program management) that negatively influenced leader/supervisory or individual performance. * **OP001 OPTEMPO/Workload**: Workload-inducing conditions on subordinate units created hazardous conditions for unit commanders and supervisors. * *Oil & Gas Example*: The corporate scheduling department consistently sets unrealistic production targets for all drilling operations, leading to unit-level pressure to work excessive hours and rush tasks, increasing risk. * **OP003 Provided Unclear, Impractical, or Inadequate Policy, Procedural Guidance or Publications**: Written standards were impractical, too vague/unclear, incorrect, or ineffectively disseminated. * *Oil & Gas Example*: The company-wide safety policy for managing hydrogen sulfide (H2S) is written in highly academic language, making it difficult for field operators to understand and implement practical safety measures. **C. Resource Support Problems (OR000)** When resource support or system safety inadequacies resulted in ineffective risk management or created hazardous conditions. Resources include personnel, equipment, materiel, supplies, services, and/or facilities. * **OR004 Purchasing or Providing Poorly Designed or Unsuitable Equipment**: Inadequacies in the acquisition and/or fielding of materiel. * *Oil & Gas Example*: The procurement department purchases new pipeline inspection drones that are not suitable for the extreme temperatures found in a specific desert operating environment. * **OR007 Failure to Provide Adequate Personnel/Staffing Resources**: The process through which personnel resource allocations, staffing, or placement processes are inadequate for mission demands. * *Oil & Gas Example*: Company-level staffing decisions lead to critical shortages of certified welders in a particular region, causing delays in essential maintenance and increasing the workload on the remaining staff. * **OR009 Failure to Provide Adequate Funding**: Subordinate organizations or an operation do not receive the financial resources to complete assigned missions/tasks. * *Oil & Gas Example*: Budget cuts from corporate headquarters lead to a lack of funds for necessary upgrades to obsolete safety equipment on an aging offshore platform. **D. Training Programs (OT000)** When a training and/or educational program of instruction is incorrect, incomplete, or insufficient for performance to standard. * **OT001 Resident Formal School Training Program is Ineffective or Unavailable**: Formal school training is incorrect, incomplete, insufficient, or unavailable for performance to standard. * *Oil & Gas Example*: The formal industry-wide training program for well control (a resident course) has not been updated to reflect new drilling technologies, leaving operators unprepared for modern challenges. **Step 2: Determine relationships between each causal factor** Once factors are identified, establish which latent failures directly affected the individual's active failure or indirectly contributed by creating hazardous conditions. Remember, some latent failures may not directly contribute to the unsafe act but may have contributed to the severity of injury or damage. Think cause and effect: "Did this supervisory and/or organizational code have any influence on one or more preconditions to the unsafe act?" and/or "Did this supervisory and/or organizational code have any influence on a severity of injury or damage?". **Step 3: Apply DoD HFACS codes to all identified active and latent failure causes** This is the coding phase. Use the questions provided in the HFACS document to guide your choice of the most appropriate codes. * **Useful Tip**: Avoid distractions and "rabbit holes". Focus on the evidence. Don't be afraid to consult other safety personnel or Human Factors experts if confused. Be willing to review and eliminate codes that don't fit well, focusing on those that support identified causal factors and require recommendations for corrective actions. **Step 4: Write a supporting statement for each selected code** For every code selected, an **evidence-based description** for the code's relationship to the causal factor must be included in the mishap report. This is crucial for developing effective recommendations. If you have difficulty writing a supporting statement, the code is likely not applicable, or you need to revisit the evidence.