MTO – a system safety view

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Human and organizational factors in accident and incident investigation – What are they and how can we find them?

Lena Kecklund Uppsala Universitet April 4th 2011

Who are we?

Consultancy and research in risk prevention concerning

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the interaction between

• HuMans (M)

• Technologies (T)

• Organisations (O)

The lecture

Human and organisational factors, what are they?

• The MTO concept Wh i it i t t?

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• Why is it important?

• How can it be applied in accident and incident investigations?

• Examples

• Discussion

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MTO – design for humans and useability!

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Design Kowledge

Goals

MTO – influences on human behavior

Technology and equipment Rules and practices

Organisation

Humans Technology

Psychology

Physiology

Attitudes and values Work environment

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gy q p

Communicaton Education and training Housekeeping

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MTO – a system safety view

HuMans

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Technologies Organisations

MTO > M + T + O

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Human factors, Ergonomics, HuMans – Technology – Organisation

(MTO)

• Systematic application of knowledge on human behaviour to optimize the interaction

b h l i d

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between Humans, Technologies and Organisations

• To apply knowledge on human behaviour and a system safety view

MTO/Human factors

An example:

”All the ”people” issues we need to consider to assure the lifelong safety and effectiveness of a assure the lifelong safety and effectiveness of a system or organisation”

”Understanding Human Factors v1.0r”,RSSB,UK, 2006

Three Mile Island  M + T

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Tjernobyl  M + T + O

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Fukushima  M + T + O + O ?

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Discussion

Which MTO problems can you find in the next slide?

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How must humans adapt?

What can go wrong?

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Why accidents occur

(Reasons ”Swiss cheese” model)

Technologies

•Design

•Equipment

•Tools Organisation

•Rules and procedures

•Planning

•Training

•Communication

•Housekeeping

•Maintenance

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•Work environment

HuMans

•Competence

•Knowledge of task

•Motivation

•Work satisfaction

ACCIDENT

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What is wrong and why?

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www.csb.gov

Summary – What MTO is about

• System safety view

• Knowledge on human behaviour

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• Methods and tools

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Texas City 2005

• Discussion based on the film

• Film sequence approx 15 min

• Discuss

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•What happened?

•What were the causes?

•Look for M, T och O

Human and organisational factors in Human and organisational factors in

accident investigation

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Why do accidents and errors occur?

• Latent failures (in different parts of the system) creates error/producing conditions

• Unsafe acts och circumstances

• Problems in the interaction beteeween Man

T h l i d O i ti

Technologies and Organisation

• Lack of protection; barriers/defences or existing defences being broken

OFTEN COMBINATIONS IN WELL DEFENDED SYSTEMS

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Laws Procure-

ment G l

Right or

wrong? Accident

Organi- sation Manag-

Society Company Work- place

Person/

Group Barriers

Error- d i

Organisational accident causation model

Goals and demand

Errors and violations g

ment Culture Information Resources

producing conditions?

Laws Procure-

ment G l

Right or

wrong? Accident

Organi- sation Manag-

Society Company Work- place

Person/

Group Barriers

Error- d i

An example from the medical domain

Goals and demand

Errors and violations g

ment Culture Information Resources

producing conditions?

Legislation:

Secrets acts

Medical journal not available on a 24 h basis for all involved in treatment

Staff on night- shift duty do not have full information

Risk of making wrong prescription

No barriers

Society

• Law

• Regulators

• Norms

• Resource allocation

• Demands made in procurements

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Company

• Management system

• Quality control systems S ffi

• Staffing

• Shift schedules/Work hours

• Training/Knowledge

• Rules, procedures, work practices

• Responsabilities

• Culture

Technical resources

• Designed for usability?

• Gives right support for the task?

• Gives feedback?

Person

• Knowledge

• Experience and skill

• Motivation

• Alertness

• Stress

• Workload

• Attitudes

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Situational factors

• Time pressures

• Staffing too short

• High workloadg

Examples – Accidents in all areas of industry

• Nuclear; TMI, Chernobyl

• Oil; Piper Alpha

• Sea; Zebrugge Estonia

• Sea; Zebrugge, Estonia

• Railways; Clapham Junction, Kings Cross fire, Paddington, Åsta

• Medical; Radiotherapy accidents

Examples of causes or error- producing factors

• Time pressure

• Sleepiness/work hours

• Poor ergonomics

• High vigilance and mental demands

• Poor training

• Problems with rules and procedures (many varieties)

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Examples of causes or error- producing factors

• Work environment – untidy work place

• Problems in communication Hi h kl d d t

• High workload and stress

• Problems in planning and control

• Inadequate allocation of resources

• Management

• System goals incompatible with safety

How to perform an accident investigation? – Parts of the analysis

• Data collection Analyse:

• Events

• Deviations

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Deviations

• Causes

• Barriers

• Consequences

• Make recommendations/suggest safety enhancing measures

How to apply the MTO view in an investigation

• Understand the peoples actions in relation to the circumstances and the situation

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• Understanding based on knowledge from the behavioural sciences

• Understand the relation to managment and organisation

• Understand the relation to regulators and society

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Example: Investigation of incident

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Exempel: Tillbud med TP 101

Verktyg &

procedurer saknas Styrning;

ledning;

uppföljning

Litar inte på mätare

Bränsle slut i huvudtank Rutiner &

regler

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Flygning planeras

Landning med en motor Färdplanering

beaktar inte meterologiska förhållanden

Flygning med tyngre last &

under längre tid än planerat

Piloter tror att bränsle‐

mätare visar fel

Motorstopp på en motor saknas

Verktyg, procedurer &

kompetens

Utrustning: Bränslemätare ej reparerad Två motorer

Uppgift: Grundorsaksanalys

• Anna arbetar i en livsmedelsbutik

• Hon ska en tidig morgon med truck köra in en pall med tvättmedel från lastkajen till butiken

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• Leveransen ska köras in i butiken med truck. De brukar vara två men kollegan är sjuk – det går influensa på arbetsplatsen

• Anna måste väja för en kollega som kommit i vägen, kör på ett föremål & trucken välter

• Anna skadar armen

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Uppgift

• Datainsamling

– Hur och vad skulle ni vilja samla in?

• Händelseanalys

– Vad hände och i vilken ordning?

• Avvikelseanalys

– Vilka avvikelser fanns mot normala förhållanden?

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• Orsaksanalys

– Vad berodde avvikelserna på?

• Barriäranalys

– Vilka barriärer fanns, vilka brast och vilka saknades?

• Konsekvensanalys

– Vad hände och vad skulle kunna ha hänt?

• Rekommendationer/åtgärder

– Vilka åtgärder skulle ni vilja vidta och hur skulle dessa genomföras?

Exempel: Orsaks- och händelseanalys

Ovan att köra truck Ordning &

reda?

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Kör in lastpall i

butik

Truck välter;

skadad arm Kör truck

ensam

Kollega i

vägen Väjning Kör på

föremål Personal i

truckens körväg

Kollega sjuk Svårt att väja;

trångt?

Ordning &

reda?

MTO-analys

Direktorsak Grundorsak

Direktorsak Direktorsak

Grundorsak Bidragande

faktor

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Händelse 1 Händelse 2 Händelse 3 Händelse 4 Händelse 5 Konsekvens

Barriär Barriär Barriär

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The Columbia Accident Investigation Board

“In our view, the NASA organizational culture had as much to do with this accident as the foam. Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of an instituti n At th m st b sic l v l institution. At the most basic level, organizational culture defines the

assumptions that employees make as they carry out their work. It is a powerful force that can persist through reorganizations and the change of key personnel. It can be a positive and negative force.”

Columbia Space Shuttle,2003

Olyckan och påverkande förhållanden

Isolering lossnade vid återinträde i jordatmosfären Kultur och förhållningssätt i organisationen som påverkade

säkerheten negativt hade utvecklats, t ex

• Tidigare tillbud hade inte bedömts som tillräckligt allvarliga

• Förlitade sig på tidigare framgångar – satte mindre tilltro till nya bedömningar och beräkningar

• Organisationens utformning förhindrade effektiv kommunikation av viktig säkerhetsinformation

• Bristande samordning i ledningsfunktioner mellan olika delprojekt

• Informell lednings‐ och beslutsstruktur som inte följde de regler som fanns i organisationen

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MTO Säkerhet in accident investigations

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Investigations where we have particpiated

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Brand i t‐banevagn i Rinkeby (Publicerad 22 februari 2007 kl 10:01)

»Det var vid halv tio‐tiden på torsdagsmorgonen som tunnelbanestationen i Rinkeby fylldes med kraftig rök. Samtliga passagerare evakuerades och Rinkeby torg spärrades av. Dessutom fick flera lokaler och en skola utrymmas.«

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