ARE YOU APPLYING

HUMAN FACTORS / HUMAN

PERFORMANCE AS PER
THE INDUSTRY GUIDANCE?
PART 1

CONTENTS:

1. Message from the Chairman of Human 5. HF / HP in risk assessment

Factors Technical Section
6. HF / HP in pro-active learning
2. What do you need to know first?
7. Behavior-Based Safety
3. HF / HP in incident investigations
8. HF / HP in accountability
4. HF / HP in procedure management

1
 1. Message from the Chairman of
Human Factors Technical Section
It has been an honor and privilege to have served as the Chairman of the
SPE Human Factors Technical Section.
Human Factors and Human Performance (HF/HP) continue to grow
in importance and recognition in the oil and gas industry and, despite
volumes of written technical reports available, there is scarcity of hands-
on material that enables meaningful progress for practitioners without
employing experts or consultants.
I am privileged to be in a position to develop many aspects of the
existing industry guidance based on combining years of successful
application of HF / HP in large organisations based on modern, science-
based insights.
One of the challenges to the practical implementation of HF / HP is that
it means so many things for many people, making it difficult to be sure
we are actually talking about the same thing. The wealth of concepts
and models becomes a barrier for progress.
This series aims to simplify navigation of the HF / HP.

HF / HP in pre-qualification questionnaires and contractual language

In 2017, I envisioned that HF / HP should be set as a contractual expectation and be part of the contract
pre-qualification, in the same way as having a safety management system is. I also wrote the very first draft of those
questions.
Four years later, I am delighted to see that, albeit with some modifications, a few of those questions are now live in the
UK SEQual system.
SEQual, the oil and gas industry contract pre-qualification platform (https://sequal.co.uk/), has now published seven
questions focused on demonstrating the practical application of Human Factors and Human Performance. This
means that any company wishing to bid for work in the UK oil and gas industry has to demonstrate how they integrate
HF / HP into their organisation.
Another important implication is that the major oil and gas operators are likely to apply these HF questions globally in
their respective “Request for Proposal” and prequalification questionnaires. One major operator has already done so.

The SEQual HF questions are:

1. Do you have a documented human factors/human 4. Please explain how your organisation integrates
performance policy? human factors/human performance into control of
a.If yes, please provide a copy of your policy. work, risk assessment and job planning.
b.If yes, please explain how your policy is 5. Please explain how you proactively identify and
implemented. address factors that increase the likelihood of human
error or procedural violations.
2. Please explain how your organisation integrates
human factors/human performance into your 6. Please explain your organisation’s approach to
management systems, procedures and work packs. behavioural safety or behaviour-based safety
program and how it is implemented.
3. Please describe how your organisation integrates
human factors/human performance into incident 7. Please explain how your organisation manages
investigations. inadequate performance or unacceptable behaviour
from your direct and indirect workforce.

SEQual is the UK-based contract pre-qualification platform where suppliers only have to fill in one questionnaire to
provide their capabilities to a range of potential customers, and buyers can expect to simplify and speed up their
search, validation and purchasing decision processes considerably, improving resource and cost efficiency.
The questions may evolve over time. This set of questions is valid on 20 July 2021.
2
2
Purpose of this document and who it is for?
The primary purpose of this document is to allow HSE professionals who provide answers to the pre-qualification
questionnaires to quickly establish if their companies apply human factors / human performance as per the industry
guidance.
Secondly, this guidance may be used by anyone who wishes to quickly get an insight into the industry guidance,
without reading dozens of reports.

Application of HF / HP can feel daunting at first, and so we also want to build a community to provide an ongoing
support and create space where people can ask all questions and have answers using company expertise, rather than
relying on external HF consultancy.

3
 2. What do you need to know first?
Without these basics, the rest of the document may not be meaningful.

Figure 1 What’s the difference between Human Factors and Human Performance?

What is Human Performance / Human Factors?

What people do is
Human Performance is influenced by a range
about what people do of factors, we call these
and how they carry out Human Factors or
their tasks Error Traps

SOCIAL PSYCHOLOGICAL

ORGANIZATIONAL PHYSICAL

Technical Definition:
Human factors is a multidisciplinary effort to generate and compile information about human capabilities and limitations
and apply that information to equipment, systems, software, facilities, procedures, jobs, environments, training, staffing,
and personnel management to produce safe, comfortable, and effective human performance.
FAA, System Safety Handbook, Chapter 17: Human Factors Principle & Practices, 2000

People are only one component of a multi-faceted “system”. Our workplaces are complex and ever-changing, so
there are many systemic issues that can get in the way of human performance. This understanding of organisational
effectiveness is fundamental to our ability to learn.

Human Factors also refers to the discipline of practice and science that combines insights from engineering
psychology, medicine, computer sciences, social, organisational and industrial psychology and many others, currently
represented globally by over 70 professional bodies and driven by scientific research translated into practical tools
and solutions.

What are Error traps?

An error trap is any condition that increases the chances of mistakes or sets people up for failure.

What are organisational factors?

Organisational factors are the processes further up in the organisation that create error traps.

NOTE: The term “Human Factors” does NOT mean :

Behavioural safety Employee engagement

Human nature Everything to do with people

4
Table 1 Examples of error traps and organisational factors.

Examples of error traps: Examples of organisational factors:

Complex or badly presented procedures. Procedure management processes

Poorly designed equipment. Competence management systems and processes
Unusual, infrequent, unfamiliar or novel situations. Staffing
Difficult system or equipment interface, labelling, Workload management
controls, alarms. Planning
Boring, trivial or repetitive actions. Financing resources
Steps where there might be insufficient time Change management
available.
Procurement processes
Unclear signs, signals, instructions or other
information. Conflicting priorities
Difficult working environment (noise, heat,
cramped conditions, lighting, ventilation, ease of
access).
Potential for interruptions or distractions.
Multitasking.
Fatigue, stress, workload.
Competency, knowledge of rules etc.

How are error traps different from hazards?

A hazard is a potential source of harm e.g. pressure, spill, hot surface etc. However, things such as “visual similarity of
buttons,” “not enough time to complete the job,” or “staffing arrangements,” are difficult to be classified as a source of
harm. Therefore, error traps and organizational factors are a different category of factors that increase the likelihood
of mistakes or doing something different from expected.

If you would like to learn the basics of Human Factors, please watch this webinar presented for the UK Institution of
Occupational Safety and Health (IOSH):

Click Here to

Watch

Have questions about HF / HP but nobody to ask?

Get personal support from
It all feels overwhelming?
Dr Marcin
You don’t know where to start?

5
 3. HF / HP in Investigations
SEQual question: Please describe how your organisation integrates human factors/human performance
into incident investigations.
HF / HP in incident investigations consists of a set of tools and processes to explain why somebody
did something. It is part of the incident investigation process specifically focused on explaining how
organisation influenced the context so that people actions made sense to them at the time.
Take your last five investigations and look at the findings and recommendations. Compare them with the
list below:
Table 2 Indications of good / insufficient integration of HF / HP with the incident investigation process.
Source: CIEHF / EI Human Factors in Investigations Toolkit. https://bit.ly/3z46EgO
You are doing it! You are not quite there

Your investigation reports provide insights on: Your investigation report claim that:
1. Error traps 1. There was one root cause
2. Organisational factors (why error traps were there) 2. The cause was:

3. Dependencies between individuals and teams Human error

4. Implications of alternative choices Human behaviour
Procedural non-compliance
5. Rich description allowing the reader to appreciate
the context and situation 3. Use judgemental labels, e.g.

6. Behavior / decisions of multiple people explained Complacency

including supervisors, engineers etc. Recklessness
7. Corrective actions are mainly engineering / Laziness
process focused Type of bias, e.g. overconfidence
4. Focused only on what the person didn’t do, or
should have done
5. Corrective actions are mainly behavioural or
administrative

Table 3 Example of output. Investigation report narrative.

Source: CIEHF / EI Human Factors in Investigations Toolkit. https://bit.ly/3z46EgO

How to report an unfolding mind-set

An incident: Narrative to consider:

An operator using a new pipe cutting The operator had 16 years of experience at the time of the incident. Traditionally, the pipes
machine trapped and badly injured were cut manually, however as the company grew and needed to process 4 times more pipes,
their hand whilst reaching in to 3 years ago the management decided to build a new production line with multiple working
stations across the shop floor responsible for different stages of the manufacturing process.
retrieve the pipe.
As the new machines were installed on the shop floor, the operators were trained on the use
Narrative to avoid: of the machines. Training was delivered by a qualified trainer, and the participants had to
demonstrate the 100% conformance to the operating procedures. The new machines had
The operator failed to conduct advanced mechanisms of protecting the users including proximity sensors and interlocked
a pre-check to identify if the machine guards which switched off the machine if a hand was close to the moving part. The side
had an interlock. effect of this solution was that due to the design of the machine it was quicker to use the
interlocked guard than to switch the machine off, remove the pipe, and start it again.
The operator ignored the sign placed
in the coffee area to not put their 6 months before the incident, the manufacturer of the machine went bankrupt.
hands close to moving machinery 2 months before the incident the machine broke and could not be replaced by the same
parts. model. The company had to find a new supplier urgently due to a building order backlog. The
newly identified machine had similar specification but no interlocks in place.
The operators were informed that they will be working on the same model of the machine as
previously.

6
Table 4 Example of Output. Depth of the investigation. Focus on error traps (equipment design, training) and
organisational factors (procurement process).
Source: Energy Institute, (2008), Guidance on Investigating and Analysing Human and Organisational Factors Aspects
of Incidents and Accidents, see also more recent IOGP report 621: http://bit.ly/2JaBh9T

ANALYSIS MORE EFFECTIVE DEPTH

Level 1 Level 2 Level 3 Level 4 Level 5

Operator is to blame Operator believed Operator had already The machine was The machine was
for reaching into the that lifting the guard received training, not fully tested needed quickly,
machine whilst still would disable the the machine used before being put to the procurement
switched on. machine. in training was use. process did not
interlocked. require the machine
purchased to have a
safety interlock.

FOCUS OF RECOMMENDATIONS MORE EFFECTIVE IN PREVENTING REOCCURRENCE

Discipline the Re-train the operator Operator training Amend the Amend the
operator. in all aspects of should be procedure for procurement
operating the completed on the introducing new procedure to include
machine. specific machine equipment into the a thorough risk
they will be expected workplace to include assessment process
to use on site. provision for pre use for equipment
testing and safety selected for
checks. purchase.

If you’d like to see an example of a human factors analysis applied to a dropped object incident, please watch this
webinar presented for the Human Performance Oil and Gas (HPOG)

Click Here to

Watch

7
 4. HF / HP in procedure management
SEQual question: Please explain how your organisation integrates human factors/human performance
into your management systems, procedures and work packs.
Note: The word “Procedures” is used as a synonym of “work instructions” also called “Standard Operating
Procedures” (SOPs), i.e. documents which describe how to complete a task step by step. These are
typically used by the front-line/shop floor employees. In this context, we are not talking about Management
System procedures and policies.
There are many genuine reasons why people do not follow procedures. Most of the time, this has
something to do with:
1. The document itself, e.g. out of date or unworkable in practice;

2. Usability / accessibility, e.g. difficult to find the right procedure;

3. Procedure management system, e.g. four procedures with conflicting instructions for the same activity.

Table 5 Good practices in developing operational procedures.

Source: HSE Guidance to revitalising procedures https://www.hse.gov.uk/humanfactors/topics/procinfo.pdf

YES – You are NO – You are not

Are you doing it? doing well quite there

1. When you write rules and procedures, employees who will be

✔
using those documents are involved in all stages of the effort.

2. Procedures are based on how the task is actually performed.

✔
Task analysis technique is used.

3. Better ways of performing the task devised by the operators

are integrated into the formal procedure.

4. Shortcuts are seen as behaviors incentivised by the work

arrangements. Those incentives are identified and addressed.
5. There is a control and review process in place to keep
procedures relevant and up-to-date.

6. Operators say that procedures are easy to use, navigate, and

understand.
7. Operators say that procedures are easy and quick to access.

8. Procedures are connected to training and competency

management. Updates to procedures are reflected in the
updated training.

9. Procedure management system ensures there are no

conflicting instructions/requirements or multiple procedures
covering the same topic.

8
Figure 3 Example. An excerpt from a procedure shut down compressor procedure. Formatting considerations are
highlighted
Source: CIEHF / EI Human Performance Competency Pathway. Module: Procedures.

K-1 Shutdown
Initiator(s): Any APS Crew Member Can Initiate a Procedure

Purpose: Shut down K-1 Refrigeration Compressor for conditions such as:
Concise purpose of Production rate reduction (K-1 is higher capacity than K-1A)
Why this SOP applies Maintenance and Inspection
Steam reduction or outage

Safety and
Environmental Rotating equipment
Unique and specific Precautions:
hazards noted Thermal burns (Steam and Condensate)

Noise
Hazard Icons used
(per the HITRA std) Egress limitations

References: P&ID of Alkylation Unit / K-1 Compressor System

Critical reference
K-1A Start-up and Operating Procedure
docs expected
to be used PEMP
Out of Service Shelving Alarm Tool

Steps in “Any Order” vs. Pre-K-1 Shutdown (in any order)

“In Sequence
Date Initial
1. OSB VERIFY K.1 Triconex is in “AUTO” mode
State by Who? OSB, (not in the Maintenance mode)
OSF or OO *** Is Maintenance” mode the right term? Or MAINT? **
ACTION VERB first:
Consistent use and 2. 00: VERIFY K-1 quench valve TV46620 is unblocked and in service.
definition for verbs 00: If not in service, then UNBLOCK and COMMISSION TV46620.
Improvement areas Improvement LABEL TV46620 IN THE FIELD
noted for field labels
K-1 Shutdown (completed in sequence)
Specific Eqpt and Instr
tag #s, with 3. OSB: REDUCE BB total feed rate (F46104 and F46104A) to the unit to
specific rates 380 to 400 BPH.
4. OSB REDUCE K-1 speed to 2500 RPM.
NOTE: Load from K-1 will shift to load K-1A.

CAUTION box ahead of CAUTION:

activity VERIFY K-1A conditions are stable before proceeding

WARNING
WARNING box is
shaded, icon, specific Minimize personnel near the K-1 skid when tripping
hazard

9
 5. Risk assessment / Job risk analysis
SEQual question: Please explain how your organisation integrates human factors/human performance
into control of work, risk assessment and job planning.
Risk assessment covers a broad category of tools and processes, from Job Safety Analyses (JSAs) to
HAZOPs and LOPAs. Here, we are focusing only on the task-level, pre-job hazard identification.

Table 6 Integration of HF with Risk Assessment process / form

YES – You are NO – You are not

Are you doing it? doing well quite there

1. Your risk assessment process covers error traps in addition to

hazards.

2. The risk assessment training cover error traps, how to identify

them, and what to do about them.

3. Error traps are integrated into various forms / templates of risk

assessment, from pre-job briefings to Control of Work processes.

4. Shortcuts are seen as behaviors incentivised by the work

arrangements. Those incentives are identified and addressed.
5. Frontline operators, supervisors and other people supporting
operations understand the concept of error traps and can point
out a range of them, from design, to procedure quality to time
available.

6. People doing the job conduct the pre-job risk assessment to

discuss the challenges they face.

10
Table 7 Example of a Job Safety Analysis form with integrated Error Traps.

Sequence of Job Steps Potential Hazard(s) Potential Error Traps Control Measures

Potential Hazards
Environmental /
Chemical Exposure Ignition Sources Spills Open Hole Weather

Hazardous Atmosphere Pressure Slips / Trips Arc / Flash Falls

Confined Spaces Lifting Chip Slivers Heat Stress Hot Surfaces

Simultaneous
Noise Overhead Pinch Points Fire / Explosion Operation

Work/Walk Surfaces Machinery Other (describe) Distraction through pain or immobility

Potential Error Traps

Steps that cannot be Unusual, infrequent, Boring, trivial or repet- Difficult system or Insufficient time
done or are inefficient unfamiliar or novel itive actions. equipment interface, available.
to do in reality. situations. labelling, controls,
alarms.

Complex or difficult to Unclear signs, signals, Difficult working envi- Relies on recognising Potential for
understand steps. instructions or other ronment (noise, heat, emerging hazard, risk, interruptions or
information. cramped conditions, or change. distractions.
lighting, ventilation,
ease of access).

Multi-tasking. Right tools might not Relies on good Procedures inadequate, Fatigue.
be available or used. communications, complex, or
with colleagues, inappropriate.
supervision.

Competence Insufficient Insufficient manning Confusing tool / Simultaneous

supervision equipment design (e.g. Operations
valves look the same)

11
 6. HF / HP in proactive learning (not BBS)
SEQual question: Please explain how you proactively identify and address factors that increase the
likelihood of human error or procedural violations.

Note: the question asks about factors that influence behaviour, not about identifying “unsafe / at risk”
behaviours, which typically is a focus of Behavior-Based Safety programs.
If a task is completed without an incident, it is typically considered a success. Vast majority of activities
are completed “successfully.”
However, rarely, attention is paid to HOW the activity was completed, what the challenges were and if there
were seeds of a future accident.
Accidents and near misses are (very) rare compared to all the tasks completed successfully (see Figure 2).
Learning typically takes place only after things go wrong with incident investigations conducted mainly
for “failed activities.” Such an approach prevents learning from all other activities, which did not result in
unwanted outcomes.

Figure 4 Limiting learning only to accidents removes opportunity to learn from normal work.
Source: IOGP (2021) Learning from normal work (TBP Q4 2021)

Worse than expected Better than expected

“Things were ok in the end“ “Things went really well“
19.1% 19.1%

15.0% 15.0%

Accident & 9.2% 9.2%

near misses

4.4% 4.4%

0.5% 0.5%
0.1% 1.7% 1.7% 0.1%

-3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.53

Untapped potential for learning

Incident Learning from normal work efforts and tools

investigations

12
Table 8 Indicators of implementing pro-active learning efforts

YES – You are NO – You are not

Are you doing it? doing well quite there

1. Your company’s leadership understands and supports

proactive learning. They can articulate concepts such as
work-as-imagined / work-as-done, non-compliance as a form
of adaptation, human error as a result of error traps etc.

You identified which activities are safety critical and can result
2.
in a high-severity event.

3. Within those critical activities, you know which tasks and steps
are safety critical.

You systematically evaluate what error traps and

4. organisational factors make the work difficult and increase the
likelihood of failure.
5. You apply those learnings at other locations where relevant.

Learn how to implement ‘Learning from Normal Work’ in your organisation:

www.learningfromnormalwork.com

Have questions about HF / HP but nobody to ask?

It all feels overwhelming? Get personal support from

Dr Marcin
You don’t know where to start?

13
One of the tools that supports proactive learning is “Walk-Through Talk-Through,” (WTTT) available through the Human Performance Oil & Gas (hpog.org).

14
 7. Behavior-Based Safety (BBS)
SEQual question: Please explain your organisation’s approach to behavioural safety or behaviour-based
safety program and how it is implemented.

NOTE OF CAUTION: BBS programs have been criticised in recent years as a tool used to blame workers and avoid focusing on
systemic contributions to safety. Such criticisms may be fair for poorly implemented programs, which are not based on science.
Although, critique and debate are vehicles of progress, we also consider a large proportion of such critical comments shared on
social media, to be uninformed on the scientific basis and best practices in this domain.

A TECHNICAL NOTE: Behavioral science, from Professor Skinner’s operant conditioning, to Gilbert’s Behavior Engineering Model
(BEM) which further evolved into e.g. Rummler’s Human Performance Improvement (HPI) methodologies, today represented
by the International Society of Performance Improvement (ISPI.org) which attracts many H&OP practitioners, to more recent
“behavioural systems” methodologies, combining post-Skinnerian developments with systems thinking, they all see behaviour as
an outcome of a person interacting with their environment over time. Isolating the person from the environment, which leads to
blame etc., is the antithesis of the behavioural science and good practice in this field.

Behavioral science has its own professional bodies and guidance offered. One of the leading, non-profit
organisations that provides certification of well implemented BBS programs is the US-based, Cambridge
Center for Behavioral Studies (CCBS).

There are four key stages of a BBS program:

1. Identify and define safety critical behaviours.

2. Gather data about factors driving behaviors.

3. Address factors driving behaviors and give feedback.

4. Use the accumulated data to identify, prioritize, and solve problems standing in the way of a safe workplace.

15
Table 9 Criteria for basic certification from the Cambridge Center for Behavioral Studies.
Source: https://bit.ly/3qZnl76

YES – You are NO – You are not

Are you doing it? doing well quite there

Behavioral Safety Team

Team is operational and sufficiently staffed.

Team is representative of the workforce.

Team members are trained on the application of

behavioral technologies, including conducting behavioral
observations and providing feedback.

Worker Knowledge, Skills, and Involvement

Workers are aware of the program and its operations.

Workers are aware that the program is no name, no blame.

Risk Assessment, Pinpointing, and Behavioral Observations

Formal observations are conducted on relevant behavioral
safety and health risks.

Observations are voluntary and anonymous.

Multiple observations are performed monthly.

Analysis and Evidence of Behavior Change

Behavioral data are compiled and trended over time to monitor
behavior change.

Trends are reviewed by the behavioral safety team and lead to

documented safety improvements.

Antecedent-only safety solutions (e.g., those including

information or training only) are common.

Performance Feedback and Goal Setting

Frequent and immediate performance feedback is provided to
workers.

Performance goals are set for safety process behaviors only

(e.g., participation in observations, behavior change). Realistic
goals are set for pinpointed behaviors.

Program status and achievements are communicated regularly

(e.g., safety briefings, meetings, posters, etc.).

If used, incentives discourage a culture of nonreporting;

incentives are linked to safety process behaviors only, not
safety outcomes such as injury rates.

Program Effectiveness

Impact of the behavioral program is assessed and tracked on

lagging outcomes (e.g., incident rates; time off work, etc.).

Management Support and Engagement

Management and key organizational leaders are supportive of
the program.

Key organizational leaders, such as the safety officers and

leaders of other organizational units, are adequately engaged.

The applications of certified organisations, describing their BBS programs in detail are freely available here:
https://bit.ly/2TZieYx

16
Examples
The documents describing how CCBS certified organisations manage behavioural safety programs in practice are
publically available on the CCBS website: https://behavior.org/help-centers/safety/Accredited%20Companies/

Here are selected examples of certified BBS program by:

The Marathon Petroleum Company - St. Paul Park Refinery (USA): https://bit.ly/3iBp4wS

Costain - a smart infrastructure solutions company (UK): https://bit.ly/2VIbwqm

17
 8. HF / HP in accountability
SEQual question: Please explain how your organisation manages inadequate performance or
unacceptable behaviour from your direct and indirect workforce.
This is about two fundamental questions: After an incident, would you like:
the involved employees to be more or less engaged in safety?
to learn more or less about this and future incidents?

If you answered: “more” and “more,” then how do you achieve that?

There are different types of accountability.

One is “backward-looking accountability” or “culpability,” based on “retributive justice” philosophy often demonstrated
in trials or lawsuits. This approach tries to find a scapegoat and blame or shame individuals for messing up. The
backward-looking accountability focuses on WHO did it, who is at FAULT. It aims to prevent re-occurrence by using
fear as a mechanism for behaviour change.
Depending on the severity of the outcome, the desire to hold people to account may range from an unpleasant
conversation to a written warning, disciplinary action, dismissal or even a jail sentence.

The alternative type of accountability is called “forward-looking,” and is based on “Restorative Justice” philosophy
in which not only should accountability acknowledge the mistake and the harm resulting from it, but it should also
lay out the opportunities and responsibilities for making the needed improvements. It recognises the challenges of
normal work and that there is never just one person involved. The focus is on how the collective of interdependent
teams can improve together using feeling of ownership as the main motivator.

To support managers to justly examine the potential culpability of the individuals involved in an incident, Professor
James Reason developed a decision tree which became popular in many industries. A major oil and gas company was
using this tree for over a decade and realised that it led to more issues than benefits. In response to those challenges,
they redesigned the process using insights from recent psychological research. Another company reworked the
framework even further based on the principles of restorative justice.

Table 10 Indicators of implementing constructive just culture process.

YES – You are NO – You are not

Are you doing it? doing well quite there

1. Human factors analysis is part of the incident investigation

to explain a range of factors that contributed to the person’s
behaviour.

2. No one works in a vacuum. The focus is on how the collective

of interdependent teams can improve together.

3. There is a process in place that prioritises learning, to

document how the decision on accountability was reached.

4. Leaders involved in response to incident and taking

accountability-related actions, understanding the basics of
HF / HP, error traps, how their response matter, side-effects of
punishment, the role of trust, etc.

5. If punitive actions are implemented, there is an informed plan

how to prevent undesired side effects such as supressed
speak-up or mistrust towards management.

18
Figure 5 Source: F. K. Bitar, D. Chadwick-Jones, M. Nazaruk, and C. Boodhai, “From individual behaviour to system
weaknesses: The re-design of the Just Culture process in an international energy company. A case study,” J. Loss
Prev. Process Ind., vol. 55, pp. 2

JC framework from Company 1

Interpet Address Conditions Work with people

1 Assess 2 Behaviour 3 people work under 4 involved

Start here
Make sure you are clear on the BP expectations
you are testing the individuals actions against*

The individual acted on the

Was the individual instructed / influenced to do this Yes Assess and coach supervision and managers on Define and test figure of authority’s action with
instruction or under the
by supervision or other figure of authority leadership. this process
influence of an authority figure
No

Clarify & verify expectations are met.

Was the expectation clear ? No Improve management of the procedure or Work with those involved to understand where
If there was a procedure was it clear, available, The expectation were unclear consider alternative means of control. there are misunderstandings or conflicts in
current and workable? or impractical Encourage people to “stop and consult” where expectations.
something is unclear
Yes

Address selection , training, assessment and

Did they understand what was required, and No The individual did not have the Provide appropriate training, coaching ,
quality of people are required to fulfill the
did they have the knowledge, experience, skill, capability or resources to meet assessment and resources for individuals

Note: Line management may consult HR in any of these situations

expectation.
physical capacity and resource to do it? the expectation involved.
Yes
Investigate factor which triggered error or made it
more likely ( e.g. Equipment, procedure , design , Work with those involved to understand where
distraction , fatigue etc. ) other errors and problems could occur.
Did they intend to act in line with BP’s Yes The individual made an
Identify tasks which would have a serious Where the individual has a history of errors in
expectations, but made a mistake ? unintentional error outcome in case of error. different circumstances.consult HR for advice on
Redesign task to eliminate & detect errors and appropriate performance improvement measures.
No recover without harm.

Work with those involved to understand why this

Investigate why the practice became routine and became the preferred approach.
how widespread it is.
Yes Coach appropriate behaviour with those involved
Were they following custom-and- practice which A custom-and-practice had Encourage use of formal continuous improvement
process Encourage individuals involved to act as role-
wa common amongst their peers ? developed amongst the team models for appropriate behaviour
Consult HSE team for advice on tackling group
No non-conformance Consult HR for advice on whether disciplinary
measures are appropriate.

Review and address what made it difficult to meet Work with those involved to agree how this
The individual found expectations in this case. situation could be managed to meet expectation
Substitutions test : Could another person with Yes Investigate factors which made the situation in future.
the same knowledge, skill & experience have themselves in a difficult
more likely ( e.g. Equipment, procedure , design , Where the individual has a history of errors in
done the same thing in the identical situation ? situation distraction , fatigue etc. ) different circumstances.consult HR for advice on
Encourage people to “stop and consult ” attitude appropriate performance improvement measures.
No

Understand what motivated the actio.

Understand how priorities set by supervision and Work with individuals involved to reinforce
Yes The individual acted to benefit management could have contributed.
Is there evidence to suggest they acted to help appropriate behaviours
self,company, to save time or effort? themselves or the company Encourage use of formal continuous improvement Consult HR for advice on whether disciplinary
process. measures are appropriate.
No

Is there evidence to suggest they intended to Yes

cause harm, damage or loss? This is a special case. Always Consult HR
No

Now test supervison / line

It’s not clear why this happened. You may need 5 manager / others contribution
to investigate further.

*Expectations = expected cunduct in line with Values and Behaviours, Code of Conduct, rules, policies and procedures

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JC framework from Company 2
Table 11 A Just Culture framework based on the principles of restorative justice.

Step Investigation Questions Answers/Comments

TRIGGER: Initiation of punitive action
Name individual
1. Individual Who are you doing this Just Culture Review for?

Was an adequate Incident Investigation with a Human

2. HF Analysis Adequate Inadequate
Factors analysis completed?
Summary of the discussion
Facilitator to provide team with overview of:
i) Error Traps that influenced this individual’s behavior.
ii) Who else contributed to the incident directly/indirectly
3. Investigation
and how?
review
Discuss what this implies regarding punishing this
individual? E.g. Does it still make sense to punish them?
Only them? What was the role of supervisors & senior
leaders in this incident?
Comment
i) Does the individual acknowledge their role in the event
and shows willingness to learn and improve?
4. Involved What is the evidence?
ii) Does the individual have a history of under-performance /
individual’s non-compliance?
assessment
What is the evidence?
iii) Is there evidence to suggest the person intended to
cause harm, damage or loss (Sabotage)?

i) Review Table of Harm (part of HF analysis) – articulate Table reviewed?

different types of harm experienced by different
(Yes / No )
stakeholders.

ii) Brainstorm and articulate, one-by-one, answers to the Facilitator to record answers / actions
following questions:
a.What action(s) would drive engagement of those
affected and demonstrate care?
5. Constructive
Action b.What action(s) would rebuild trust between those
affected?
c.What action(s) would help the team and broader
organisation to learn?
Articulate your decision and rationale
iii) In light of the answers above, is the originally proposed
punitive action still the best way to move forward to put
things right and maximise the learning and engagement of
the individual and organization?
Explain plan in detail
If punitive action is still being considered, explain how you
will manage the potential unintended consequences, (e.g.
6. Manage negative creating a culture of fear, disengagement, suppressing
Consequences speak-up).
Involve HR and legal teams

7. Repeat If punitive action is still being considered for the individual, considered also taking punitive action
for others who share accountability (refer to Step 3.ii)? In this case, repeat the process for the
other individuals for whom punishment is proposed

Source: IOGP, (2021), Learning when nothing goes wrong.

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 9. HF / HP Policy
SEQual question: Do you have a documented human factors/human performance policy? If yes, please
provide a copy of your policy. If yes, please explain how your policy is implemented.

An HF / HP Policy is a governance document or documents embedded in the Safety / Quality Management System
that outline(s) the requirements on how the human factors concepts and tools should be integrated with the existing
processes as per the guidance described above.

Table 12 Indicators of an HF Policy integrated into a management system.

YES – You are NO – You are not

Are you doing it? doing well quite there

There is a high-level policy embedded in the Safety / Quality

Management System that outlines the requirements on how the
human factors concepts and tools should be integrated with the
existing processes.

The policy describes how you integrate HF / HP with:

a. Operating procedures
b. Incident investigations
c. Risk assessment
d. Proactive learning
e. BBS
f. Accountability
* The specific requirements can be integrated into policies /
management system procedures covering specific topics, e.g. HF
/ HP requirements for incident investigations can be part of the
“investigations procedure / policy”.

The policy covers:

1. Roles and responsibilities
2. Competencies and how they are achieved
3. References to tools and templates
4. Desired quality of the output

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What is next
This all may feel like a lot, and overwhelming. That is ok. We are here to help.

We will be publishing further guidance on how and where to start.

If this guidance is useful and relevant to you, share it with your colleagues.

Have questions about HF / HP but nobody to ask?

It all feels overwhelming? Get personal support from

Dr Marcin
You don’t know where to start?

22
 ABOUT SPE HUMAN FACTORS TECHNICAL SECTIONS
HFTS VISION: We will achieve that vision through:
HFTS endeavours to connect the HF expertise and best 1. Organising events, workshops and providing
HF practices to the oil and gas practitioners and build informative materials;
a living community of people interested in practical 2. Building bridges between various communities of HF
application of HF. experts, academia, practitioners, students and
regulators;
We will educate the SPE community and the industry on
HF in order to enhance (process) safety, efficiency and 3. Influencing curricula of academic and engineering
engineering practices in our industry. programs;
4. Collaborating with other industry bodies and creating
We will lead the industry by promoting the integration
HF landscape maps, e.g. what other bodies are doing
of HF with educational and professional competencies
and collaborating with other industry bodies so that all 5. Promoting oil and gas among the HF professionals
professions in the industry have common understanding outside oil and gas;
of HF and how to apply it. 6. Integrating HF into SPE initiatives where appropriate,
e.g. Petrobowl, and working across SPE communities
and technical sections; and
7. Promoting, rewarding and recognising practical
application of HF.

Access HFTS Webinars – SPE members only

Title: Understanding, Predicting and Title: Human Factors in Drilling: Are there
Preventing Bias: how psychology practical tools for use at the wellsite?
can help industry decision making Speaker: Dr. John L. Thorogood
Speaker: Dr. Matthew Welsh

OPEN OPEN

Title: Origins of H&OP in the Commercial Title: Human Factors in Automation

Nuclear Power Industry Speaker: Amanda DiFiore
Speaker: Tony Muschara

OPEN OPEN

Title: Human Factors in accident Title: Human Factors / Crew Resource

investigations Management: Perspectives for Inputs to Risk
Speaker: Simon Robinson & Diane Chadwick-Jones Management Framework
Speaker: Philip Grossweiler

OPEN OPEN

Title: Human Performance in Practice:

Challenges and Resources
Speaker: Dr. Marcin Nazaruk

OPEN Contact us: [email protected]

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