Competence?

Robert Miles: Human & Organisational FactorsOffshore Safety Division, Health and Safety Executive

rob.miles@hse.gsi.gov.uk

The UK offshore safety in regime is a permissioning regime:

• The duty holder (usually the operator) sets out all of the hazards, and all of the means by which these are controlled, in a Safety Case.

• The HSE assesses that case and accepts it once it is satisfied that the measures described are sufficient for safe operation.

• The duty holder (operator) must then operate the installation (or rig) in the same manner as described to HSE in the Safety Case.

• For HSE integrity is “doing what you told us you would” and through that staying safe.

For HSE integrity is “doing what you told us you would”.In a safety case operators usually tell us that they:

• Only employ staff competent for the job.• Allow enough time for planning and completing the job safely.• Conduct adequate risk assessment.• Provide all necessary training.• Manage contractors to the same standards as their own operations.• Have up to date procedures for every hazardous task.• Maintain equipment to a safe standard.• Audit and review their performance.• Comply with the Regulations.

..but…..

• When we investigate accidents and incidents or carry out inspections we usually find one or more of these things has not been happening.

• The reasons why often relate to the way people throughout the organisation value (or not) safety and integrity and how they learn.

• Safety is everyone’s responsibility, it is shared between workers, managers and owners.

Safety Businessrisk

Psychosocialrisk

Accidents & injuries

Losses & bankruptcy

Sickness &Resignations

Accidents & injuries

Losses & bankruptcy

Sickness &Resignations

“I don’t know how to do my job”

Explosion & fires at BP Texas City refinery, March 23, 2005

BP Texas City, 23 March 2005

• “Failure to follow the startup procedure contributed to the loss of process control. Key individuals (management and operators) displayed lack of applied skills and knowledge and there was a lack of supervisory presence and oversight during this startup.”

Raffinate tower overfilled for 3 hours:

Training and competence issues• Move to computer-based training without effective

verification (“a business decision driven by cost”)• 1998 to 2004: training staff reduced from 28 to 8

and budget halved• 2002 -2005: audits and reviews identified on-going

deficiencies in operator competency …• … yet managers relied more on operating personnel

and less on engineering controls to prevent accidents• No effective training for abnormal situation

management

Esso Longford, Sept. 1998

Esso Longford, Sept. 1998

• “Those who were operating GP1 on 25 Sept 1998 did not have knowledge of the dangers associated with loss of lean oil flow and did not take steps necessary to avert those dangers.

• Nor did those charged with supervision of the operations have the necessary knowledge, and the steps taken by them were inappropriate”

Royal Commission Report

Leading indicators?

• Predictive of accidents• Gas detection vs fire alarm• inspection• attendance at training?• near miss reports acted upon• un- actioned defect reports (-ve)• % competent staff• need to be things that we can change: not

independent• We inspect leading indicators!

Enough competent crew

A well organised work place

An effective shift system

Reliable usable equipment

A weakness any element can emerge as a problem everywhere

Published Guidance• Developing and maintaining staff

competence (Railway Safety Publication 1), Second edition 2007, Office of Rail Regulation (ORR), ISBN 07176 1732 7

• Competence assessment for the hazardous industries. HSE research report RR086/2003

Competence management system

These are corporatepolicy decisions

How to stay alive...

A Bow-Tie approach

RR637 – Optimising Hazard Management by Workforce Engagement and Supervision

Specify human element in this barrier (i.e. operator competence or maintenance competence

Specify the human element in this barrier (i.e. operator competence or maintenance competence

Do this for all the safety barriers

Specify the human element in this barrier (i.e. operator competence or maintenance competence

Do this for all the safety barriers

Post A

Post BAggregate these into posts

Post A Barrier 1 Skill 1 x

Skill 2 x

Skill 3 x

Barrier 2 Skill 1 x

Skill 3 x

Skill 4 x

Barrier 3 Skill 4 x

Post B Barrier 4 Skill 1 x

Skill 2 x

Barrier 5 Skill 1 x

Skill 2 x

Skill 3 x

Post A Barrier 1 Skill 1 x

Barrier 1 Skill 2 x

Barrier 1 Skill 3 x

Barrier 2 Skill 1 x

Barrier 2 Skill 3 x

Barrier 2 Skill 4 x

Barrier 3 Skill 4 x

Post B Barrier 4 Skill 1 x

Barrier 4 Skill 2 x

Barrier 5 Skill 1 x

Barrier 5 Skill 2 x

Barrier 5 Skill 3 x

Post A Barrier 1 Skill 1 x

Skill 2 x

Skill 3 x

Barrier 2 Skill 1 x

Skill 3 x

Skill 4 x

Barrier 3 Skill 4 x

Post B Barrier 4 Skill 1 x

Skill 2 x

Barrier 5 Skill 1 x

Skill 2 x

Skill 3 x

A Regulatory perspective:• HSE would serve a Prohibition Notice

for a failure to provide sufficient competent staff to undertake a hazardous activity safely.

• We would serve the PN on the activity and set criteria for a resumption.

• We may choose to allow limited operation to enable competence to be improved by on-the-job training.

Leadership and management • Texas city showed that there could be a lack of

competence in senior management.• Regulators are now alert to this and prepared

to act• These failings could be:

– in safety leadership, or– technical ability – knowledge of the processes and

plant.

• An organisation needs competent specialists• Competent investigations - how else do you

learn?

After Texas City BP trained executives in how a refinery works!

What do I understand by “competence”?

• An individual attribute?• A team attribute?• A trait like personality, a “quality” or an

aptitude, or something anyone can learn? Psychometric testing!

• How long does it last?• Bought-in or developed in-house?• Trained in a class or learned on the job?

*Manager: “Joe keeps having accidents”, HSE : “Well why do you keep employing him?”

How would I capture a lack of competence?

• When recruiting?• Before the job started?• During a job?• When appointing a contractor?• During the contract?• When a contractor’s employee arrives

offshore?• What happens then?

The Real World..

• Most competence is bought in on contract.• Managed through the supply chain.• Competence assurance can become a

monster – 1 job – 340 pages of criteria.• One large operator – system can not get

above 70% because it is too complex. Now downgraded to an “advisory element” of the SMS. Cost £Ms

The Real World …2

• People do forge certificates, so verify!• Self assessments are very unreliable. The truly

incompetent lack insight• Training centres who fail too many do not survive.• Multi-choice is not understanding• Beware of inclusiveness – (the dyslexia issue)• Is Competence being used to personalise

organisational failings (i.e a lack of procedures)?• Licensing – people and organisations. How often

does the I.Mech.E strike people off.

The Real World …2

• People do forge certificates, so verify!• Self assessments are very unreliable. The truly

incompetent lack insight• Training centres who fail too many do not survive.• Multi-choice is not understanding• Beware of inclusiveness• Is Competence being used to personalise

organisational failings (i.e a lack of procedures)?• Licensing – people and organisations. How often

does the I.Mech.E strike people off.

The standing of a profession is proportional to the number of members struck off.

AKA the “John West” approach