Fatigue Workshop Human Factors in Process Safety Presented by Bill Gall, Kingsley Management Ltd At EPSC Conference 5 th -6 th October 2006.

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Fatigue Overview Fatigue is an HSE ‘top ten’ issue Under-reported problem? Primary or secondary cause of incidents?
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  • 1 Fatigue Workshop Human Factors in Process Safety Presented by Bill Gall, Kingsley Management Ltd At EPSC Conference 5 th -6 th October 2006
  • 2 Workshop Facilitator Bill Gall, CPsychol, MErgS, MEI 28 years HF experience Manufacturing Consultancy Health and Safety Executive Kingsley Management since 2002 IP/EI Working Group
  • 3 Fatigue Overview Fatigue is an HSE ‘top ten’ issue Under-reported problem? Primary or secondary cause of incidents?
  • 4 The Fatigue Problem “Fatigue has been recognised around the world as a contributor to many accidents involving means of transport. There have been many incidences where fatigue has been suspected of contributing to or causing transportation and industrial accidents; however, that connection was difficult to justify” IMO
  • 5 The Fatigue Problem 29% of UK drivers felt close to falling asleep while driving A quarter of New York drivers reported having fallen asleep at the wheel 10% of almost 68,000 serious road crashes in good conditions affecting only one vehicle were related to fatigue in France HSE survey: workforce identified fatigue due to shift work and stress about work as the factors most affecting their health in the offshore environment’ Quote: “We do far too much time offshore to be in good condition (mind and body)…I’m coming to the end of my trip and I’m very tired. I’ve lost lots of sleep due to shiftwork Fatigue cited in –Exxon Valdes –Chernobyl/Three Mile Island –Challenger space shuttle –Many marine accidents
  • 6 Fatigue Definition ‘a combination of symptoms including: impaired performance (loss of attentiveness, slower reaction times, impaired judgement, poorer performance on skilled control tasks and increased probability of falling asleep) and subjective feelings of drowsiness or tiredness’. Australian Transport Safety Bureau “…a result of prolonged mental or physical exertion; it can affect people's performance and impair their mental alertness, which leads to dangerous errors.” HSE
  • 7 Energy Institute Guide HSE guidance ‘Managing Shiftwork’ –Duties under law, risks of shiftwork, systems to control fatigue, legal duties, risk assessment, risk reduction, checking and review Energy Institute guidance –Stand-alone, specific topics, guidance and tools, case studies –based on, research material, case studies – problems/solutions, most relevant process industry guidance Objective is to allow organisations to –Recognise fatigue causing conditions –Take effective remedial action
  • 8 Factors Affecting Alertness Long Hours Shift Work/Night Working Shift Patterns Poor Quality of Sleep Sleep Apnoea Sleep Deficit Unstimulating (boring) Work Warm, Dark, Comfortable Environment Chemical Substances
  • 9 Specific Offshore and Driving Issues Offshore –Environment – for sleep, travel –Shift Patterns – 12 hr, rotating Driving –Largest risk –Effective Countermeasures – sleep, caffeine, –Ineffective Countermeasures – fresh air, radio on, rest without sleep
  • 10 Effects of Fatigue Short Term Effects –Impaired concentration –Irritability –Poor judgement –Reduced hand-eye coordination –Reduced visual perception –Reduced vigilance –Slower reaction times –Cardiovascular disorders
  • 11 Effects of Fatigue Possible Long Term Effects –Cardiovascular disorders –Gastrointestinal disorders –Childbirth problems - miscarriage, low birth weight and premature delivery
  • 12 Effects of Fatigue Short Term Effects can result in poor performance leading to: –Reduced quality/quantity of output –Incidents/accidents –Inability to respond to off-normal conditions Long Term Effects –Impaired health
  • 13 Alertness & Fatigue Guide How to explore the issue –Incident Investigation –Risk Assessment –Survey methods – informal interviews and discussion, questionnaires –Toolkits e.g. HSE ‘Fatigue and Risk Index Calculator’, sleepiness scales
  • 14 Alertness & Fatigue Guide A note on questionnaires –Questions will mostly of two types: –Those seeking objective information from individuals concerning their experiences of fatigue –Those seeking subjective information relating mainly to underlying causes of fatigue Supplement with follow up questions: ‘if so, why?’, ‘list these’, consider multiple choice Purely factual information about shift patterns etc from other sources, for example, HR dept
  • 15 Alertness & Fatigue Guide Guide provides sample questions Aim is to find out whether fatigue is a problem What systems deficiencies and cultural factors contribute to this
  • 16 Alertness & Fatigue Guide Solutions focused on: –Shift design and scheduling –Work environment –Management procedures –Education of workforce and managers –Additional factors (ageing, exercise) –Innovation – ‘sleep contracts’
  • 17 Exercise - Task Two types of syndicate –Risk assessment –Accident investigation Purpose –Use formal techniques – one proactive one reactive – to identify problems and solutions
  • 18 Hazard Identification Accident InvestigationRisk Assessment What went wrong and exposed people to the hazard? What could go wrong that could expose people to the hazard? What were the immediate causes?What would be the immediate causes? (What – ‘human failures’ – error/violation)? What were the underlying causes?What would be the underlying causes? (Influencing factors) What in our protection systems failed and led to exposure to this hazard? What deficiencies in our systems could fail and lead to exposure to this hazard? (Inadequate procedures; lack of ‘barriers’)
  • 19 Exercise - Findings Mate had been awake for 19hrs 25mins. Last sleep was poor quality Alcohol consumption exacerbated this – failed breath test Wheelhouse environment was conducive to sleep Zero tolerance drug policy contravened Excess hours overtime – not evenly spread Short off duty periods and master and mate did not take opportunities for rest Company had not provided guidance on hours of work Industry guidance not followed for regulated hours of work and rest Lone watchkeeping common at night – poor practice: against industry guidance Lack of properly used watch alarm as per guidance
  • 20 Exercise - Recommendations Introduce specific instructions and guidelines on hours of work and rest Consider employing additional watch- keeper/lookout Consider fitting watch alarm to all vessels
  • 21 Sleep Contracts Separate EI study and report Employers and employees formally document how they will: –identify and report fatigue risk –respond to reports of fatigue problems –record, review and address reports of fatigue risk
  • 22 Sleep Contracts
  • 23 Workshop Conclusions Fatigue is a top 10 issue Research shows underlying causes Effects – short term/long term Safety is key concern HSE cross-industry guide on shiftwork EI petroleum industry guide with basic tools
  • 24 Fatigue Workshop Human Factors in Process Safety Presented by Bill Gall, Kingsley Management Ltd At EPSC Conference 5 th -6 th October 2006
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