SYDNEY TRAINS SAFETY MANAGEMENT SYSTEM SYSTEM PROCEDURE 07: HUMAN FACTORS

Transcription

1 SYDNEY TRAINS SAFETY MANAGEMENT SYSTEM SYSTEM PROCEDURE 07: HUMAN FACTORS Purpose Scope Out of scope The purpose of this document is to describe the process for managing Human Factors (HF) to support the system safety risk management requirements at Sydney Trains. This document is applicable to Change Managers, Project Managers, Change/Project Sponsors and Human Factors practitioners involved in identifying and addressing human factors issues in systems. This document is relevant to human factors issues that may cause or contribute to human error. This procedure should be read in conjunction with: SMS-07-SP-3067 Manage Safety Change SMS-07-SP-3089 Manage Operational Safety Risk. This procedure does not cover risks related to common workplace hazards. These are dealt with through the suite of documents in Element 6 Work Health and Safety, including assessments for human errors, where appropriate (e.g. SWMS/SWIs). In the business, Human Factors practitioners may be referred to as: Human Factors Professional or Human Factors Specialists. UNCONTROLLED COPY WHEN PRINTED Page 1 of 15

2 Process Flow Process Responsibility Tools & Forms 7.3 Integrate Human Factors in Safety & Operational Systems Identify Requirement for Human Factors Integration (HFI) Change /Project Managers Change/Project Sponsors Line Managers SCARD Complete a Human Factors Work Determination Safety Assurance Manager Human Factors practitioners HFWD Form HFWD Register Plan human Factors activities Manage HFI Human Factors Tools Guide HFIPMP HFIP Manage Human Factors Governance Group Manager Safety HF Issues Register Independent Verification Figure 1 Process Flow for Human Factors in Safety & Operational Process Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 2 of 15

3 Process Description 7.3 Integrate Human Factors in Safety and Operational Systems For an operational system to deliver the expected benefits to our customers, it is essential that the human interactions with the system and system elements are well designed through the application of established human factors (HF) principles and knowledge. The process for achieving this is Human Factors Integration (HFI). The aim of the HFI process is to ensure the human-system interactions optimise system performance, and identify and mitigate risk : Identify requirement for Human Factors Integration (HFI) The application of human factors involves the evaluation and design of products and systems to make sure that they are safe, and easy to maintain and operate. It encompasses individual, organisational and job factors which can influence safety and performance at work. This includes people and their interactions with products, systems, processes and environments. This system procedure looks at the roles and responsibilities of Change Managers, Change Sponsors, Project Managers and Human Factors practitioners in managing human factors in the context of system safety risk and safety change management. Appendix A provides more detail on human factors fundamentals. The following are some examples of human factors issues/risks: poorly designed systems or equipment signs and labels are incorrectly applied poor verbal or written communications inadequate systems knowledge inadequate supervision people not following procedures strength or size of individuals is inadequate for the demands of the task poor layout of equipment social pressures/ organisational culture and norms attending to multiple, repetitive or prolonged tasks. Daily operating tasks should be conducted with some awareness of how to apply human factors and how to identify human factors issues. Operational issues may be identified by line or project managers through day-to-day management of workplace safety risks. Human factors should be considered as part of these activities (see Appendix A for more background information on human factors). Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 3 of 15

4 7.3.1: (continued) All Line and Project Managers must be aware of how human errors should be addressed and apply the human factors fundamentals. This includes: considering human factors during workplace risk assessments and developing safe systems of work proactively identifying practices and procedures where the required level of performance is often not achieved due to task requirements that are beyond, or close to the limitations of human performance; providing an appropriate remedy for these situations reviewing operational procedures and work practices to identify the potential for human error and to enhance the potential for recovery from any such errors. Human Factors practitioners must support day-to-day operational issues such as: promoting the benefits of human factors across the organisation and provide support to the business as required maintaining the human factors documents in the SMS and making sure that the human factors process is followed ensuring that human factors is integrated into other SEQR activities reviewing Safety Change Assessment and Reporting Determinations (SCARDs) reviewing safety management system documents, study reports, and other material produced by any Sydney Trains division to make sure that any implicit human factors issues are adequately addressed attending steering committees, project control groups, action groups and working groups conducting human factors activities for Sydney Trains divisions providing support to stakeholder workshops (including risk assessments) on operational issues to help identify human factors issues and mitigation strategies providing support to rail resource management activities and the development of non-technical skills providing support to fatigue risk management activities providing support to safety incident investigators to understand human error contributions to incidents ensuring integration of human factors to people processes such as selection, training and competence assurance Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 4 of 15

5 7.3.1: (continued) supporting initiatives aimed at delivering a positive safety culture providing support to identify where SCARDs need to be completed providing training for SMS requirements to Sydney Trains personnel providing human error training as required by the business facilitating lessons learned activities across the human factors community, including gathering lessons from external projects (such as regulator initiatives) The Group Manager Safety or GM SEQR must delegate human factors activities to Human Factors practitioners as required. When human factors issues are apparent, line and project managers must conduct a Human Factors Work Determination (HFWD) using SMS-07- FM The assessment should determine which, if any, human factors activities need to be undertaken to investigate and resolve the issue, and make recommendations for addressing the issue. Human Factors in Operational Safety Risk Management Line Managers will make sure that human factors risks and issues (i.e. anything that affects human performance, particularly factors that may cause or contribute to human error) will be considered whenever an operational safety risk assessment is undertaken, in accordance with the System Procedure Manage Operational Safety Risks (SMS-07-SP- 3089). When human factors issues become apparent, Line Managers and Project Managers must complete a HFWD to determine which human factors activities need to be undertaken to investigate and make recommendations for addressing the risk(s). Human Factors in Safety Change Management Change Sponsors will complete a SCARD at the beginning of a planned change or project in accordance with the System Procedure Manage Safety Change (SMS-07-SP-3067). The SCARD questions consider the impact of a change on human performance. The output of the SCARD (i.e. its impact level) determines the level of safety assurance and human factors activities required. Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 5 of 15

6 7.3.1: (continued) The SCARD can have three outcomes: minor, important and significant. Minor: no specific human factors activities are required if the SCARD impact level is minor, but the change sponsor should consider completing a HFWD form where opportunities to improve efficiency or operability are identified Important: the Change Sponsor must complete a HFWD form to determine the human factors activities required Significant: the Change Sponsor must make sure complete the following activities and documentation are completed, as required: o HFWD o Human Factors Integration Plan (HFIP) o Human Factors Integration Project Management Plan (external scope only) (HFIPMP) o Human Factors Issues Register : Complete a Human Factors Work Determination The Change Sponsor/Project Sponsor/Line Manager or Project Manager must complete a Human Factors Work Determination form (SMS-07-FM- 4142) when a: SCARD shows the impact level of the change as important or significant; or Review of practices, procedures, or workplace risks reveals the potential for human error, and requires specialist input to understand and solve problems with a safety risk impact. The change sponsor/project Sponsor/Line Manager or Project manager should complete a Human Factors Work Determination form (SMS-07- FM-4142) when an opportunity is identified to improve efficiency or operability as a result of a change or a review of practices, procedures or workplaces. The HFWD should be assigned a TRIM reference number and filed in TRIM. The Human Factors practitioner, in consultation with the initiator, the Safety Assurance Manager (SAM) and any other relevant stakeholders, may conduct a HFWD workshop or meeting to determine the human factors activities that should be conducted. The Group Manager Safety must make sure Human Factors Work Determination forms are reviewed and stored in the HFWD register. Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 6 of 15

7 7.3.3: Plan human factors activities The Human Factors practitioner determines the resource requirements for the human factors activities required. Human Factors Integration Plan (HFIP) (Internal) A Human Factors practitioner should develop and maintain a Human Factors Integration Plan (HFIP) for internal work when a SCARD shows the impact level of a change is significant. The plan utilises the output of the Human Factors Work Determination form (see section 7.2 in this document), and coordinates all internal human factors activities relating to a specific issue or project. The plan must be written with input from the Change Sponsor, in conjunction with the Project Management Plan, Safety Change Plan and any other relevant project documents. It is a living document that should be developed and updated throughout the project. The HFIP must include: human factors issues that will be addressed by the change activity inputs needed to conduct the work and when they are required outputs planned and when they will be completed resourcing arrangements and scheduling (e.g. user involvement for gathering requirements, design assessments, prototyping, and user trials) constraints (such as pre-selected or legacy equipment, fixed staffing levels, training capacity limitations, the organisational context in which the system is operated, safety constraints) dependencies on other development activities dependencies on other contracts or projects design considerations monitoring and control methods for the plan required processes, mechanisms, and forums for integration process for updating and maintaining the plan. Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 7 of 15

8 7.3: (continued) The Change Sponsor must make sure: the HFIP is completed that human factors has been incorporated into project management and systems engineering processes at the start of the project. Human Factors Integration Project Management Plan (HFIPMP) (External) A Human Factors Integration Project Management Plan (HFIPMP) may be required when external work is being conducted in projects with a significant SCARD outcome. The purpose of the plan is to define the mechanisms to manage and monitor the work of contractors. It should refer to a plan that the contractors produce to detail their work. The Human Factors practitioner lead on a significant project will: complete the plan develop it and reissue it in line with the HFIP. The HFIPMP is a more detailed document than a high-level scope of work and includes: the context and conditions of contract the parties involved in the work and the role of each of those parties communication strategies between the different parties Sydney Trains review and audit process definition of criteria for review and audits safety assurance framework for decision-making processes to be integrated into the project. The HFIPMP may be used in conjunction with an internal HFIP, where the internal HFIP details the activities done by internal resources and the HFIPMP is used to manage and monitor activities by external parties throughout the project lifecycle. Note A Scope of Works is required whenever external contractors are engaged for human factors work. Where a Scope of Work has not been signed by a Human Factors practitioner, it is then subject to Independent Verification. Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 8 of 15

9 7.3.4: Manage Human Factors (HF) The Human Factors practitioners will determine what human factors activities to undertake as part of the HFWD. Apply the ALARP principle (SMS-07-OP-3085 SFAIRP Determination and Demonstration) to determine which issues are addressed and what level of effort can be afforded to address them. The Human Factors practitioners must: incorporate human factors issues into related project documents, including the Risk Register and Safety Change Plan, where appropriate make sure that appropriate resources and timescales are allocated to carry out human factors activities make sure that all stakeholders and user groups impacted by the proposed change are identified at the outset and that their needs are clearly identified communicate the need to access representative users and subject matter experts to line and project managers make sure the timely execution and completion of all human factors activities establish and maintain a Human Factors Issues Register, if required make sure that all human factors issues and recommendations identified are appropriately tracked and managed through a Human Factors Issues Register or Risk Register, or other appropriate means make sure that documentation provides a clear audit trail of the relevant human factors processes, methodologies, assumptions and findings Minimum HFI requirements for significant SCARD outcomes For changes or projects with a significant impact, Human Factors practitioners will: establish a Human Factors Issues Register (or make sure the issues are tracked in another appropriate register) conduct a preliminary human factors analysis to identify issues document the identified human factors issues in a Human Factors Issues Register and manage the register throughout the project Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 9 of 15

10 7.3.4: (continued) develop and maintain a Human Factors Integration Plan (HFIP) for internal work develop and maintain a Human Factors Integration Project Management Plan (HFIPMP) for external work. Documenting human factors findings, incorporating into work, and capturing lessons learned The methodology and findings of any human factors work should be formally documented. The nature of this document will depend on the human factors activities undertaken. The output should be incorporated into daily operations or safety assurance work as appropriate. At the end of the process, capture any lessons learned based on applying the tools and implementing outcomes in the Sydney Trains environment. These should be communicated to the Group Manager Safety and the relevant project sponsor Manage Human Factors governance Peer review All human factors draft documents must be peer reviewed by a Human Factors practitioner who provides feedback to the author. Independent verification The following documents must be sent for independent verification: Internal Human Factors scoping documents, including Human Factors integration plans and Human Factors Work Determination, and any other significant assurance documents identified in the scope. scope of work documents to engage external contractors for human factors work that are not signed by a Human Factors practitioner Human Factors Integration Plans and any other human factors documents (plans, reports, etc.) produced by external contractors. The Human Factors Specialist must review human factors documents submitted for independent verification. Document endorsement The final output from any human factors work should be: approved by a Human Factors practitioner endorsed by the Group Manager Safety/GM SEQR, if appropriate. Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 10 of 15

11 7.3.5: (continued) Records management Responsibilities A copy of each document should be stored in the central human factors document library maintained by the Human Factors Specialists. Group Manager Safety Organise and manage appropriate resources by delegating human factors activities to Human Factors practitioners as required or provide advice to the GM SEQR on this issue. Review and store Human Factors Work Determination forms in the HFWD Register. Provide advice on the timescales allocated to carry out human factors activities, if required. Conduct independent verification of human factors reports produced by external contractors, ensuring that the human factors tools are appropriately applied. Review and endorse deliverables from human factors work, where appropriate. Human Factors practitioners Review SCARDs. Determine HF activities to be applied. Develop and maintain a Human Factors Integration Plan (HFIP) for internal work. Develop and maintain a Human Factors Integration Project Management Plan (HFIPMP) for external work. Write the HFIP in conjunction with the Project Management Plan, Safety Change Plan, and any other relevant project documents. Make sure that all stakeholders and user groups impacted by the proposed change are identified at the outset and that their needs are clearly identified. Communicate the need to access to representative users and subject matter experts to line project managers. Make sure that all human factors issues and recommendations identified are appropriately tracked and managed through a Human Factors Issues Register or Risk Register, or other appropriate means. Make sure that documentation provides a clear audit trail of the relevant human factors processes, methodologies, assumptions and findings. Peer review human factors documents. Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 11 of 15

12 Line and Project Managers Be aware of how human errors should be addressed and the Human Factors fundamentals (see appendix A) Apply human factors principles in day-to-day operations: make sure appropriate consideration is given to human factors during workplace risk assessments and when developing safe work systems proactively identify practices and procedures where the required level of performance is often not achieved because the requirements of the task are beyond or close to the limitations of human performance; provide an appropriate remedy for these situations review operational procedures and work practices to identify the potential for human error and enhance the potential for recovery from any such errors develop error-tolerant working practices when human factors issues are apparent, complete a HFWD. Change Sponsors Complete the Human Factors Work Determination form when a SCARD outcome is important or significant. Make sure minimum requirements HF activities and documentation are completed. Provide input into the HFIP. Make sure human factors and systems engineering processes are in place and include human factors considerations early on in project development. Note Training programs available in Human Factors include the Introduction to System Safety SM33. References SMS-07-SP-3089 Manage Operational Safety Risk SMS-07-SP-3067 Manage Safety Change SMS-07-FM-3142 Human Factors Work Determination Form SMS-07-OP-3088 Conduct Independent Verification Activities Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 12 of 15

13 Version Control Version Change from previous Date Comment 1.0 First release of Sydney Trains SMS 01/07/2013 Launch of Sydney Trains SMS documents added to the process flow and minor number changes to the process. Approver and custodian names amended. Hop logo added. Dot points added to 7.3.1,Paragragh added to and paragraph added to Figure 1 amended to modify minor SCARD outcome and Appendix A updated. 23/12/2014 Review of procedure Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 13 of 15

14 Consider whether Human Factors activities are required Figure 1 Human factors process diagram Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 14 of 15

15 Appendix A Human factors fundamentals Human Factors Human factors aims to optimise system performance through the design of systems and technology to make sure that they are safe, and easy to maintain and operate. It encompasses individual, organisational and job factors (shown in Figure 2 below) which can influence safety and performance at work, particularly factors that may cause or contribute to human error. Figure 2 Human Factors The application of human factors can improve safety by: making sure human characteristics are accounted for in the design (or re-design) of new or existing systems and equipment identifying the issues which may cause or contribute to human errors conducting activities and applying controls to reduce the likelihood and consequences of human error. Other benefits of integrated human factors activities include: assurance that behaviours and human performance align with customer and operational requirements a better fit between the product or system and the user population and the objectives of the organisation reducing resistance to change and increasing user satisfaction with end products by incorporating user requirements saving time and money by considering human factors early in the system design process, thereby reducing the need for redesign at a later stage improving reliability by supporting systems to be easy to use and error tolerant. Sydney Trains UNCONTROLLED COPY WHEN PRINTED Page 15 of 15