Managing Human Factors in the Signalling Programme

Transcription

1 Managing Human Factors in the Signalling Programme The latest development in the work of the Human Components Mapping Dr. Amanda C. Elliott Safety Team Banedanmark

2 Presentation Outline Overall aim: To present the development of a method being used by the Signalling Programme to improve the completeness of hazard analysis, risk assessment and operational testing. Agenda: 1. Introduction 2. Linking human factors and hazards 3. The story of Human Components mapping 4. Outline steps for the method 5. Summary & conclusions 2

3 1. INTRODUCTION 3

4 Introduction The Signalling Programme The Signalling Programme is complex, with both S-Bane and Fjernbane having major upgrade works. The modifications to the railway encompasses: o Infrastructure o Onboard equipment o Operational Rules The Signalling Programme Safety Team are working with the G-ISA and the NSA and applying CSM-REA. 4

5 Introduction Safety and human factors The safety and human factors teams work closely together on the Signalling Programme because we recognise that whilst the technical implementation is the deliverable ; the human elements are what will make or break the system in terms of operational performance and safety. 5

6 2. LINKING HUMAN FACTORS & HAZARDS 6

7 Linking human factors and hazards It s about the bigger picture of hazard composition The evidence from the (technical) supplier closes very few (if any) hazards completely at a railway level. Yet In the past much focus has been on providing evidence related to the technical aspects of hazards, with less rigorous effort spent on the human aspects. 7

8 Linking human factors and hazards It s about the bigger picture of hazard composition Our intensity of focus is still on technical products. The methods we use often push human beings to be measured in a similar way to technical components. What reasons do we give ourselves in the safety community for this? Especially when our technical solutions are more robust and reliable than they ever were? 8

9 Linking human factors and hazards It s about the bigger picture of hazard composition What do YOU think? 9

10 Linking human factors and hazards It s about the bigger picture of hazard composition Is it because we are more comfortable with solid numbers and figures that we can model and justify? 10

11 Linking human factors and hazards It s about the bigger picture of hazard composition Is it because the complexities of a socio-technical system can be interpreted in so many ways? 11

12 Linking human factors and hazards It s about the bigger picture of hazard composition Is it because we can t put humans into simple boxes? 12

13 Railway organisational structure HMI communications Task design Human decision making support Systematic failure prevention/ processes Anticipation of system problems Environmental ergonomics Competence Allocation of function Motivation and aspirational support Perception of risk Reaction to abnormal situations Working patterns Human interfaces to the system Human error Human V&V New technology introduction HF concepts Railway culture Human reaction time and space in Involvement in critical areas Human interface for automated tools Deliberate rule violation Quality of information Human feedback Human /system interface design & operation Human behavioural changes Independence Rate of information transfer Interworking and team interaction Training Monitoring and override Density of information transfer Professional railway vocabulary Contribution to human strain Involvement and intervention Operational safeguards 13

14 Linking human factors and hazards It s about the bigger picture of hazard composition Is it because conclusions are hard to determine when people are so changeable, so adaptable and so uninform? 14

15 Linking human factors and hazards It s about the bigger picture of hazard composition Is it because our educational practices, standards and regulations tend to place the humans outside of the measurable system? 15

16 Linking human factors and hazards It s about the bigger picture of hazard composition What do YOU think? 16

17 Linking human factors and hazards It s about the bigger picture of hazard composition It can be argued that CSM-RA now places more emphasis on considering the whole system, including the human and operational aspects because it is focused on what the change means. The challenge is Will we and can we start to change the way we present our safety cases, hazard analysis and testing evidence? 17

18 Linking human factors and hazards It s about the bigger picture of hazard composition We also have the lessons learnt: o It has become clear to the Signalling Programme that HF and human components are essential as key measures of operational testing. o There s been a lot of emphasis placed upon the competence and confidence in individuals (which is a regular occurrence for HF). o The complexity of Fjernbane railway is higher, with more suppliers involved. 18

19 2. THE STORY OF HUMAN COMPONENT MAPPING 19

20 The story of Human Component mapping First awakening the recognition of humans! The apportionment of hazard causes was agreed with the NSA. For most hazards, the human components determine the outcome. Leading to our first awakening the recognition that there s a lot riding on us providing a means to support our closure arguments through human factors analysis! 20

21 The story of Human Component mapping Next Allocating the complexities of humans in a viable way What methods could be used to meet our needs: o Justifiable (to all authorities and beyond) o Understandable (by all) o Communicable (between all parties) o Connectable (links to hazards) o Re-usable (for all different situations / hazards) o Measurable (can be structured & recorded but not necessarily quantitative) o Repeatable (person-independent) o Possible (in the timescales presented) 21

22 The story of Human Component mapping Simplification isn t easy to do E.g. Incident Factor Classification System (IFCS) UK RSSB/NR still uses abstract terms and is focused on past events 1. Knowledge, skills & experience 2. Practices & processes 3. Information 4. Workload 5. Communications 6. Team work 7. Supervision & management 8. Equipment 9. Work environment 22

23 The story of Human Component mapping For S-Bane, 3 HC areas were developed for key measures 23

24 The story of Human Component mapping For S-Bane, 3 HC areas were developed for key measures OT02 Close & Open station OT06 Fail a (northbound) train in station (Birkerød) & turn back at Holte OT12 Run Yellow Fleet Vehicle into single possession at Lyngby OT09 Set & Remove Reduced Braking Rate 24

25 The story of Human Component mapping Fjernbane distinctions There are now 4 HC s: o Application & Comprehension o Design o Communications o Workload (has been added) 25

26 The story of Human Component mapping Fjernbane distinctions So an overview may look like this: 26

27 The story of Human Component mapping For Fjernbane, there are more distinctions But that doesn t show the whole story The HC s are allocated in 3 contexts: o Roles o Products o Organisation 27

28 The story of Human Component mapping Fjernbane distinctions Leading us to allocation by HC: 28

29 The story of Human Component mapping Fjernbane distinctions Or allocation by context Organisation Roles Products 29

30 The story of Human Component mapping Fjernbane distinctions Or a combined map Description of Hazard XYZ ROLES PRODUCTS ORGANISATION Role 1 A&C HC1 Role 1 A&C HC2 Role 1 A&C HC3 Role 1 W/L HC1 Role 1 W/L HC2 Role 2 A&C HC1 Role 2 A&C HC2 Product 1 A&C HC1 Product 1 D HC1 Product 1 D HC2 Product 2 D HC1 Product 3 A&C HC1 Organisation 1 A&C HC1 Organisation 1 A&C HC2 Organisation 1 C HC1 Organisation 1 C HC2 Organisation 1 C HC3 Organisation 2 A&C HC1 Role 2 W/L HC1 Role 3 A&C HC1 Role 3 A&C HC2 Product 3 D HC1 Product 4 D HC1 Organisation 2 C HC1 30

31 The story of Human Component mapping So how does this help us? It s true that the human components of any situation, scenario or hazard have complex interactions; their nuances can t be captured. However, we do have a need to move forward and support the safety case, as well as operational testing. 31

32 The story of Human Component mapping So how does this help us? The HC mapping method allows us to record one version of the hazard: o There s a clear step-wise method to produce the result (justifiable). o The HC map of a hazard can be shown as a single, one-page output that summarises the HC s (understandable & communicable). o One HC map can be produced per hazard and other scenarios e.g. a HC map of an Operational Rule (re-usable). o There is a syntax for each type of HC, which is agreed with the operational testing team for Fjernbane (measurable). 32

33 The story of Human Component mapping So how does this help us? o The method can be done by anyone with the right competences, so that there is no over-reliance upon history & individuals (repeatable). o The HC map is the central point for connection to other elements of the Signalling Programme, using a database and taxonomy and can be used to structure the HF records (connectable). o We have already completed HC maps for all Operational Rules and a large majority of programme level hazards (possible). 33

34 The story of Human Component mapping The final outcome 34

35 3. OUTLINE OF STEPS FOR THE METHOD 35

36 Outline steps for the method 6 Steps to Human Component mapping STEP 1: Set rules and questions for each of the HC s and produce context specific pick-lists. STEP 2: Identify HC structure and allocate HF records using HC structure. STEP 3: Describe hazards and other elements in terms of their HC s. STEP 4: Validate descriptions. STEP 5: Complete HC mapping and link evidence. STEP 6: Identify where further evidence & tests are required. 36

37 Outline steps for the method Step 1: Set rules and questions for each of the HC s and produce context specific pick-lists The aim of this step is to produce a set of rules and questions that suit the particular project, so that HC s can be allocated correctly. In order to be repeatable and verifiable, sets of questions and pick-lists were built up. 37

38 Outline steps for the method Step 1: Set rules and questions for each of the HC s and produce context specific pick-lists Example for Application & Comprehension: o Q: Does the situation require a person to comprehend and apply the <equipment/system> OR <operational rule> OR <organisational context>? Example for Communication: o Q: Does the situation require communication between individuals or a group of people that is initiated by a person and sent to a person? 38

39 Outline steps for the method Step 1: Set rules and questions for each of the HC s and produce context specific pick-lists o Examples for HC statements (A&C and Comms): 39

40 Outline steps for the method Step 2: Identify HC structure and allocate HF records using HC structure Iterative with Step 1, as the structure develops, new thinking will evolve and gaps will be identified. Once the high level structure has been developed, brainstorm Human Component content and HF grouping using: HF best practice and experience. Operational concept. Systems definition. Review of the hazard log. Any reference HF issues logs, scoping, etc. 40

41 Outline steps for the method Step 2: Identify HC structure and allocate HF records using HC structure Communications There are limited levels of structure for each Role with Role communication. It may be necessary to add a purpose: Possible deeper level of structure for each Normal operations Emergency situation Failure condition To fulfil a specific task Workload Possible deeper level of structure for each role for workload management/ increase/ significant reduction: Specific reasons for workload increase Specific reasons for workload significant reduction Specific content that requires workload management Design Possible deeper level of structure for each product: Usability Availability Technology introduction Equipment integration Layout and placement Product specific concerns Maintainability Application & Comprehension Possible deeper level of structure for each type of activity: Groups of duties; Different conditions of service Different conditions of equipment; Understanding information inputs Compliance with procedures; Understanding & applying specific communication types Situational awareness 41

42 Outline steps for the method Step 2: Identify HC structure and allocate HF records using HC structure 42

43 Outline steps for the method Step 3: Describe hazards and other elements in terms of their HC s Once you have understood the content and power of the HC groups and statement idea, you can use them to analyse the project hazard records. Each hazard should be analysed by the appropriate people (e.g. expert users, development team, safety team & HF team). Where possible, carry out this analysis with separate groups, so that you gain a more detailed and thorough review from each interested party (they will come together at the formal workshop in Step 4). 43

44 Outline steps for the method Step 3: Describe hazards and other elements in terms of their HC s The aim is to produce a full understanding of the hazard, with respect to HC s, so that anyone seeing this can: o Understand the scope of HC s; o The roles involved; o The products they use and the HMI design elements; o What they have to apply and comprehend; o Who communicates with whom; o What workload changes they may be subjected to; o What organisation/ group they work within; o Get a clear view of the potential complexity of the HC s involved; o Therefore, gauge the hazard and understand the wider human context. 44

45 Outline steps for the method Step 3: Describe hazards and other elements in terms of their HC s We produced a tool in Excel & used pick-lists wherever possible, with additional free-form text to record the exact HC statements. 45

46 Outline steps for the method Step 4: Validate descriptions Use a systematic process to agree the descriptions and allocations. Our suggested approach (for completeness argument) is to have each and every potential HC actively allocated to either: o dismissed o relevant o causal Organise a workshop with the appropriate people to allow a once and for all approach to check the HC map of the hazards. Having a visualisation to communicate the process and outcomes is valuable 46

47 Outline steps for the method Step 4: Validate descriptions Remember the HC map Description of Hazard XYZ ROLES PRODUCTS ORGANISATION Role 1 A&C HC1 Role 1 A&C HC2 Role 1 A&C HC3 Role 1 W/L HC1 Role 1 W/L HC2 Role 2 A&C HC1 Role 2 A&C HC2 Product 1 A&C HC1 Product 1 D HC1 Product 1 D HC2 Product 2 D HC1 Product 3 A&C HC1 Organisation 1 A&C HC1 Organisation 1 A&C HC2 Organisation 1 C HC1 Organisation 1 C HC2 Organisation 1 C HC3 Organisation 2 A&C HC1 Role 2 W/L HC1 Role 3 A&C HC1 Role 3 A&C HC2 Product 3 D HC1 Product 4 D HC1 Organisation 2 C HC1 47

48 Outline steps for the method Step 4: Validate descriptions Here s the same for the HC s that are actively NOT part of the HC map Role x A&C HCx Role x A&C HCx Role x W/L HCx Product x D HCx Product x D HCx Organisation x C HCx Relevant but not casual HC s ROLES PRODUCTS ORGANISATION Role x A&C HCx Role x A&C HCx Role x A&C HCx Role x A&C HCx Role x A&C HCx Role x W/L HCx Role x W/L HCx Role x W/L HCx Role x W/L HCx Role x W/L HCx Product x D HCx Product x D HCx Product x D HCx Product x D HCx Product x D HCx Product x A&C HCx Product x A&C HCx Product x A&C HCx Product x A&C HCx Product x A&C HCx Product x A&C HCx Dismissed HC s Organisation x Organisation A&C HCx x Organisation A&C HCx x Organisation A&C HCx x Organisation A&C HCx x Organisation A&C HCx x A&C HCx Organisation x Organisation C HCx x Organisation C HCx x Organisation C HCx x Organisation C HCx x Organisation C HCx x C HCx 48

49 Outline steps for the method Step 5: Complete HC mapping and link evidence This step makes the connection between the structured HF records and the HF work completed as a matter of course within a project. The linking can be done by: o Direct many to many linking content within a database (where the HF records log is in DOORS & the HF evidence is listed e.g. document titles/ numbers); o One HF piece of work to many HF records linking in a report-based approach (e.g. summaries of HF evidence and how they close HF issues); o One HF record or HF issue to many HF pieces of work. In reality, a combination is often required to satisfy the authorities but what should NOT be needed is to go through each and every hazard repeating HF evidence; the mapping through HC s takes care of this. 49

50 Outline steps for the method Step 6: Identify where further evidence & tests are required Human Components are the centre of the mapping: o HC s of hazards are linked to HC groups o Which in turn are linked to HF records o Which in turn are linked to HF evidence So they can be used to identify whether there are gaps in the current documented design evidence. Also, what needs more emphasis in testing due to theory & design being unable to provide enough. Gaps in the HF evidence for HF issues may require further work, as would be the case through a traditional HF issues log. 50

51 5. SUMMARY & CONCLUSIONS 51

52 Summary and conclusions So where are we? There is a need to link to human factors Human components of hazards have complex interactions The Signalling Programme is attacking the issue head-on! The work on S-Bane has been effective and has directly guided the operational testing. The Fjernbane is more complex and we have lessons learnt from S-Bane. The development of the Human Component maps and mapping method is the direction being used to produce results. 52

53 Summary and conclusions Final remarks All things appear and disappear because of the concurrence of causes and conditions. Nothing ever exists entirely alone; everything is in relation to everything else. Buddha 53

54 Managing Human Factors in the Signalling Programme The latest development in the work of the Human Components Mapping Dr. Amanda C. Elliott Safety Team Banedanmark