In our previous blog, we introduced human factors and explored PABIAC’s requirements for the paper and board industry. We discussed why traditional approaches to safety often fall short and highlighted the promise of human factors—fewer incidents, improved efficiency, and better employee engagement.
But what does human factors implementation look like in practice? How do you move from concept to reality? This second instalment explores the systematic approach that successful organisations use to integrate human factors into their operations.
Recap: The Promise of Human Factors
Human factors is about designing for people—recognising their capabilities and limitations, and creating systems that work with human psychology rather than against it. When implemented effectively, human factors delivers:
- Safer operations through better design of equipment, tasks, and environments
- More reliable performance, with fewer errors and recovery mechanisms for when errors do occur
- Higher productivity as tasks become easier to perform correctly
- Greater employee satisfaction as frustrations are addressed and resolved
However, realising these benefits requires a structured approach. Ad hoc or piecemeal implementation rarely delivers the transformative results organisations seek.
A Structured Approach to Human Factors Risk Management
Successfully integrating human factors requires following a structured approach aligned with regulatory expectations. The HSE’s Human Factors Roadmap, detailed in the COMAH Delivery Guide, provides an excellent framework for paper and board establishments to follow.
This approach is tried and tested across high-hazard industries. It ensures a comprehensive assessment that addresses all aspects of human performance. Let’s break it down into practical steps:
1. Start with Major Accident Hazards
The first step is to identify your major accident scenarios. For paper and board facilities, these typically involve:
- Loss of containment of hazardous substances (like chemicals used in the process)
- Fires and explosions (particularly in areas with combustible dust)
- Pressure system failures (in steam systems and other pressurised equipment)
- Structural failures (such as storage rack collapses)
This foundation ensures your human factors work focuses on what matters most for safety. Many organisations already have this information in their risk assessments or safety reports – the key is connecting it to human performance.
2. Identify Critical Tasks
From your major accident hazards, identify the critical tasks where human performance is crucial in:
- Preventing these scenarios (like chemical transfers or cleaning operations)
- Controlling them (like emergency shutdowns or process monitoring)
- Mitigating their effects (like emergency response procedures)
Most companies prioritise tasks that could be involved in one or more fatalities. Tasks that should receive priority attention are those with the most severe consequences, that have a high level of human involvement, and might be vulnerable to error (e.g., due to complexity, poor working conditions, potential for workarounds).
For example, a typical paper mill might identify these as critical tasks:
- Machine cleaning and broke removal
- Testing level trips and other safety systems
- Maintenance on hazardous systems like dryer sections
- Loading/unloading hazardous chemicals
- Web threading operations
- Emergency response duties
3. Systematic Task Analysis
Once you’ve identified critical tasks, each needs to be analysed systematically to understand:
- The sequence of steps involved
- Where things could go wrong
- What influences human performance
- What controls are already in place
- What additional measures might be needed
This is typically done through Hierarchical Task Analysis (HTA) – a method that breaks down complex tasks into simpler components, making it easier to identify potential issues.
Importantly, this isn’t just a paper exercise. It requires getting out onto the shop floor to explore the gap between work-as-imagined (what procedures say) and work-as-done (what actually happens). This should involve:
- Walking through tasks with operators who perform them
- Observing real working conditions
- Understanding practical challenges
- Identifying performance influencing factors
We often find revealing insights during this stage. For instance, at one manufacturing site, operators could not find a valve that they said they used in practice, and at another site field operators assumed the control room operators were doing checks which they weren’t.
4. Human Failure Analysis
With a detailed task description in hand, the next step is failure analysis – reviewing what could feasibly go wrong and what the consequences might be.
To be systematic, this isn’t just brainstorming. It involves applying human failure guidewords (similar to a Human-HAZOP) to assess, for example:
- Could a step be omitted or performed incompletely?
- Could the right action be done on the wrong object?
- Could an action be too much or too little?
- Could a check be missed?
- Could something be miscommunicated or miscalculated?
This structured approach ensures you don’t miss potential failure modes. For example, when analysing a chemical transfer task, systematically considering each step might reveal that while valve selection errors are well-controlled, time pressures during emergencies could lead to missed checks.
5. Performance Influencing Factors (PIFs)
The analysis should consider all factors that shape how people perform tasks. Performance Influencing Factors can either increase the likelihood of a particular failure (negative impact) or decrease it (positive impact).
Key PIFs include:
- Equipment design (controls, displays, feedback mechanisms)
- Workplace environment (lighting, noise, temperature, space)
- Procedures and documentation (clarity, accessibility, usability)
- Competence and training (knowledge, skills, experience)
- Supervision and leadership (oversight, support, priorities)
- Workload and time pressure (demands, resources, scheduling)
- Organisational factors (safety culture, communication, resources)
Understanding these factors is crucial. For instance, a paper machine control panel might be perfectly usable during day shift but problematic at night due to glare on screens – a workplace environment PIF that only affects specific circumstances.
6. Implementing Controls
Based on this analysis, you can identify improvements following the hierarchy of control:
- Elimination: Can we eliminate reliance on human performance through automation, engineered solutions, or process redesign? For example, could we introduce automated paper threading rather than manual threading?
- Engineering Controls: If we must rely on human performance, can we optimise equipment design, improve workplace layout, and enhance control interfaces? For example, installing clear plastic sheets to enable visual checks without exposure to hazards.
- Administrative Controls: Finally, strengthen administrative controls through better procedures, enhanced training, improved supervision, and organisational arrangements. For example, ensuring clearing blockages is always fully supervised.
This systematic approach ensures you:
- Focus on what matters most for safety
- Consider all relevant factors
- Implement effective solutions
- Can demonstrate risk reduction to the regulator
Real-World Applications From Adjacent Industries
While human factors integration is still emerging in the paper and board industry, our experience from adjacent sectors demonstrates the value of this systematic approach, e.g.:
- At an oil refinery, we carried out a study on proof testing procedures for safety instrumented systems. The analysis revealed inconsistencies in how these critical tests were performed with best practices. Learning from that single study prompted a site-wide review of proof testing procedures, significantly reducing risks associated with inspection and testing of critical control equipment. Similar approaches could benefit paper mills’ safety critical equipment testing regimes.
- When we scrutinised a risk assessment for drum charging at a small batch processing facility, we discovered that assumptions made during the assessment weren’t as robust in practice as originally thought. The study revealed unofficial but beneficial practices that weren’t captured in procedures, along with opportunities for additional safeguards. This highlights the importance of understanding the gap between work-as-imagined and work-as-done – particularly relevant for paper industry batch operations.
- Following a near miss at a chemical plant, we reviewed their processes for storing, selecting, checking and charging hydrogen peroxide. This led to a deep analysis of their verification procedures, which had previously failed. The review uncovered how shift patterns and documentation were undermining these critical checks, leading to redesigned procedures and verification methods. Similar principles could apply to chemical handling in pulp production.
These examples demonstrate that human factors analysis often reveals unexpected insights that traditional safety approaches miss. The systematic methodology remains consistent across industries, making these lessons directly applicable to paper and board facilities implementing PABIAC’s human factors objectives.
Common Implementation Challenges
While the approach is straightforward in theory, implementation often faces challenges:
- Resource constraints: Human factors work requires time and effort. Start with your highest-risk areas and develop a phased implementation plan.
- Resistance to change: Operators may initially be reluctant to discuss workarounds or shortcuts. Create psychological safety by emphasising improvement rather than blame.
- Integration with existing systems: Human factors shouldn’t be a separate program but integrated into existing safety management. Look for opportunities to enhance current processes rather than creating parallel ones.
- Sustainability: One-off assessments deliver limited value. Build ongoing capability through training and make human factors part of your regular risk management approach.
What’s Next?
In our final blog post, we’ll explore practical steps to get started with Safety Critical Task Analysis (SCTA) – the industry standard approach for detailed and systematic human reliability assessment. We’ll cover resources, training options, and how to build capability within your organisation.
Want the complete guide?
Download our comprehensive PABIAC Human Factors guide. This detailed resource covers everything from identifying critical tasks to implementing effective controls, with real-world examples from the paper and board industry.
References:
HSE Human Factors Delivery Guide for COMAH sites: https://www.hse.gov.uk/comah/assets/docs/hf-delivery-guide.pdf
HSE. Making Paper Safely: Managing safety I the papermaking process. (HSG279) https://www.hse.gov.uk/pubns/priced/hsg279.pdf
Energy Institute’s Guidance on Human Factors Safety Critical Task Analysis
