Patrick Hudson

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Safety culturetheory and practice

The Human Factor in System ReliabilityIs Human …, 2000

8-1 Safety CultureTheory and Practice Patrick Hudson Centre for Safety Science Universiteit Leid... more

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The Rule of Three: Situation Awareness in Hazardous Situations

Proceedings of SPE International Conference on Health, Safety, and Environment in Oil and Gas Exploration and Production, 1998

The criteria for making Go -No Go decisions are often conservative because the decision rule (i.e... more The criteria for making Go -No Go decisions are often conservative because the decision rule (i.e. to stop flying helicopters, to go around with a tanker, to shut down a platform or halt concurrent operations) does not take the interaction of multiple factors into account. All of the situations and events leading to an incident are sub-standard, but taken in isolation none of them usually appear dangerous enough to warrant halting operations and taking stock. Accidents rarely happen because of a single catastrophic failure, except when that failure is at the end of a chain of non-catastrophic failures and organisational oversights. Go -No Go decisions are hard to make, especially when situations have been deteriorating slowly, and a clear decision rule can help. The Rule of Three is proposed as a way of combining information to make operational decisions in order to maximize opertunities and minimize regrets..

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Cost and Benefit in HSE: A Model for Calculation of Cost-Benefit using Incident Potential

Proceedings of SPE International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production, 2000

A study is reported in which costs and benefits of safety are studied using three different appro... more A study is reported in which costs and benefits of safety are studied using three different approaches. Costs were split into Direct costs that arise as a direct result of an accident, Associated costs that arise because an incident is reported, Remedial costs and indirect costs that impact on the company. In an EP company a sample of 70 incidents was studied in detail to arrive at an average cost per incident of £ 14,000 and a platform cost approaching £1m, in close agreement with an earlier study by the UK HSE. An alternative approach, using estimates of likely costs for different types of incidents, arrived at a slightly higher incident cost. Both these approaches use historical events to estimate costs. A third approach, using incident potential, combines costs of possible incidents with associated probabilities of those events to arrive at an expected cost. These expected costs may be expressed in terms of Net Present Value (NPV) to allow a consistent representation of financial and operational risks. On the basis of this study it is clear that level 3 and 4 incidents, minor incidents equivalent to Potential levels 2 and 1 in the Shell Group Risk Assessment Matrix, cost the company in excess of £10m in a year. Indeed, when treated in terms of Net Present Value (NPV) and allowing for undiscovered indirect costs across the company, the risk being carried is probably in excess of £200m. The effectiveness of remedies and their benefits decay over time. Quick fix remedies lose most of their value within a month, so their benefit measured in NPV is negligible. Effective remedies have long decay rates and learning is well propagated. Safety is seen to pay off when looking at the costs of incidents that have been actively prevented.

Response 3 Designing for risk: New materials and new approaches

Around Glare

In conclusion, I would like to say that the talk from Airbus indicates a sensible approach. It is... more In conclusion, I would like to say that the talk from Airbus indicates a sensible approach. It is appropriate, risk-based and evolutionary. It is also useful to note the inclusion of maintainability concepts and a whole-system concept, which does not concentrate too much on operations or manufacturing, for example. However, when you do have new and improved developments, experience shows that people will always push the envelope in ways you never expected, and when they do that, I fear I may have to come and investigate.

Integrating Cultural and Regulatory Factors in the Bowtie: Moving from Hand-Waving to Rigor

Ontology Modeling in Physical Asset Integrity Management, 2015

Recent analyses of major incidents, such as BP’s Texas City and Macondo disasters and the loss of... more Recent analyses of major incidents, such as BP’s Texas City and Macondo disasters and the loss of the space shuttle Columbia, have moved from considering immediate factors and basic organizational failings to including cultural issues. Culture is, however, even more difficult to incorporate into incident investigations and analyses than are organizational factors. This chapter provides a structured approach to analyzing individual, organizational and cultural/regulatory factors based upon the bowtie methodology, using well-defined rules to distinguish three levels of causation.

Modelling human and organizational behaviour in a high-risk operation

A core part of the risk modelling program for the Oil and Gas industry being carried out at Delft... more A core part of the risk modelling program for the Oil and Gas industry being carried out at Delft University of Technology is the influence of humans, within an organisation, as well as the technical factors. Specific attention is given to the incentive structure of operators, staff and managers, which in previous models had only been indicated more generally by motivation and conflict resolution. An incentive structure represents an empirical framework for an organisation which characterises the relationship between specific behaviours of employees and the probabilities of receiving various incentives. Most of the scientific literature on incentives is about the formal incentive structure that companies have in place. There are however, many more incentives so that a decision to choose one from several possible courses of action and decide to commit to safety above other personal and organizational goals is certainly influenced by personal safety attitudes, but there are also strong organizational aspects to these influences. Management influences and management actions are considered important in this respect because their actions influence personal safety attitudes to some degree. For instance, personal "need" and "incentives" are factors / motivations that can be coupled with a company's goals influenced by management influences. Employees who feel they have access to good career development opportunities, or who are praised by managers for doing a good job, are more motivated and more likely to committed to their work. Lin (2008 studied quantifying the influences of management actions on human performance, expressed through the quality and operation of the management actions. Interviews with personnel serve to uncover which signals are sent by managers and colleagues and how they are received. This paper discusses the different incentive structures identified and describes methods used to uncover and quantify them in a wider risk model.

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Why Improving the Safety Climate Doesn't Always Improve the Safety Performance

All Days, 2010

This paper will discuss the results of a study outside the petrochemical industry (Vandevis (2008... more This paper will discuss the results of a study outside the petrochemical industry (Vandevis (2008), but the results may have a profound effect on the way organizations try to influence their safety climate by setting so called SMART goals. It was conducted within the electrical high voltage contracting industry in Ontario, Canada and the objective was to investigate the relation between goal setting as a way to influence the safety climate and several safety related parameters and injury experiences. A quantitative survey based on Zohar's (2000) Safety Climate Scales was conducted with 564 surveys returned from 26 companies. Safety climate was not found to be correlated to self-reports of injury nor to lost-time or no-lost-time injury statistics. Safety climate was strongly and positively correlated with organizations setting at least partly SMART safety goals and in particular very strongly correlated when setting a goal of zero injuries and moderately and inversely correlated ...

Moving from Investigating to Analyzing Incidents: Supporting Organizational Learning

All Days, 2010

Incident investigation techniques in all high-hazard industries concentrate primarily on the imme... more Incident investigation techniques in all high-hazard industries concentrate primarily on the immediate causes, such as the technical failures and the more frequent human shortcomings that led to the incident. Issues that are identified at these superficial levels of investigation and analysis tend to be local and hard to relate to deeper underlying causes that may be company-wide. Answers to more abstract questions, about organizational and cultural issues, provide much more useful information that organizations can use to implement preventative programs with far-reaching benefits rather than just treat symptoms of the underlying problem that may do little to prevent the next incident. The ‘statistical’ approach described in this paper relies upon the notion that lower accuracy of assignment to a cause category in any single accident analysis can be compensated by averaging over larger numbers of incidents. Investigators often remain close to the event because the evidence is more c...

Meeting Expectations: A New Model for a Just and Fair Culture

All Days, 2008

The paper first discusses the problem of non-compliance in high hazard industries, as these const... more The paper first discusses the problem of non-compliance in high hazard industries, as these constitute the most frequent type of dangerous activities in terms of accident outcomes. Evidence is drawn from aviation and the petrochemical sectors. The causes of non-compliance are found to form a ‘lethal cocktail’ of i) the expectation that rules will have to be bent, ii) the feeling of powerfulness, iii) the existence of opportunity and iv) poor planning of work. Non-compliant behaviour can be seen as a natural response of motivated and competent individuals, often selected for their ability to show initiative, in the face of poor planning and the existence of alternative ways to get the job done. Six distinct types of non-compliance are identified, two unintentional – failures of Understanding and Awareness -, Situational, Exceptional and one for Company Benefit and one type for Personal Benefit. The issue of reckless non-compliance is discussed, together with the difference that must ...

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Managing Non-Compliance: Moving from Theory to Practice

All Days, 2002

Rules and procedures form a major part of the system of barriers and controls As there is the ass... more Rules and procedures form a major part of the system of barriers and controls As there is the assumption in a HSE _Management System that the rules and procedures will be followed, rule-breaking and other violations constitute a major threat to HSE management. This paper reviews earlier work on why people violate and introduces the ‘Lethal Cocktail’ four factors that predict and promote violation, Expectation, Powerfulness, Opportunity and Planning, as well as the counter effect provided by good personal norms. This paper describes the philosophy and application behind a brochure "Managing Rule-Breaking – the Toolkit" that supports the management of violation in operations in a stand-alone manner. The structure of the brochure and the procedures proposed to identify and remedy procedural and compliance problems are introduced. There is a discussion of the factors that can lead to failure even if the supporting material is good.

How to Win Hearts and Minds: The Theory behind the Program

All Days, 2004

The Hearts and Mind program was originally intended to develop intrinsic motivation in the workpl... more The Hearts and Mind program was originally intended to develop intrinsic motivation in the workplace. Unlike many change and behaviour-based HSE programs, often based upon the use of common sense and experience, the Hearts and Minds program relies upon scientifically validated models to ensure robustness and effectiveness, but the supporting material does not describe the scientific bases used to develop processes and supporting materials. This paper describes those theories and provides a reference for those who wish a deeper level of understanding. Introduction There are two ways to improve HSE performance in high-risk industries such as the Oil and Gas industry. One approach concentrates upon the identification and management of the hazards of the workplace. This is the approach taken, with considerable success, with the implementation of HSE-management systems. However, this approach is relatively coarse-grained and takes little account of the contribution of the individual, exc...

Holding up the Leadership Mirror then Changing the Reflection: The Seeing Yourself as Others See You tool

All Days, 2006

Regulators, researchers and professionals in the oil and gas industry all agree on the importance... more Regulators, researchers and professionals in the oil and gas industry all agree on the importance of leadership commitment to HSSE. The right safety leadership is the most important factor in building a strong HSSE culture, but historically the focus has been on the workforce through traditional behavior based safety programmes. What this paper does is explain a tool Seeing Yourself As Others See You, which gives leaders personal feedback on whether they are seen to walk the talk, know what the issues are in their organization, build trust and put a priority on safety. This tool has been developed over a number of years by the Universities of Aberdeen, Manchester and Leiden as well as the UK Step Change initiative and Shell International Exploration and Production. One component is a web-based tool, developed and supported by Leiden University, to ensure the confidentiality of the information submitted. This also allows the tool to be used by other organizations. The most important ...

Hearts and Minds: The Status After 15 Years Research

All Days, 2002

In 1986 Shell International Exploration and Production started sponsoring a research programme to... more In 1986 Shell International Exploration and Production started sponsoring a research programme to better understand why accidents occur and what can be done to avoid them. After 15 years of research involving the universities of Leiden, Manchester and Aberdeen it is time to take stock of the know-how that has been generated and analyse how this has changed life in Shell Companies. Both the theory and the practical tools to make the theory accessible for a wide audience are outlined in this paper.

Hearts And Minds Change Programmes Make A Difference

All Days, 2004

For many years Shell, have shared at SPE conferences the insights gained from research together w... more For many years Shell, have shared at SPE conferences the insights gained from research together with universities of Leiden, Manchester and Aberdeen, into incident prevention and human behaviour. Some of the tools developed from this research, notably Tripod BETA and Tripod DELTA have been made available to the industry. During the last conference an overview was given of 15 years of research and its results. The present paper provides an overview and update of recent research, the practical tools that have been developed and the methods and strategy to successfully turn science into practice. A stage has now been reached in which these "Hearts and Minds" tools really start to make a difference and successes become visible in the form of revived enthusiasm and genuine care for HSE, which is not forced by the management system but comes from "inside" because the people believe in it. As Shell believes that the tools represent "best practice" in behaviour...

A Guide to Selecting Appropriate Tools to Improve HSE Culture

SPE International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production, 2010

There is a wide range of HSE tools available – some function at the broadest organizational level... more There is a wide range of HSE tools available – some function at the broadest organizational level and some target individual activities. Many managers and supervisors simply use the tools that are familiar, missing potential opportunities for improving HSE performance. In other cases, groups may try every new tool they encounter to give the impression of active engagement in HSE improvement, searching for a "quick fix". As companies develop more advanced HSE cultures, they should consider updating or changing the HSE tools used to reflect the improvement and maturity of their HSE culture. HSE culture, however, may not be the same across all the parts of a large organization. Therefore care should be taken when considering company-wide initiatives. The specific culture of the business unit or geographic location should be considered in selecting appropriate tools and indicators. This paper provides information about HSE tools that can be used to improve Health, Safety & Env...

Further development of a method to calculate frequencies of loss of control including their uncertainty

Beyond the Horizon, 2013

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Implementing a safety culture in a major multi-national

Safety Science, 2007

This paper reports on the implementation of an advanced safety culture in a major oil and gas mul... more This paper reports on the implementation of an advanced safety culture in a major oil and gas multi-national. The original proposal came from the company after it had become clear that expectations had been raised after the successful implementation of Health, Safety and Environment (HSE) Management Systems subsequent to the Piper Alpha disaster. The proposal made by the company, to develop a workforce intrinsically motivated for HSE, was operationalised as the development of an advanced safety culture after a review of the literature on motivation. The model used was the HSE Culture Ladder that had become the industry standard accepted by the OGP (International Association of Oil and Gas Producers). This model was intended to show that there were considerable opportunities for improvement even after HSE-MS had been implemented and that the more advanced cultures were ones people felt were desirable and achievable for themselves. Once top management had provided the initial support for the development of a more advanced safety culture, a number of supporting tools were developed, under the Hearts and Minds brand, and a strategy for implementation was developed that relied more on bottom-up 'pull' rather than topdown 'push' -the standard implementation model for new initiatives. The tools were designed to provide a clear direction, a road map to an advanced culture defined in terms provided by people within the industry, to support lasting changes in attitudes and beliefs, to promote an increased feeling of control when solving HSE-specific problems -all components of a more advanced culture. The tactics employed, using a pull rather than a push approach, had to allow for local variation within the general limits set by the strategy that eventually became a mixed top-down and bottom-up approach. Next there is a discussion of the current status and the lessons to be learnt from the implementation so far: moving away from command and control is hard for large organizations; such programs have to be driven by different performance indicators; managers have to

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Towards BBN based risk modelling of process plants

Safety Science, 2014

Recent disasters in high hazard industries such as Oil and Gas Exploration (The Deepwater Horizon... more Recent disasters in high hazard industries such as Oil and Gas Exploration (The Deepwater Horizon) and Petrochemical production (Texas City) have been found to have causes that range from direct technical failures through organizational shortcomings right up to weak regulation and inappropriate company cultures. Risk models have generally concentrated upon technical failures, which are easier to construct and for which there is more concrete data. The primary causes lie firmly rooted in the culture of the organization and determine the way in which individuals go about risky activities. Modelling human activities, especially collectively rather than individual human errors as is done in most human models, is a quite different proposition, in which complex interactions between different individuals and levels change over time as success and failure alter the pattern of payoffs. This paper examines the development of a dynamic integrated model for risk in a real-time environment for the hydrocarbon industry. It is based originally on the CATS model for commercial aviation safety, which first attempted to address some of these problems in a relatively simple way. Aviation is, however, a relatively simple activity, with large numbers of common components in a constrained environment. The Oil and Gas industry is significantly more diverse, covering the gamut from exploration, drilling, production, transport, refining and chemical production, each with its own potential for large scale disaster, but in the case of an integrated oil company all run by individuals within a common company culture.

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Attentional dynamics and a chorus of geons

Behavioral and Brain Sciences, 1998

This commentary discusses three main requirements for models of vision, namely, translation and s... more This commentary discusses three main requirements for models of vision, namely, translation and scale invariance, scalability, and hierarchy. Edelman's Chorus model falls short of fulfilling these requirements because it ignores the highly dynamic nature of vision. Incorporating an attentional mechanism and assuming geon-like prototype representations may enhance Chorus's plausibility as a model of human object recognition.

Integrating organisational culture into incident analyses: Extending the Bow Tie model

SPE International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production, 2010

Recent analyses of major incidents, such as BP's Texas City disaster and the loss of the spac... more Recent analyses of major incidents, such as BP's Texas City disaster and the loss of the space shuttle Columbia, have moved from considering immediate factors and basic organisational failings to considering cultural issues. Cultural issues are, however, even more difficult to incorporate into incident investigations and analyses than are organisational factors. This paper provides a structured approach to analysing individual, organisational and cultural/regulatory factors based upon the Bow Tie methodology, using well-defined rules to distinguish three levels of causation. Level 1 analysis describes barriers implemented at the individual and immediate hardware level; Level 2 describes the organisational factors that support level one barriers; Level 3 describes the cultural and regulatory environment that ensures that the organisation implements level 2, thereby ensuring the integrity of level 1 barriers. Incident investigation and analysis can be performed as a structured sea...

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