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Human, technology and organisation (HTO) as regards major accident risk

Experience from investigation of serious incidents confirms that complex and safety-critical activities still depend on human actions as a central precondition for good decisions, safe operations and handling of nonconformities.

Furthermore, in spite of the fact that the human beings in the system can make mistakes, they are also a source of robustness as regards safety.

Recent research, e.g. from the HSE research program, points out that supervisors’ and employees’ competence and ability to improvise are key elements in restoring safe conditions in the event of an unexpected course of events. This speaks in favour of increasing emphasis on human behaviour as a positive safety factor that must be taken into consideration in the same way as the risk of mistakes is taken into account.

There appears to be agreement between the parties that the regulations generally provide good framework conditions for attending to the safety importance of human actions in complex and safety-critical work systems. The expansion of the PSA’s sphere of authority to include specific land facilities contributes to a broad and integrated focus on good working environment between the offshore activities and the land facilities.

HTO factors that have been granted special emphasis by the authorities in their follow-up, and which must also be followed up in the years to come, include the following:

  • Psycho-social and organisational factors
  • HTO in safety-critical systems
  • Alarm systems in operations
  • Competence, training

Investigation of serious incidents and major accidents in safety-critical industries has put the spotlight on change processes as a significant potential contributor to risk. Consequently, the PSA has emphasised follow-up of the extensive change processes that have affected the petroleum sector on the Norwegian Continental Shelf in recent years.

Important experience gained from review and follow-up of such processes shows that:

  • Clear HSE targets must be established for changes.
  • Working environment/organisational risk contributors must be emphasised just as thoroughly and systematically as technical contributors.
  • The players must apply appropriate methods of risk assessment.

The various parties’ interests must be acknowledged and handled through planned participation, which can also include impartial expert assessments of actual risk factors. In addition to having a direct impact on HSE in the affected work processes, changes may also have unintended consequences in other places in the activities, which increases the risk that important elements are not adequately evaluated, thus creating latent weaknesses in new solutions.

Thorough analyses of how the changes affect HTO interplay in the work processes are important preconditions in this respect.