HFC - Human Factors in Control
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HF incidents and recoveries
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Human Factors Barriers
HF incidents and recoveries
In the following we have listed some recent deviations, accidents and successful recoveries where Human Factors (Organizational issues, Cognitive issues and HF issues) have played a central role from design through implementation.
PTIL (2019) -
Report after audit - Alarm load and HF in control room - Oseberg A
: illustrates the failures in critical controls and procedures in drilling operations that
caused the ‘holes’ in the ‘Swiss Cheese’ model to align, resulting in blowout, 5 fatalities and total
Sikker Evakuering fra store skip
NTSB Issues 7 Safety Recommendations to FAA related to Ongoing Lion Air, Ethiopian Airlines Crash Investigations
Report on the air accident near Turøy 29 april 2016 with Airbus Helicopters EC 225 LP
2017 Ergos -
Safety Board Report (OVV) on Esso 2017 fire
Why is the recent ESSO fire investigation important for ergonomics?
Human Factors and Ergonomics in Offshore Drilling and Production: - The Implications for Drilling Safety
PSA (2016) -
Supervision of Heimdal - Deviation barrier management, control, alarms
Human Factors assessment of Safety Critical Task Analysis
Committee on the Application of Real-Time Monitoring of Offshore Oil and Gas Operations
: Final Report
C. Chambers (2016) the
Buncefield final report
where Appendix 2 covers LOPA and how we dealt with a number of Human Factors issues
ESREDA (2015) -
guidelines_Barriers to learning from incidents and accidents
Accident Investigation Board (2015) -
Preliminary report on serious incident at Svolvær Airport Helle, Norway on 2 December 2010
Fukushima Daiichi (2015) -
from The Fukushima Daiichi Accident
PSA (2015) -
Valemon - Local control room offshore - Central Control Room onshore at Sandsli
PSA (2015) – "
Utilstrekkelig styring i Statoil vedrørende kontinuerlig forbedring og læring etter hendelser
Statoil (2015) Investigation report -
Condensate leak at Gudrun 2015.02.18
RSSB (2015) "
Fatigue and its contribution to railway incidents
PTIL investigation -
Nødavstengning og akutt oljeutslipp til sjø på Eldfisk
S. Kondo (2014) -
Lessons Learned from the Severe Accident at Fukushima Daiichi
Ptil (2014) "
Revisjonsrapport fra PTIL - CRIOP som en sjekk på organisatoriske- og operasjonelle barriere-elementer
" (Audit report from PTIL- CRIOP as a check on organizational and operational barrier elements)
Rune Valle: "
Safety in Action - Designing a Crew Resource Management prototype for N-USOC
". Master Thesis NTNU (2014).
Tone Skare (2014) et al. "
Characteristics of Dynamic Positioning Operators' Situation Awareness and Decision Making during Critical Incidents in Maritime Operations
". Proceedings of the 5th International Conference on Applied Human Factors and Ergonomics AHFE 2014, Kraków, Poland 19-23 July 2014
M. Cummings (MiT & Duke/HAL) (2014) -
Man versus Machine or Man + Machine?
Eurocontrol (2013) "
From Safety-I to Safety-II: A White Paper
Tone Skare (2013) "
Characteristics of critical incidents in dynamic positioning
", Master in Maritime Management at Vestfold University College
Tone Skare (2013) et al. "
Understanding human decision making during critical incidents in dynamic positioning
Ptil (2013) "
Tilsynsrapport NSOAF - Eni - Saipem - Organisatoriske og menneskelige faktorer ved ivaretakelse av brønnkontroll
In Waraich Q.R, Mazzuchi T.A., Sarkani S., & Rico D.F. (2013) "
Minimizing Human Factors Mishaps in Unmanned Aircraft Systems
January 2013, ergonomics in design "Although DoD UAS mishap rates vary between platforms, an average of 100-300 mishaps occur every 100,000 flight hours. In contrast, DoD human-operated aircraft average one mishap per 100,000 flight hours (Weibel & Hansman, 2005).". More completely, see: Qaisar Raza Waraich PhD thesis "
Heterogeneous Design Approach for Ground Control Stations to Marginalize Human Factors Mishaps in Unmanned Aircraft Systems
OGP (2013) "
Offshore safety: Getting it right now and for the long term
Sidney Dekker (2012) - "
Second Victim: Error, Guilt, Trauma and Resilience
NFA (Norwegian Society og Automatic Control) - "
Autonomous Systems (2012)
Ptil (2012a) "
Gransking Saipem - Ballasthendelse Scarabeo 8, 2012.09.04
"Tilsynsrapport NSOAF - Statoil - Transocean - Organisatoriske og menneskelige faktorer i håndtering av brønnkontroll" 10.07.2012
Ptil (2012) "
Brann på Valhall PCP den 13.7.2011 - HF design av krankabin?
MIT (2012) The
SHT (2011) -
Report on railway accident with freight car set that rolled uncontrolledly from Alnabru to Sydhavna on 24 March 2010
NC (2011). National Commision on the BP Deepwater Horizon Oil Spill and Offshore Drilling "
DEEP WATER - The Gulf Disaster and the Future of Offshore Drilling
Norsk Olje (2010) Well control incidents - Reducing well control incidents and a focus on well integrity are significant for reducing the risk of major accidents, lost production and higher costs on the NCS.
IFE (2009) "
Vurdering av organisatoriske faktorer og tiltak i ulykkesgransking
Ptil (2009) Collision between
Big Orange and Ekofisk
- Investigation report
Ptil (2007) "
Human Factors in drilling and well operations - working conditions
Successful recovery - Apollo 13: S. CASS (2005) "
Apollo 13, We Have a Solution
Mark A. Staal, NASA (2004) "
Stress, Cognition and Human Performance: A Literature Review and Conceptual Framework
NASA/TM-2004-212824 Ames Research Center, Moffett Field, California.
Fartum, H.R. (2002) "
Safety reviews – state of the art and future developments
HSE (2001) - "
Accident investigation - The drivers, methods and outcomes
Ptil (2001) "
A710 - Prinsipper for utforming av alarmsystemer
February 19, 2013
Network for Transport safety
SAREPTA - Human Factors in Autonomous transport
SMACS - Sensemaking in Critical operations
The CORD method
Security of SAS systems
SjekkIT - culture and security
SafeCulture - train
Responsible project manager HFC: