About HFC and benefits Become a member Minutes of meeting Discussions Communities-of-Practice Education, Training and Theory References to standards Other HF networks, useful links Members Certification of HF competence HF incidents and recoveries 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. CSB: 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 rig loss. Anders Ulfvarson: Sikker Evakuering fra store skip (2019) Human Performance (2019) NTSB Issues 7 Safety Recommendations to FAA related to Ongoing Lion Air, Ethiopian Airlines Crash Investigations (2019) AIBN (2018) Report on the air accident near Turøy 29 april 2016 with Airbus Helicopters EC 225 LP (ref: https://www.aibn.no/Aviation/Published-reports/2018-04) Safety (2018) Addressing-Differences-in-Safety-Influencing-Factors-A-Comparison-of-Offshore-and-Onshore-Helicopter-Operations 2017 Ergos -  Safety Board Report (OVV) on Esso 2017 fire - Why is the recent ESSO fire investigation important for ergonomics? OESI (2016) Human Factors and Ergonomics in Offshore Drilling and Production: - The Implications for Drilling Safety PSA (2016) - Supervision of Heimdal - Deviation barrier management, control, alarms HSE (2000/2016) Human Factors assessment of Safety Critical Task Analysis (SCTA) NAS/TRB (2016) 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) - IAEA report 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 (norwegian) RSSB (2015) "Fatigue and its contribution to railway incidents". PTIL investigation - Nødavstengning og akutt oljeutslipp til sjø på Eldfisk (2014) S. Kondo (2014) - Lessons Learned from the Severe Accident at Fukushima Daiichi (PSAM12) 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" (2013) 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" Ptil (2012b) "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 Costa Concordia event 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. http://www.norskoljeoggass.no/en/Activities/HSE-and-operation/Sharing-to-be-better/ 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" Published February 19, 2013	Available languages   Other webs 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