The Herald of Free Enterprise capsized on March 6, 1987, killing ~200 people. It sank because its inner and outer bow doors had been left open on sailing due to a combination of factors and decisions. The subsequent investigation found that all of these could have been avoided or ameliorated. Management failures set up a…...
In the world of process safety, we have a thing called “human factors” and signage is part of this aspect. Take this sign for example, do you see anything odd about this sign? Any of the data confusing to you? Look closely… By the looks of this photo, this appears to be a “misprint”. See…...
Several years ago the Pipeline and Hazardous Materials Safety Administration (PHMSA) enacted the following regulations in response to some large scale pipeline incidents: § 192.631 Control room management PHMSA published the Control Room Management/Human Factors final rule in the Federal Register on December 3, 2009, which became effective on February 1, 2010. The agency actually…...
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This is one of those MUST READ studies for all safety professionals who deal with machine gaurding and interlocks, and/or have a behavior based safety process! Although the study was done on Computer Numerical Control (CNC) machines in the UK, we can certainly see how the results can be expected on ANY machinery and by ANY…...
A study of equipment failures in the process industries indicates human and organizational errors are the major cause. One in five accidents caused by equipment failures in the chemical process industries is the result of human and organizational errors. Significant factors in equipment failures included: Poor contractor control Failure to follow procedures Lack of planning…...
Can you find the “human factors” issues in these photos? This next photo is not quite as obvious as the one above, but this is an emergency egress hatch for a bus used to shuttle workers at a mine site. Myself and another safety professional were doing a site assessment for them and on the…...
Identifying human error is a starting point, not a conclusion. If we aim to learn from the error and to lessen the chances of it happening again, we need to consider the organizational context that surrounds the person’s action, including equipment, procedures, people, the environment, and management. There are two aspects to managing error:… Membership...
We have all heard the term before, but what exactly did OSHA and EPA really mean when they stated that “human factors” must be part of a Process Hazards Analysis (PHA)? In the USA, we can look to OSHA’s PSM Compliance Directive, CPL 02-045, to get an idea of what we should consider “human factors”…...
Another major incident investigation finds serious cultural failures, poor training for operators and emergency responders, poor emergency planning, and technical failures in the Mechanical Integrity program. The crude oil pipeline company’s pervasive organizational failures caused a massive 2010 spill in Michigan, a National Transportation Safety Board (NTSB) preliminary investigation has found. The investigation found that…...
There are only two (2) different types of HUMAN FAILURES: ERRORS (Inadvertent) NON-COMPLIANCE (VIOLATIONS) (Deliberate) A HUMAN ERROR is an action or decision that was not intended, involved a deviation from an accepted standard, and led to an undesirable outcome. A NON-COMPLIANCE (VIOLATION) is a deliberate deviation from a rule or procedure…. Membership Required You...
People do not err intentionally. Error is a human action that unintentionally departs from expected behavior. Error is behavior without malice or forethought; it is not a result. Human error is provoked by a mismatch between human limitations and environmental conditions at the job site, including inappropriate management and leadership practices and organizational weaknesses that…...
