Three (3) things that a Human Error is NOT: a sin an event, and most importantly a root cause Tony Muschara, Risk-Based Thinking Managing the Uncertainty of Human Error in Operations, 2018… Membership Required You must be a member to access this content.View Membership LevelsAlready a member? Log in here...
Three (3) things that a Human Error is NOT Read More »
There is a common phrase in Human Factors Engineering… “Error Trap.” This is the image we will put next to this phrase in my new book… (i.e., an actual real-life “error trap” door). Scenario: Your singing your favorite song in the shower. The spouse needs to go down to the basement and start a load…...
Human Factors 101… when you see it (a virtual error trap) Read More »
Over the past several years, I have focused on my SMS/HF postings rather than the traditional technical postings. Being a safety pro means we wear many hats. I break these down into just two (2) main categories: 1) Technical and 2) Management Systems, including the soft skills we need to possess. Those who have followed…...
Reason’s take on the causes of Bhopal, Challenger, Chernobyl (Active & Latent Failures) Read More »
The Institute of Nuclear Power Operations (INPO) manages the Significant Event and Information Network for its member utilities both within and outside the United States. In 1985 they issued an analysis of 180 significant event reports received in 1983- 84 (INPO 1985). A total of 387 root causes were identified. These were assigned to five…...
INPO Study showed 92% of all root causes were man-made, but don’t fall for the trap Read More »
Human error can be divided into either intentional or unintentional actions. INTENTIONAL actions—those actions that involve conscious choices. These actions are primarily due to judgment or motivational processes. UNINTENTIONAL actions—those in which the right intention or plan is incorrectly carried out or where there is a failure to carry out an action. These actions typically…...
Unintentional errors vs. Intentional errors Read More »
Before disciplining a worker for an “error” or “mistake” that led to undesired consequences, we need to ask ourselves one simple question… How often have we written 2022 when signing checks and documents this year? It is February 15th, 46 days into the new year, yet I just had to correct a document that I…...
Check writing and Human Factors Read More »
As more facts are coming to light regarding the runway incursion incident at JFK on January 13, 2023, it appears that a “safety system” used by ground controllers may have saved the day. In the NTSB’s preliminary report on the incident, it is stated: The ASDE-X alerted the JFK ATC tower to the conflict, and…...
Did a “safety system” prevent the largest runway incursion disaster? Read More »
For most senior safety professionals, we have arrived at a place in our careers where we can understand the significance of what Dr. Reason said in 1997. Although most would agree, we started our careers in a very different place when it comes to how we derived the root causes of accidents throughout our careers. …...
Human Error is a Consequence, not a Cause Read More »
The significance (or severity) of an event depends upon the consequences suffered and not on the error that initiates it. The error that triggers a serious accident … and the error that is one of hundreds with no consequences… can be the same error. Human Error, James Reason, Department of Psychology University of Manchester,…...
Weekly thought on human errors Read More »
Your OSH or PSM/RMP audit report declares a human factor issue was found. You honestly wonder how much of a risk this really is, but you’re told it has to be fixed so we can close out the finding. So I present to you HF Engineering 2023… Membership Required You must be a member to...
Things that make you go hmmmm (HFE 2023) Read More »
I thought I had shared this image before, but I could not find it. I did NOT create this image but have had it since 1994. It came from my first HF Engineering Course in preparation for Process Safety, specifically the HFA part of a PHA…. Membership Required You must be a member to access...
Human Errors are … Read More »
This was a nice attempt to correct the obstructed clock on the wall. Why they did not just move the clock 6″ to the right or run the conduit differently is beyond me….. Membership Required You must be a member to access this content.View Membership LevelsAlready a member? Log in here...
Human Factors 101… when you see it (obstructed clock) Read More »
