What Happened: Two contractors re-injected the wrong clamp. The flange bolts failed, and the two contractors involved in the work died in the steam released. In the legal case, the judge focused on the possibility of human error. The company should have anticipated the possibility of this human error and concluded that the site did […]
The conditions that increase the risk of violations can differ from those that produce errors. Violations are often associated with time pressure, poor procedures, poor supervision, and shortages of equipment or spares. The table below shows some reasons people gave for not following procedures in one study.
Some error-producing conditions are more powerful than others. The table below shows estimates of how different conditions create the risk of error. Poor instructions or procedures are said to triple the rate of error. Lack of experience with the task is estimated to result in a 17-fold increase in the risk of error.
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:
15 human error thoughts we need to consider during our next incident investigation and causal analysis:
We see this often in our PHAs/HFA and audits… an emergency shutdown procedure would need an Olympic athlete to carry out before the LOPC event begins. And to top it off, the operators we witness as those who would be expected to carry out this ESD SOP are “senior” operators who tend to be out
The main objective of any safety data collection and analysis system is to make events, hazards, safety trends, and their contributing factors VISIBLE and UNDERSTANDABLE so that the organization can take effective corrective action. Generally, the same decision-making, communication breakdown, and distraction problems we see in a serious accident will also tend to see in
The control of human error requires two (2) different approaches. First, it is necessary to MINIMIZE THE OCCURRENCE of errors, and the second is to REDUCE THE CONSEQUENCES of the remaining errors by
To contain and control human error, one must first understand its nature. There are basic concepts associated with the nature of human error: the origins of errors can be fundamentally different, and the consequences of similar errors can also be significantly different. While some errors are due to carelessness, negligence, or poor judgment, others may
As we have discussed before, all drivers (including all parts of the world) can recognize the universal symbol for STOP. It is a RED OCTAGON-shaped sign LOCATED on the side of the road at the SAME height in all locations. Granted, the sign may be on different sides of the road, based on the country
As we work on a project for a client, I am reminded of the stark contrast in HF expectations across industries. Having grown up in the chemical industries managing PSM/RMP-covered processes, Human Factors (HF) has been “a thing” since 1992. HF was very much a steep learning curve and still is for many. I spent
Nine (9) principles for incorporating human factors into LEARNING investigations:
