AN ENGINEERS VIEW OF HUMAN ERROR Trevor Kletz Loughborough University

ALL ERROR IS HUMAN ERROR AS:

People have to decide what to do.
People have to decide how to do it.

People have to do it.

The concept of human error is unhelpful as it lumps together different types which need different actions.

TYPES OF HUMAN ERROR 1 MISTAKES Does not know what to do Poor training or instructions. Intention wrong. ,

TYPES OF HUMAN ERROR 2 VIOLATIONS

Does not want to do it Poor motivation

TYPES OF HUMAN ERROR 3 MISMATCHES Is not able to do it Beyond ability

TYPES OF HUMAN ERROR: 4 SLIPS OR LAPSES OF ATTENTION.

Inevitable from time to time.

THIS CLASSIFICATION HELPS US SEE THE BEST METHODS OF PREVENTION FOR EACH TYPE OF ERROR.

PREVENTING MISTAKES
Teach flexibility Provide training and instructions Make task easier Avoid contradictory instructions (What you dont say is as important as what you do say.)

Human Error

Are your instructions written to help the readers or protect the writer?

PREVENTING VIOLATIONS
Explain need Make task easier Checks and audits Dont turn a blind eye

BEFORE BLAMING SOMEONE ASK:

Were the rules known & understood? Was it possible to follow them? Were the reasons for them known? Were previous violations overlooked? Did the rules cover the problem? Was he/she trying to help?

Human Error

AN IRREGULAR VERB
I SHOW INITIATIVE YOU BREAK THE RULES HE IS TRYING TO WRECK THE JOB

Human Error

If instructions are wrong (due to ignorance or slips) violations can prevent accidents

A good method of persuasion is to discuss accidents and let those present say what they think should be done.

REASONS FOR MISMATCHES Impossible tasks Overload Underload Habit breaking Mind-sets

PREVENTING MISMATCHES Change Work Situation ie, design or methods of working

PREVENTING SLIPS AND LAPSES OF ATTENTION (Intention correct but not fulfilled) Change work situation

SLIPS & LAPSES OF ATTENTION OCCUR ONLY WHEN PEOPLE ARE WELLTRAINED.

MANAGERS & DESIGNERS ERRORS: are rarely slips as there is usually time to check. Sometimes violations. Usually mistakes.

ERROR TYPE
MISTAKES Does not know what to do VIOLATIONS Decides not to do it MISMATCHES Unable to do it SLIPS & LAPSES OF ATTENTION

ACTION
Better training & instructions/CHAOS Persuasion/CHAOS CHAOS CHAOS

CHAOS = Change Hardware And/Or Software

To face mask

From air bulb

Early chloroform dispenser

Typical Piping Settling Leg arrangement

Phillips 66 Incident
October 23, 1989 23 lives lost More than 130 people injured $750 million in property damages Explosive Force = 2.4 tons of TNT

DURING ROUGH WEATHER WATER ENTERED SHIPS ENGINE ROOM THROUGH VENTILATION INTAKE AS LOUVRES WERE INSTALLED INCORRECTLY.

Wrong

Right

WATER FELL ON SWITCHBOARD. ALL POWER LOST. SHIP TOWED TO PORT.

RECOMMENDATION: INSPECT LOUVRES. NO MENTION OF DESIGN

PROBABILITY OF SUCCESS TOTAL

0.9999 x 0.9995 x 0.9998 x 0.9985 x 0.9998 x 0.9996

= 0.9971 ie, three or four errors can be expected in every 1000 operations.

Furnace A Temperature recorder controller & high temperature trip Auto Hand control

Furnace B Temperature recorder controller & high temperature trip Auto Hand control

Figure 5

ACTIONS IN ORDER OF
CHOICE 1 Avoid hazards by IS design 2 Passive protection 3 Active protection 4 Procedures 5 Behavioural science

OPERATORS ARE THE LAST LINE OF DEFENCE. STRONG OUTER DEFENCES REDUCE THE DEMANDS ON THEM.

CAN THE TECHNIQUES OF BEHAVIOURALSCIENCE BE EXTENDED TO INCLUDEE DESIGNERS AND MANAGERS?

DONT ASK FOR CAUSES. ASK WHAT WE SHOULD DO DIFFERENTLY. DONT SAY AN ACCIDENT WAS DUE TO POOR DESIGN, MAINTENANCE, OPERATION etc. SAY IT COULD BE PREVENTED BY BETTER DESIGN, MAINTENANCE, OPERATION etc.

Blaming human error diverts attention from what can be done by better engineering.

ERRORS BY DESIGNERS TURN OPERATORS SLIPS INTO ACCIDENTS.

We cannot change the human condition but we can change the conditions in which humans work. - James Reason

Man was a creature made at the end of a weeks work. when God was tired. - Mark Twain