engineers view of human error - kletz
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AN ENGINEERS VIEW OFHUMAN ERROR
Trevor Kletz
Loughborough University
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ALL ERROR IS HUMAN ERRORAS:
People have to decide what to do.
People have to decide how to do it.
People have to do it.
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The concept of human error
is unhelpful as it lumps
together different typeswhich need different
actions.
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TYPES OF HUMAN ERROR1 MISTAKES
Does not know what to do -
Poor training or instructions.
Intention wrong.
,
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TYPES OF HUMAN ERROR
2 VIOLATIONS
Does not want to do it -
Poor motivation
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TYPES OF HUMAN ERROR
3 MISMATCHES
Is not able to do it -
Beyond ability
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TYPES OF HUMAN ERROR:
4 SLIPS OR LAPSES OF
ATTENTION.Inevitable from time to time.
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THIS CLASSIFICATIONHELPS US SEE THE
BEST METHODS OFPREVENTION FOR EACH
TYPE OF ERROR.
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PREVENTING MISTAKES
Teach flexibilityProvide training and instructions
Make task easierAvoid contradictory instructions
(What you dont say is asimportant as what you do say.)
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Human Error
Are your instructions written
to help the readers or protectthe writer?
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PREVENTING VIOLATIONS
Explain need
Make task easier
Checks and audits
Dont turn a blind eye
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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?
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Human Error
AN IRREGULAR VERB
I SHOW INITIATIVE
YOU BREAK THE RULES
HE IS TRYING TO WRECK THE JOB
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If instructions are wrong (dueto ignorance or slips)violations can preventaccidents
Human Error
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A good method of
persuasion is to discussaccidents and let those
present say what they think
should be done.
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Impossible tasks
Overload
Underload
Habit breaking
Mind-sets
REASONS FOR MISMATCHES
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PREVENTING MISMATCHES
Change Work Situation
ie, design or methods ofworking
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PREVENTING SLIPS ANDLAPSES OF ATTENTION
(Intention correct but notfulfilled)
Change work situation
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SLIPS & LAPSES OFATTENTION OCCUR ONLY
WHEN PEOPLE ARE WELL-
TRAINED.
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MANAGERS & DESIGNERS
ERRORS:are rarely slips as there is
usually time to check.
Sometimes violations.Usually mistakes.
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CHAOSSLIPS & LAPSES OFATTENTION
CHAOSMISMATCHES
Unable to do it
Persuasion/CHAOSVIOLATIONS Decides not to do it
Better training &instructions/CHAOS
MISTAKES Does notknow what to do
ACTIONERROR TYPE
CHAOS = ChangeHardware And/Or Software
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Early chloroform dispenser
From air
bulb
To face
mask
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Typical Piping
Settling Leg arrangement
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Phillips 66 IncidentOctober 23, 1989
23 lives lost
More than 130 people injured $750 million in property damages
Explosive Force = 2.4 tons of TNT
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DURING ROUGH WEATHER
WATER ENTERED SHIPS
ENGINE ROOM THROUGH
VENTILATION INTAKE AS
LOUVRES WEREINSTALLED INCORRECTLY.
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Wrong Right
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WATER FELL ON
SWITCHBOARD.
ALL POWER LOST.SHIP TOWED TO PORT.
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RECOMMENDATION:
INSPECT LOUVRES.
NO MENTION OF DESIGN
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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 canbe expected in every 1000operations.
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Figure 5
Temperature recordercontroller
& high temperaturetrip
Temperature recordercontroller
& high temperaturetrip
Furnace A Furnace B
Auto Hand control Auto Hand control
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ACTIONS IN ORDER OF
CHOICE1 Avoid hazards by IS design
2 Passive protection
3 Active protection
4 Procedures
5 Behavioural science
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OPERATORS ARE THELAST LINE OF DEFENCE.
STRONG OUTERDEFENCES REDUCE THE
DEMANDS ON THEM.
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CAN THE TECHNIQUES OF
BEHAVIOURALSCIENCE BEEXTENDED TO INCLUDEE
DESIGNERS ANDMANAGERS?
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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.
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Blaming human error
diverts attention from
what can be done by
better engineering.
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ERRORS BY DESIGNERS
TURN OPERATORS
SLIPS INTO ACCIDENTS.
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We cannot change the human
condition but we can change the
conditions in which humans work.
- James Reason
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Man was a creature made at the
end of a weeks work. when
God was tired. - Mark Twain
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