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Human Failure

The document discusses types of human failure including unintentional errors like slips and mistakes, intentional errors like violations, and different levels of mental working. It also covers performance influencing factors, managing human performance through task analysis and human error analysis, and a seven step process to manage human performance involving identifying hazards, activities, potential failures, and controls.

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Fernando Pretola
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23 views13 pages

Human Failure

The document discusses types of human failure including unintentional errors like slips and mistakes, intentional errors like violations, and different levels of mental working. It also covers performance influencing factors, managing human performance through task analysis and human error analysis, and a seven step process to manage human performance involving identifying hazards, activities, potential failures, and controls.

Uploaded by

Fernando Pretola
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Health

Healthand
andSafety
Safety
Executive
Executive

An Introduction to
Human Failure
Types of Human Failure

• Human failures are not random - there


are patterns or types:
• Unintentional
• Intentional
• Physical (decisions)
• Mental (decisions)
• This is important because they:
1.Have different causes
2.Need to be managed differently
Human Failure

Unintentional Errors

Slips/Lapses Mistakes

Intentional Errors

Violations
Levels of Mental Working
Skill-Based Automatic
Automated routines with
little conscious attention

Rule-Based
IF symptom X THEN cause is Y
IF the cause is Y THEN do Z

Knowledge-Based
No routines or rules available
for handling situation
Conscious
Performance Influencing Factors

• Job factors
– Equipment design, environment, etc
• Individual factors
– Competence, fatigue, etc
• Organisational factors
– Work planning, culture,
communication, etc
Managing Human Performance

Performance
Error Analysis
Influencing Factors

Task Analysis Prevention

Safety Critical Task Mitigation

Consider Main Site Hazards


Task Analysis

• Logical description of how to complete


task.
– Hierarchical Task Analysis (HTA)
– Flow Charts
– Lists
• Based on walk through.
• Consensus views sought.
• Multi-skilled team.
Human Error Analysis

• Human HAZOP guidewords


– Action errors
– Checking errors
– Information retrieval errors
– Etc
• Consider PIFs
Risk Controls

Prevention
Engineering
Procedures
Automation
Mitigation
Maintenance &
Inspection Task Analysis Human Error
Analysis

Engineering/
Automation Procedures PIFs

PIFs Human Error Training


Analysis

Task Analysis Monitor & Consolidation


Review

Safety Critical Competence


Tasks Assurance
Summary of 7 steps

1. Consider main site hazards (e.g. LPG, chlorine)


2. Identify human activities for these (bulk transfers,
maintenance, startup, reactor charging)
3. Outline key steps in these activities – remember to talk to
operators!
4. Identify potential human failures for key steps –
slips/lapses, mistakes and violations
5. Identify Performance Influencing Factors (PIFs) that
make failure more likely – job, person, organisation
6. Use hierarchy of control – don’t rely on humans as last line of
defense, but automation introduces new issues
7. Manage error recovery – make it more likely that errors will be
detected by others or the system
Human Failure – Brief Review

• Different types of failure – different


controls
• Managing human performance
• Optimise performance influencing factors

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