The Human Error Study

These failure analyses all involved plant site visits and interviews with many plant
personnel. In the study, we realized that, because of our various clients directives, we
couldnt guarantee that all the human roots had surfaced but are reasonably confident
that a good representation was found.
The study divided the major human error into six categories as follows:
1. Design There are two types of design errors, those of omission and those of
commission.
a) An omission error is one in which the engineer/designer fails to notice a
design flaw that results in a premature failure, such as a stress concentration
or an improper material selection.
b) A commission error is one in which the decision is made to use an otherwise
acceptable design under conditions that lead to failure. An example of this
could be a situation in which the output of a machine that is operating well at
500 units per day is increased to an operating rate of 550 units per day
without a serious study and, as a result of the increase, failure occur.
2. Manufacturing A manufacturing error occurs when a machine that is properly
specified and designed is improperly manufactured.
3. Maintenance Maintenance errors occur when a well-designed and
manufactured machine is improperly repaired, or the repaired unit is improperly
reinstalled. An example of this is when a millwright decides to slip fit, rather
than shrink fit, a coupling that then enables torsional fatigue forces to crack the
shaft.