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

ACTION

MISTAKES Does not

know what to do
VIOLATIONS
Decides not to do it
MISMATCHES
Unable to do it
SLIPS & LAPSES OF
ATTENTION

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

Furnace B

Temperature recorder
controller
& high temperature
trip

Temperature recorder
controller
& high temperature
trip

Auto

Hand control

Auto

Figure 5

Hand control

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