Human reliability

Introduction
This document provides guidance on the different types of human error and a
process for the effective assessment of human reliability.

It is a commonly-held belief that many accidents are the result of 'human error' by an
individual or group, beyond the control of management. Once arrived at, this
conclusion has been taken as sufficient explanation. However, this is no longer
acceptable: in many accidents the human failure was not the sole cause but one of a
number of factors, including technical and organisational failures, which led to the
final outcome.

We all make errors irrespective of how much training and experience we possess or
how motivated we are to do it right. There are established methods to identify,
categorise and mitigate against the effect of such errors occurring.

Case study
In Longford, Victoria, Australia there was an accident at an Esso Gas Plant in 1998
which killed two people and cut off Melbourne's gas supply for two weeks. The
direct cause of the accident was initially blamed on the operators not recognising
exactly what was happening at the plant and carrying out an incorrect sequence of
actions.

However the underlying cause, established after a Royal Commission investigation,

was a series of organisational failures. Incidents that had happened a month before
had not been investigated and the resident engineers had been removed because
their role was seen to be redundant. If these engineers had been there they could
have spotted the underlying causes of the problems and offered advice to the
operators. The operators had no one to turn to for an expert opinion.

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 Issues
Types of human failure
The types of human failure can be sub-divided as shown in this diagram:

A human error is an action or decision, which was not intended, which involved a
deviation from an accepted standard and which led to an undesirable outcome.
These can be further divided into slips, lapses and mistakes:

• Skill-based errors, i.e. slips and lapses, occur in very familiar tasks which we
carry out without much need for conscious attention:
o Slips are failures in carrying out the actions of a task, for example
picking up the wrong component from a mixed box, operating the
wrong switch or mis-ordering steps in a procedure.
o Lapses of memory cause us to forget to carry out an action, to lose our
place in a task or even forget what we intended to do.

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 • Mistakes are a more complex type of error where we do the wrong thing
believing it to be right:
o Rule-based mistakes occur when our behaviour is based on
remembered rules and procedures.
o Knowledge-based mistakes occur when the operator has to resort to
an expert judgement unsupported by rules and procedures.

Violations are deliberate deviations from rules, procedures, instructions and

regulations:

• Routine violations occur when breaking a rule or procedure has become a

normal way of working within a group, for example a belief that the rules no
longer apply or there is a lack of enforcement.
• Situational violations occur to due to time or workload pressures, the wrong
equipment being available or other situation-specific factors such as weather.
• Exceptional violations only happen when something has gone wrong and to
address the problem rule breaking is considered 'worth the risk'.

Human Reliability Assessment

Human reliability is the opposite of human error. It is the probability of successfully
performing a task. Human Reliability Assessment (HRA) is a structured and
systematic way of estimating the probability of human errors in specific tasks. There
are three main reasons for performing an HRA:

• To give a benchmark for safety cases and design briefs

• To enable comparison of alternative designs or organisational solutions
• To identify the weaker human links in a system so that the appropriate control
measures can be introduced

A suggested programme of tasks is shown on this diagram:

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 The key stages are as follows:

• Define the scope

This will need to consider issues such as:
o Is the HRA part of a wider assessment?
o Is estimation of error probabilities needed?
o What criteria are to be applied to the consequences, e.g. fatalities,
injuries?
o What resources and expertise are available?

• Gather information
Collect background information on the tasks to be analysed, select the
techniques to be used and the resource commitment required.

• Describe the tasks

Formally describe the tasks in terms of its goals, steps and the interactions
between the person and the system.
• Identify any human errors
Attempt to identify all the significant human errors that the person could
make. Methods exist to do this in a structured way. Questions would include:
o What human errors can occur with each task?
o What influences are there on performance, such as time pressure,
workplace design, training, fatigue, supervision, etc.

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 o What are the consequences of the identified errors?
o Are there any opportunities to detect each error and recover from it?
o Are there any interdependencies between specific errors, e.g. one
enables another?

• Estimate human error probabilities

This can be done using historical or field data if it is available or by asking
subject matter experts. Formal methods exist to support the process.

• Develop control measures

Control measures to reduce the likelihood or impact of identified human errors
may include: redesign of the task or working environment, improvements to
the selection and training of staff or placing additional barriers in the system to
prevent the consequences of errors.

Techniques have been developed to address each stage in this process. References
can be found in Further Information.

Further information

• Human reliability assessment

RSSB Human Factors Fact Sheet 3, June 2002
• Reducing error and influencing behaviour (HSG 48)
HSE Books
ISBN 0-7176-2452-8
• A guide to practical human reliability assessment
Barry Kirwan Taylor and Francis, 1994
• Lessons from Longford: The Esso gas plant explosion
Andrew Hopkins CCH Australia Ltd, 2000
• Evaluation of Human Work
J.R. Wilson & E.N. Corlett Taylor and Francis, 1995

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