Health and Satety Executive 43. Human failures can be grouped into errors and violations, | Ahuman error is an action or decision, which was not intended, which involved @ deviation from an accepted standard, and which led fo an adverse outcome. | A Violation is 2 deliberate deviation from a rule or procedure and usually arises because of a desire to cary out the job despite barriers such as work or time pressures, lack of staff, unavailability of the right equipment or tools, and or extreme weather conditions, Examples of human fallures relevant to isolation include: {allure to complete or reverse isolations fully before starting work or restarting plant; {allure to prove and monitor isolated valves; poor communication (eg at shift handover); and ‘allure to check P&Ds'schematic diagrams against the actual instaled pant and equipment, men mb 45. Competency is a key contributor to sale isolations, Competent workers are Jess prone to human failures. However, even experienced and trained staf, familiar with a site, may make errors. Further training alone may not address the root causes of such error. Training and competence for Solation activities are further discussed in paragraphs 49-57. 46 Examples of isolation-speciic contro that make fallures less likely, and help to detect and correct them, include: For errors | Estabiishing and maintaining adequato understanding of hazards and the integrity of isolation arrangements. Providing well-designed, cleat, concise, available, up-to-date procedures and instructions, including checklists and other job aids, that are accepted and used by the workforce. Clear identification of plant and equipment, including valves. ‘Aolear system for tagging valves, and recording on P&lDs and schematic diagrams. Providing good access (eg for valves} and working environment (eg lighting), for isolation tasks. Effective checking (independent where necessary) and supervision for isolation proving and monitoring, and for reinstatement. Good communications (og at shift handover). Considering the potential for hurnan error in tisk assessments and incident investigations, ‘Te safe lslation of plant and equiprnt Page 11 of 81