238 6.

Human error

respond to breakdowns and production problems but struggle to find (or make) time to do the
more routine tasks intended to avoid these problems in the first place.

6.3.8 Signs and labels

Kletz identified the importance of labelling [10].

Text Box 6.25

Many incidents have occurred because equipment was not clearly labelled. Some of these inci-
dents have already been described in the section on the identification of equipment under mainte-
nance. Seeing that equipment is clearly and adequately labelled and checking from time to time to
make sure that the labels are still there is a dull job, providing no opportunity to exercise our tech-
nical or intellectual skills. Nevertheless, it is as important as more demanding tasks are. One of the
signs of good managers, foremen, operators, and designers is that they see to the dull jobs as well as
those that are interesting. If you want to judge a team, look at its labels as well as the technical prob-
lems it has solved.

6.3.8.1 Problems caused by poor labelling

Kletz identified a number of instances where poor labelling has caused problems including
[10]:
• Indication of damper status, whether it was open or closed;
• Incorrect labels on electrical fuses or switchgear resulting in the wrong equipment being
isolated before work commenced;
• Sample points not identified and so the wrong sampling and testing procedures are
followed;
• Connecting to a low pressure service line allowing back-flow of process into service supply
system;
• Filling tankers with the wrong product;
• Lifting devices labelled with the wrong capacity;
• Confusion about units being shown on gauges;
Copyright © 2021. Elsevier. All rights reserved.

• Confusion about chemical identity.

6.3.8.2 Loading oxygen instead of nitrogen

A potentially very serious incident occurred when filling tankers with nitrogen [10].

Text Box 6.26

A tank car was fitted with nitrogen connections and labelled Nitrogen. Probably because of vib-
ration, one of the hinged boards fell down so that it read Oxygen. The filling station staff therefore
changed the connections and put oxygen in the tank car. Later, some nitrogen tank trucks were filled
from the tank car—which was labelled Nitrogen on the other side—and supplied to a customer who

Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-22 06:03:06.
 6.3 Reducing human error probability 239
wanted nitrogen. The customer off-loaded the oxygen into his plant, thinking it was nitrogen. The
mistake was found when the customer looked at his weigh-bridge figures and noticed that on arrival
the tanker had weighed 3 tons more than usual. A check then showed that the plant nitrogen system
contained 30% oxygen.

6.3.8.3 Signs vs labels

Signs and labels perform different purposes. A sign should convey information and a label
is primarily for identification. For example, it would be good practice for every valve on plant
to have a unique identification number which will be shown in the field via a tag or similar.
This will allow it to be positively identified by an operator or maintenance technician,
allowing them to cross check with P&ID, instructions, etc. However, if identification of that
valve is particularly critical or its status has to be controlled in a particular way it may be
appropriate to provide a sign in addition to the identification label. This would be displayed
prominently and its design should ensure it is legible from the position where the valve will
be operated.

6.3.8.4 Maintaining signs and labels

One of the common problems with signs and labels is that they become damaged, weath-
ered, painted over, or are removed during maintenance and are not replaced. They should be
subject to routine inspection and maintenance to ensure these problems are rectified.
It is generally accepted at original design and construction that signs and labels are critical.
However, few organisations have an effective mechanism for formally recognising this and
incorporating the requirement into their maintenance management system. The result is that
many sites have allowed signs and labels to disappear over the years, which can have a sig-
nificant impact on human error probability.

6.3.9 Behavioural safety

Most of this chapter has been focussed on reducing the likelihood of error through better
design and systemic changes. This can cause people to worry that it takes away personal
Copyright © 2021. Elsevier. All rights reserved.

responsibility. This is something Kletz was aware of [2].

Text Box 6.27

The reader who has got this far may wonder what has happened to the old-fashioned virtue of
personal responsibility. Has that no part to play in safety? Should people not accept some respon-
sibility for their own safety?
We live in a world in which people are less and less willing to accept responsibility for their act-
ions. If a man commits a crime it is not his fault, but the fault of those who brought him up, or those
who put him in a position in which he felt compelled to commit the crime. He should not he blamed,
but offered sympathy. If someone is reluctant to work, he or she is no longer work-shy or lazy but a
sufferer from chronic fatigue or some other recently discovered syndrome.

Brazier, Andy, et al. Trevor Kletz Compendium : His Process Safety Wisdom Updated for a New Generation, Elsevier, 2021. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/sheffield/detail.action?docID=6461868.
Created from sheffield on 2021-03-22 06:03:06.