Checklist human error

Process Hazards Analysis. Analysis of processes for unrecogni2ed or inadequately controUed ha2ards (see Hazard analysis and risk assessment) is required by OSHA (36). The principal methods of analysis, in an approximate ascending order of intensity, are what-if checklist failure modes and effects ha2ard and operabiHty (HAZOP) and fault-tree analysis. Other complementary methods include human error prediction and cost/benefit analysis. The HAZOP method is the most popular as of 1995 because it can be used to identify ha2ards, pinpoint their causes and consequences, and disclose the need for protective systems. Fault-tree analysis is the method to be used if a quantitative evaluation of operational safety is needed to justify the implementation of process improvements. 

A Checklist on Procedures Extracted from the Short Guide to Reducing Human Error" (UK Atomic Energy Authority, 1987)... 

The intention of this chapter has been to provide an overview of analytical methods for predicting and reducing human error in CPI tasks. The data collection methods and ergonomics checklists are useful in generating operational data about the characteristics of the task, the skills and experience required, and the interaction between the worker and the task. Task analysis methods organize these data into a coherent description or representation of the objectives and work methods required to carry out the task. This task description is subsequently utilized in human error analysis methods to examine the possible errors that can occur during a task. 

Several qualitative approaches can be used to identify hazardous reaction scenarios, including process hazard analysis, checklists, chemical interaction matrices, and an experience-based review. CCPS (1995a p. 176) describes nine hazard evaluation procedures that can be used to identify hazardous reaction scenarios-checklists, Dow fire and explosion indices, preliminary hazard analysis, what-if analysis, failure modes and effects analysis (FMEA), HAZOP study, fault tree analysis, human error analysis, and quantitative risk analysis. 

Like checklists, the comprehensiveness of the various predefined trees varies. Some are very detailed with numerous categories and subcategories, whereas others may not fully reach root causes. This is hardly surprising, as the predefined trees are essentially a graphical representation of numerous checklists, organized by subject matter, such as human error, equipment failure, or other topics. The more comprehensive techniques were developed from many years of incident experience and management system experience across the chemical and allied industries. 

It is easy to blame accidents on human error, but good design can often minimize this.161 Avoid poor lighting or contrast. Provide a checklist so that the operator will find it easy to recall all of the necessary information. Most valves have right-handed threads. Do not mix in any that have left-handed threads. Mount them so that they are easy to access, and the labels are easy to see. 

There are various types of analyses that are used for a process hazard analysis (PHA) of the equipment design and test procedures, including the effects of human error. Qualitative methods include checklists, What-If, and Hazard and Operability (HAZOP) studies. Quantitative methods include Event Trees, Fault Trees, and Failure Modes and Effect Analysis (FMEA). All of these methods require rigorous documentation and implementation to ensure that all potential safety problems are identified and the associated recommendations are addressed. The review should also consider what personal protective equipment (PPE) is needed to protect workers from injuries. 

In a two-year project, reported by Simpson (1994) and Fox (1992), the human error audit described in Section 3.2 was applied to two colliery haulage systems. The results of the first study will be presented here. In both systems, data collection focused on potential errors and the performanceshaping factors (PSFs) that can influence these errors. Data was collected by observation, discussion and measurement within the firamework of the broader man-machine systems and checklist of PSFs, taking some 30-40 shifts at each site. The whole haulage system from surface operations to delivery at the coal face was covered. 

Investigations of industrial accidents reveal that most are caused by human error. The twentieth century s worst industrial disasters—Bhopal, Three Mile Island, and Chernobyl—helped clarify the complex chain of system problems that lead to human error. System problems are problems caused by a process system with built in design and operating deficiencies. The accidents provided numerous checklists and case studies for control room and equipment design. A partial list of some of the problems found at the industrial sites mentioned above are ... 

It was revealed that most of the events due to a work planning problem where a work procedure is provided occurred during low-power states or startup operations. The reason for this can be inferred as the variable characteristics of plant configuration and dynamics of the low-power states of NPP, which may cause the identification of human error potentials and prediction of physical transition to be difficult. Therefore, the identification of human error possibilities or potentials during low-power states seems not to be an easy task to be accomplished by a list of simple checklist items, but belongs to a hard task that requires a careful investigation on the potential of human error by a concerted effort between experts in plant systems and hiunan errors, and, as necessary, may requires the use of thermal-hydraulic and reactor analysis computer codes. 

Human error The proof test procedures should be designed in such a manner that it would minimize human error. For this, a checklist including tick boxes and cross-checking for critical steps could be helpful. Many structure the tests in a way so that errors that could be introduced are revealed by subsequent test steps [17]. 

ABSTRACT This paper will present the HuDeM (Human Dependability Model) project financed by the European Space Agency (ESA). The project has focused on developing a Human Dependability Model to be applicable for space activities and projects. The project is based on relevant perspectives from other industries like aviation, petroleum, nuclear and railways. Human Dependability is described as the contribution of the human in a space system to safety and reliability, a subject to reduce the incidence of human error and minimize its effects. Existing literature suggests that there is a trend towards an understanding and acknowledgement of the importance of humans in accidents and recoveries. In addition to propose a Human Dependability Model, the project validated the implementation of one proposed method. The initial validation is based on a case study. The validation method focuses primarily on the use of scenarios and checklists. This paper will outline and discuss some experiences and key challenges. 

An early example of a causal factors checklist is Swain s checklist on human-performance-shaping factors (Swain, 1974). It is human-factor oriented and lists factors that affect the quality of human performance and thus the likelihood of human errors. Table 6.11 shows an extract from this checklist. 

The checklist has been used as a design tool as well as an accident-investigation tool in cases where human errors have played a central role. It draws attention away from blaming the person that made the error. Instead, it focuses on the identification of dysfunctions in the design of the man-machine system from an ergonomics point of view. The intention is to identify accident-prone workplaces rather than accident-prone persons. 

Checklists in Tables 26.2 and 26.3 support the human-factor evaluation. First, the analysis team evaluates whether the human error is related to wrong detection or diagnosis of the disturbed situation or to erroneous execution of action. Thereafter, the team looks into causes. Here a variation of Swain s checklist in Table 6.11 on human performance-shaping factors is used. The checklist includes items related to working conditions, physiological and psychological stresses and expected individual characteristics of the operators. The results of the human-factor evaluation are documented in columns three and four. Finally, the team makes an overall evaluation and comes up with recommendations on remedial actions. 

Checklist of Statements to Reduce Human Error in Railway Operations... 

This section presents a checklist of statements considered useful in ensuring good human-factors practices in railway-associated projects. In turn, this exercise or action will be helpful in reducing human error in railway operations. These statements are presented in Table 10.1 [2,13]. 

At the time of the study addressed in the present paper, [Pitblado 88] a total of 17 incidents had been reported in the Netherlands over a 4 year period on computer controlled plants, which related to the computer system or to the human interaction with the computer. These failures led mainly to small and medium scale releases from the flare systems, but in one case led to plant damage and in another to a fireball. Table 1 shows a summary checklist indicating the number of failures in each category (hardware, software, human), from which it can be seen that human errors during operations were associated with 59% of the incidents. Errors were mainly due to inadequate, insufficient or incorrect information supplied to the operators (59%) and a failure to correctly follow procedures (47%). Human errors in design were involved in 29% of incidents. Hardware and software failures were less prominent. 

Behavioral methods applied in hazardous situations include techniques to gain personally evaluated information on technical, organizational, and human aspects of safety conditions. Those are direct methods trying to identify accident potentials and to establish a safe working environment. Methods applied are checklists, questionnaires, and interviews, including the critical incident technique. Behavioral methods to analyze human behavior in terms of human error and reliability are discussed in Chapter 5 and 7. 

For more complex processes, the What If study is best organized through the use of customized checklists. Aspects of the process a re assigned to analysis team members with the greatest experience or skill in areas of concern. As a What-lf study could include but not be limited to audits of equipment operator practices and job knowledge, the suitability of equipment and materials of construction, the chemistry of the process and its control systems, and the operating and preventive maintenance records (Task Analysis Tools Used Throughout Development, Human Error Analysis, n.d.). 

Although checklists are a useful way of transferring information about human-machine interaction to designers and engineers, they are not a standalone tool and they cannot provide a substitute for a systematic design process. The main concern with checklists is that they do not offer any guidance about the relative importance of various items that do not comply with the recommendations, and the likely consequences of a failure due to a noncompliance. To overcome such problems, checklists should be used in combination with other methods of task analysis or error analysis that can identify the complexities of a task, the relationships among various job components, and the required skills to perform the task. 

ANALYSIS DOCUMENTATION. PrHA report documentation should include the PrHA worksheets, checklists, logic diagrams, human reliability analyses, and any other analysis made to better understand the scenarios. The PSM Rule requires that human factors that impact scenarios as cause or protection be expanded to analyze the basic cause of errors or response failures. For example, a cause may identify that an operator can turn the wrong valve to initiate an accident. The PSM Rule requires that basic causes also be identified. For example, valve is not labeled the operator has not been trained on the operation or the operator forgot the step. There may be more than one basic cause. (See also Section 3.2, paragraph on Human Factors.)... 

Usability refers to the auditor s ease of use of the audit system. Good human factors principles should be followed, such as document design guideUnes in constructing checklists (Patel et al 1993 Wright and Barnard 1975). If the instrument does not have good usabiUty, it will be used less often and may even show reduced reliability due to auditors errors. 

Helimeich, R.L., Ktinect, J.R., Wilhelm, J.A. and Jones, S.G. (1999), The Line LOS Checklist, Version 6.0 A checkhst for human factors skills assessment, a log for external threats, and a worksheet for flightcrew error management , The University of Texas Team Research Project Technical Report 99-01. 

A safety culture is key. No matter how advanced the technological system, if humans are involved, errors are inevitable. The key to patient safety and accident prevention is managing the inevitable error by doing two things First, by training to use specific teamwork and communications behaviors, and second to implement safety tools (policy and procedures, protocols, checklists, briefings) to complement behaviors to detect and trap (small) errors before they become a chain creating a serious or even fatal accident (table 1). 

---