Error management design/procedure

Accident investigation is the determination by qualified personnel as to the specific causing for a particular accident or mishap. Causal factor considerations include management errors, technical design, hardware failures, procedural errors, and so on. An accident investigation can be conducted by a formal board or by an informal analysis performed by one or more individuals. 

Human performance. The commission first reviews the tasks performed by the operators to identify human errors and to evaluate the adequacy of recovery actions and emergency response. Influences from design, procedures and other circumstances (including emotions) should be evaluated, see Chapter 8. The commission should also look into errors and omissions made by management (latent failures). 

Management policies are the source of many of the preconditions that give rise to systems failures. For example, if no explicit policy exists or if resources are not made available for safety critical areas such as procedures design, the effective presentation of process information, or for ensuring that effective communication systems exist, then human error leading to an accident is, at some stage, inevitable. Such policy failures can be regarded as another form of latent human error, and will be discussed in more detail in Section 2.7. 

In addition to the management level factors which can be specifically linked to operational level factors (procedures, training, and design), the HFAM tool also provides an assessment of other management level factors which will impact upon error likelihood in a less direct way. Some of these factors, for example, "safety priorities" and "degree of participation," are... 

Management and Policy Influences on Error and Accident Causation As has been emphasized in Chapters 1,2, and 3, the system-induced error view states that it is insufficient to consider only the direct causes of errors. The underlying organizational influences also need to be taken into accoimt. However, most of the available techniques stop when an immediate cause has been identified, such as less than adequate procedures or poor equipment design. The questions of why the procedures were poor, or why the equipment was badly designed, are rarely addressed at the level of policy. Kletz (1994a)... 

Representativeness Sampling design error Field procedure error Data interpretation error Sample management error Data management error... 

US NRC (2000) also raised several human performance issues associated with CBPs. The issues are as follows methodological and criterion requirements for evaluating CBP effects, role of plant personnel in procedure management, team performance, situation awareness, response planning, and operator error level of automation of procedure functions keyhole effects and use of multiple CBP procedures CBP failure in complex situations hybrid procedure systems and specific CBP design features. 

Other causes of stmctural failure are improper assembly and maintenance. Some failures may result from human error or may be due to designs that are difficult, impractical or impossible to implement. Some may simply result from careless work and poor decisions on the part of workers and management. Sometimes several causes combine and lead to failure. Lack of communication, skill, knowledge, training, procedures, and management commitment can all contribute to faulty workmanship. 

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