From Theory to Practice

An opportimity for error recovery would have been to implement a checking stage by a supervisor or independent worker, since this was a critical maintenance operation. However, this had not been done. Another aspect of the unforgiving environment was the vulnerability of the system to a single human error. The fact that the critical water jacket flow was dependent upon a single pump was a poor design that would have been detected if a hazard identification technique such as a hazard and operability study (HAZOP) had been used to assess the design. 

8 FROM THEORY TO PRACTICE TURNING THE SYSTEMS APPROACH TO A PRACTICAL ERROR REDUCTION METHODOLOGY 

This chapter has provided an overview of the book and has described its underlying philosophy, the system-induced error approach (abbreviated to the systems approach in subsequent chapters). The essence of the systems approach is to move away from the traditional blame and punishment approach to human error, to one which seeks to understand and remedy its underlying causes. 

The first component of the systems approach to error reduction is the optimization of human performance by designing the system to support human strengths and minimize the effects of human limitations. The hiunan factors engineering and ergonomics (HFE/E) approach described in Section 2.7 of Chapter 2 indicates some of the techniques available. Design data from the human factors literature for areas such as equipment, procedures, and the human-machine interface are available to support the designer in the optimization process. In addition the analytical techniques described in Chapter 4 (e.g., task analysis) can be used in the development of the design. 

Introduction The Role of Human Error in Chemical Process Safety 

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