Human error causes

PHECA Potential Human Error Cause Analysis Kirwan, 1992... 

The first area focuses on the cultural and organizational factors that will have a major influence on the effectiveness of a human error data collection system and how well the information derived from such a system is translated into successful error reduction strategies. Regardless of how effectively the technical issues are dealt with, the system will not be successful imless there is a culture in the organization which provides support for the data gathering process. No data collection system aimed at identifying human error causes of accidents will be workable without the active cooperation of the workforce. 

Senders J, Moray N. 1991. Human Error Cause, Prediction, and Reduction. Hillsdale, NJ Lawrence Erlbaum Associates. 

Equipment failure and human error cause most releases at facilities. 

Man-machine interface consists of such aspects as allocation of functions (man vs. machine), automation, accessibility, human tasks, stress characteristics, information presented to the human, and the reliability of interfaces coupled with the decisions on the basis of such information. Both human and machine elements of a system can fail, and their failures have varying effects on the system s performance. Some human errors cause total system failute or increase the risk of such failure. Human factors exert a strong influence on the design and ultimate reliability of a system (Kirwan 1994). 

PVC profile bending using laser and PLC controlling system is a part of the arched PVC joinery, where the bending of the PVC profiles is completely automatized thus removing any possible human error caused by operating the machine manually. 

Whittingham, R.B. (2004) The Blame Machine - Why Human Error Causes Accidents. Butterworth-Heinemann, Oxford. 

Characteristics of human error caused by a planning failure... 

Characteristics of human errors caused by procedural problems... 

Human errors caused by inherent problems in a work object mean that the failure of the maintenance activities can be attributed to the inherent, structural characteristics of the work objects to be acted. All the events caused by the inherent characteristics of a work object occurred during a planned maintenance, which is performed during the overhaul period of a plant. The events related to the strucmral characteristics of a work object are usually revealed in the form of insufficient... 

All who undertake an inquiry to determine what additional actions may be taken to reduce serious injury potential will learn from R. B. Whittingham s The Blame Machine Why Human Error Causes Accidents. Whittingham describes how disasters and serious accidents result from recurring but potentially avoidable human errors. He shows how such errors are preventable because they result from defective systems within a company. 

Whittingham, R. B. The Blame Machine Why Human Error Causes Accidents. Burhngton, MA Elsevier Butterworth-Heinemann, 2004. 

Sutton s statement describes a necessity for superior results to be achieved. And safety professionals should be working toward influencing management that it is in their best interest to put processes in place to uncover, confront, and address hazards and the risks that derive from them. Never the less, realism with respect to the management practices in some companies must be acknowledged, as is discussed in the next section. Unfortunately, what R. B. Whittingham wrote in the Preface to The Blame Machine Why Human Error Causes Accidents speaks to what is sometimes actuality ... 

Engineering and Safety Management Yellow Book. Application Note 3. Human Error Causes, Consequences and Mitigations. Issue 1.0. 

You will need to understand which particular events led to the event scenario. For example, it is important to identify the sequence of events or failures that could lead to a loss of in-flight aircraft control. Or, for example, the event could be that a blocked valve causes system overpressure. If humans are in the process, then some sort of human factors safety analysis will help find human error causes. 

Senders and Moray, Human Error Cause, Prediction, and Reduction, 1991, p. 20. (Volume 1 Concepts and principles, human performance improvement handbook, public domain, 2009. U S. Department of Energy) define The initiating action is an action by an individual, either correct, in error, or in violation, that results in a facility event . 

Senders, J. and Moray, N. (1991). Human Error Cause, Prediction and Reduction. Mahwah, NJ Lawrence Erlbaum. 

Root cause analysis (RCA) It includes everything the RCI covers plus the minor human error causes and, more importantly, the management system problems that allow the human errors and other system weaknesses to exist. An RCA can sometimes extend to sites other than the one involved in the original problem. 

Table 1. Human error causes comparison (own elaboration on the basis of www.poznan.oip.pl).

Human error causes can be determined and eliminated, or the effects minimized. 

Critical action (See STEP diagram) Human errors Causes in the man-machine interface (Table 26.2) Performance-shaping factors (Table 26.3) Consequences Recommendations... 

Whittmgham, R. B. 2004. The blame machine Why human error causes accidents. Oxford, U.K. Elsevier Butterworth-Heinemann. 

Railway Safety. 2003. Human error Causes, consequences, and mitigations. Application Note 3. London Railway Safety, Evergreen House. 

The collision of the MV Santa Cruz II and the USCGC Cuyahoga due to a human error caused 11 fatalities [22,29]. 

Example 1 refers to the application of the bar code label to the patient sample tube. The word no referred to the absence of a label (deviation from design intent) due to human error (cause) with the result that the tube could not be processed on the analyser. Other than denoted the application of the incorrect label (deviation from design intent) with the result that the sample tube was aUributed to the wrong patient. It was found that the application of guide words to activities was useful in stimulating the team to investigate deviations from design intent. 

Human error remains a causal factor in the majority of serious aircraft accidents. Human error causes accidents of fail-safe, fully functional designs. 

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