Human error designed

Proper design of equipment, procedures and the work environment can greatly reduce the probability of human error. Designing and maintaining operating procedures is a challenge for batch systems because of the multiplicity of procedures for each piece of equipment, and the variety of operations within... 

Woods, David D. Lessons from beyond human error Designing for resilience in the face of diange and surprise. Design for Safety Workshop, NASA Ames Research Center, October 8-10,2000. 

Endsley, M.R. (1999), Situation Awareness and Human Error Designing to Support human Performance, Proceedings of the High Consequence Systems Surety Conference. Albuquerque NM 1999. 

Management systems feilure Human error Design Construction Operations Maintenance Testing and inspection Externsu events Extreme weather conditions Earthquakes... 

Human error Design errors including incorrect dimensioning, neglected dynamic effects, unrecognised stability problems Construction errors such as material flaws and incorrect assembly... 

Human errors—design error, material flaw, construction error, misuse, lack of maintenance. 

The worst nuclear power plant accident occurred at the Chemobyl-4 plant in the Soviet Union. A remarkable series of events began on April 25, 1986 and continued over several days, resulting in more than 30 deaths and 237 injuries from radiation exposure, as well as massive contamination of wide geographical areas. The radiation released was measurable over much of the globe. A combination of human errors, design errors, and complacency contributed to the accident. In many ways, the attitude toward nuclear safety in the Soviet Union was similar to the pre-TMI attitude in the United States. This section provides a brief overview of the Chernobyl reactor design, a description of the sequence of events leading to the accident, and a discussion of the relevance of the accident to U.S. plants. 

Chemical Reactivity Evaluation and Application to Process Design Preventing Human Error in Process Safety... 

Inherently Safer Design Rather than add on equipment to control hazards or to protect people from their consequences, it is better to design user-friendly plants which can withstand human error and equipment failure without serious effects on safety, the environment, output, and efficiency. This part is concerned with this matter. 

For many years the usual procedure in plant design was to identify the hazards, by one of the systematic techniques described later or by waiting until an accident occurred, and then add on protec tive equipment to control future accidents or protect people from their consequences. This protective equipment is often complex and expensive and requires regular testing and maintenance. It often interferes with the smooth operation of the plant and is sometimes bypassed. Gradually the industry came to resize that, whenever possible, one should design user-friendly plants which can withstand human error and equipment failure without serious effects on safety (and output and emciency). When we handle flammable, explosive, toxic, or corrosive materials we can tolerate only very low failure rates, of people and equipment—rates which it may be impossible or impracticable to achieve consistently for long periods of time. 

At one time most accidents were said to be due to human error, and in a sense they all are. If someone—designer, manager, operator, or maintenance worker—had done something differently, the accident would not have occurred. However, to see how managers and supervisors can prevent them, we have to look more closely at what is meant by human error-. 

In general, the risk of human error ean he redueed hy properly designing the equipment, proeedures, and the work environment and hy proper staffing, training, and implementation of management eontrols. 

To be able to systematically identify opportunities for reducing human error, it is useful to ask the question, What is human error One definition is that human error is an inappropriate or undesirable human decision or behavior that reduces, or has the potential for reducing safety or system performance (Rasmusssen 1979). There is a tendency to view errors as operator errors. However, the error may result from inadequate management, design, or maintenance of the system. This broader view which encompasses the whole system can help provide opportunities for instituting measures to reduce the likelihood of errors. 

Humans control all chemical and nuclear processes, and to some extent all accidents result from human error, if not directly in the accident then in the process design and in the process inadequate design to prevent human error. Some automatic systems such used in nuclear power reactors because the response time required is too short for human decisions. Even in these, human error can contribute to failure by inhibiting the systems. 

In addition to these formal studies of human error in the CPI, almost all the major accident investigations in recent years, for example, Texas City, Piper Alpha, Phillips 66, Feyzin, Mexico City, have shown human error as a significant causal factors in design, operations, maintenance or the management of the process. Figures 4.4-1 and 4.4-2 show the effects of human error on nuclear plant operation. 

Uehara and Hoosegow (1986) Human error accounted for 5S% of the fire accidents in refineries du.j lo improper management 12. improper design 12. improper m,iterials 11 misoperation i improper inspection improper repair 9 - other errors 27%... 

Core damage and containment performance was assessed for accident sequences, component failure, human error, and containment failure modes relative to the design and operational characteristics of the various reactor and containment types. The IPEs were compared to standards for quality probabilistic risk assessment. Methods, data, boundary conditions, and assumptions are considered to understand the differences and similarities observed. 

A related concept to inherently safer design is user-friendly design designing equipment so that human error or equipment failure does not have serious effects on safety (and also on output or efficiency). While we try to prevent human errors and equipment failures, only very low failure rates are acceptable when we are handling hazardous materials, and, as this book has shown, it is hard to achieve them. We should, therefore, try to design so that the effects of errors are not serious. The follov,/-ing are some of the ways in which we can accomplish this ... 

By simplifying designs complex plants contain more equipment that can fail, and there are more ways in which human errors can occur. 

Many accidents, particularly on batch plants, have been due to runaway reactions, that is, reactions that get out of control. The reaction becomes so rapid that the cooling system cannot prevent a rapid rise in temperature, and/or the relief valve or rupture disc cannot prevent a rapid rise in pressure, and the reactor ruptures. Examples are described in the chapter on human error (Sections 3.2.1 e and 3.2.8), although the incidents were really due to poor design, which left traps into which someone ultimately fell. 

The application of the science of human factors to eliminating error in all aspects of process design, management, operation, and maintenance is the focus of this work. Human error has been a major cause of almost all of the catastrophic accidents that have occurred in the chemical process industries (CPI). If one adopts the broad view of human error as being the result of a mismatch between human capabilities and process demands, then clearly management s role is critical in the following areas ... 

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. 

Measures to reduce human error are often implemented at an existing plant, rather than during the design process. The decision to conduct an evaluation of the factors that can affect error potential at an existing plant may be taken for several reasons. If human errors are giving rise to unacceptable safety, quality or production problems, plant management, with the assistance of the workforce, may wish to carry out a general evaluahon or audit of the plant in order to identify the direct causes of these problems. 

This section illustrates some of the more global influences at the organizational level which create the preconditions for error. Inadequate policies in areas such as the design of the human-machine interface, procedures, training, and the organization of work will also have contributed implicitly to many of the other human errors considered in this chapter. 

Analysis of accidents and major losses in the CPI indicates that they rarely arise from a single human error or component failure. Often there is a combination of some triggering event (hardware or human) together with preexisting conditions such as design errors, maintenance failures or hardware deficiencies. 

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. 

The second perspective to be considered in this chapter is the human factors engineering (or ergonomics) approach (HFE/E). This approach, described in Section 2.5, emphasizes the mismatch between human capabilities and system demands as being the main source of human error. From this perspective, the primary remedy is to ensure that the design of the system takes into account the physical and mental characteristics of the human. This includes consideration of factors such as ... 

Motivational campaigns are one way of dealing with routine violations (see Section 2.5.1.1). They are not directly applicable to those human errors which are caused by design errors and mismatches between the human and the task. These categories of errors will be discussed in more detail in later sections. 

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