Human error perspectives

From a human error perspective, Guerrero et al. (2008) stated that an incident scenario is a composition of actors, objectives, instruments, action sequences, errors, error causes and error consequences, and context elements. 

From a human factors perspective, the chemistry of the process can be made inherently safer by selecting materials that can better tolerate human error in handling, mixing, and charging. If a concentrated reagent is used in a titration, precision in reading the burette is important. If a dilute reagent is used, less precision is needed. 

This section reflects on the limitations of the PSA process and draws extensively from NUREG-1050. These subjects are discussed as plant modeling and evaluation, data, human errors, accident processes, containment, fission product transport, consequence analysis, external events, and a perspective on the meaning of risk. 

Chapter 1, The Role of Human Error in Chemical Process Safety, discusses the importance of reducing human error to an effective process safety effort at the plant. The engineers, managers, and process plant personnel in the CPI need to replace a perspective that has a blame and punishment view of error with a systems viewpoint that sees error as a mismatch between human capabilities and demands. 

The structure of this book is based on a model of human error, its causes, and its role in accidents that is represented by Figures 1.4 and 1.5. This perspective is called the system-induced error approach. Up to now, only certain... 

The last area addressed by the systems approach is concerned with global issues involving the influence of organizational factors on human error. The major issues in this area are discussed in Chapter 2, Section 7. The two major perspectives that need to be considered as part of an error reduction program are the creation of an appropriate safety culture and the inclusion of human error reduction within safety management policies. 

The analysis of accidents and disasters in real systems makes it clear that it is not sufficient to consider error and its effects purely from the perspective of individual human failures. Major accidents are almost always the result of multiple errors or combinations of single errors with preexisting vulnerable conditions (Wagenaar et al., 1990). Another perspective from which to define errors is in terms of when in the system life cycle they occur. In the following discussion of the definitions of human error, the initial focus will be from the engineering and the accident analysis perspective. More detailed consideration of the definitions of error will be deferred to later sections in this chapter where the various error models will be described in detail (see Sections 5 and 6). 

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 ... 

I Comparisons between Various Perspectives on Human Error... 

These explanations do not exhaust the possibilities with regard to underlying causes, but they do illustrate an important point the analysis of human error purely in terms of its external form is not sufficient. If the underlying causes of errors are to be addressed and suitable remedial strategies developed, then a much more comprehensive approach is required. This is also necessary from the predictive perspective. It is only by classifying errors on the basis of underlying causes that specific types of error can be predicted as a function of the specific conditions under review. 

The previous sections have presented an extensive description of some of the central concepts from the cognitive modeling perspective. These topics have been dealt with in some depth because they provide a comprehensive basis for the reduction of human error in the CPI. 

In the previous chapter, a comprehensive description was provided, from four complementary perspectives, of the process of how human errors arise during the tasks typically carried out in the chemical process industry (CPI). In other words, the primary concern was with the process of error causation. In this chapter the emphasis will be on the why of error causation. In terms of the system-induced error model presented in Chapter 1, errors can be seen as arising from the conjunction of an error inducing environment, the intrinsic error tendencies of the human and some initiating event which triggers the error sequence from this imstable situation (see Figure 1.5, Chapter 1). This error sequence may then go on to lead to an accident if no barrier or recovery process intervenes. Chapter 2 describes in detail the characteristics of the basic human error tendencies. Chapter 3 describes factors which combine with these tendencies to create the error-likely situation. These factors are called performance-influencing factors or PIFs. 

From a human reliability perspective, a number of interesting points arise from this example. A simple calculation shows that the frequency of a major release (3.2 x lO"" per year) is dominated by human errors. The major contribution to this frequency is the frequency of a spill during truck unloading (3 X10" per year). An examination of the fault tree for this event shows that this frequency is dominated by event B15 Insufficient volume in tank to imload truck, and B16 Failure of, or ignoring LIA-1. Of these events, B15 could be due to a prior human error, and B16 would be a combination of instrument failure and human error. (Note however, that we are not necessarily assigning the causes of the errors solely to the operator. The role of management influences on error will be discussed later.) Apart from the dominant sequence discussed above, human-caused failures are likely to occur throughout the fault tree. It is usually the case that human error dominates a risk assessment, if it is properly considered in the analysis. This is illustrated in Bellamy et al. (1986) with an example from the analysis of an offshore lifeboat system. 

This indicates that error management comprises two strategies proactive methods are applied to prevent errors occurring, and reactive strategies are used to learn lessons from incidents that have occurred and to apply these lessons to the development of preventive measures. Both proactive and reactive methods rely on an understanding of the courses of human error based on the theories and perspectives presented in this book. The tools and tech-... 

From the perspective of the coal industry, through making analysis about many coal mine accidents, it established the coal mine accident human error model by observation and interpretation on the coal mine accidents mechanism from a new angle, and provided the reference for coal mine accident prevention business. 

Human error rates are notoriously difficult to quantify from a reliability perspective and depend heavily on the situation, training, distractions, tiredness, etc. While human error databases have been compiled, the human error being modelled should be matched as closely as possible to the same type of human error in the database. It is advisable to consult expert opinion when estimating human error rate due to these factors, and the rate selected should factor in possible variations in human performance and conditions as well as statistical estimation error. 

This section summarizes the insights gained from the human error characteristics by error types from the perspective of the prediction of human error possibilities or potentials. 

Therefore, from the public health perspective, appropriate epidemiological approaches should be used to identify the causes of emergency medicine-related errors and their resulting adverse events or consequences [13,16,17]. Also, questions such as those presented below can be useful in reducing the occurrence of human errors in the area of emergency medicine [13] ... 

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