Root cause human factors

Many organisations already use root cause analysis techniques that allow the identification of critical factors in the occurrence of incidents. For each critical factor, related behaviours can be isolated. A number of these factors can be related closely to human error, violation or safety culture. Formal approaches are required to perform in-depth analysis of such factors and determine the root of human factors problems and how they could be dealt with. 

The intention of this section is to provide a selection of case studies of varying complexity and from different stages of chemical process plant operation. The purpose of these case studies is to indicate that human error occurs at all stages of plant operation, and to emphasize the need to get at root causes. The case studies are grouped under a number of headings to illustrate some of the commonly recurring causal factors. Many of these factors will be discussed in later chapters. 

In the case of root cause analysis systems, more comprehensive evaluations of PIFs will normally be carried out as part of a full-scale human factors audit. This could make use of the types of comprehensive PIF evaluation methods described in Chapter 2 (see Section 2.7.7 and Figure 2.12). 

Root causes 6, 7, and 8. Human factors aspects were inadequately addressed. Specifically, ergonomics of the plant was poor, there were differences in layout among different areas and the labeling was poor. 

Checklists may also be used to supplement other tools for example, checklists on human factors may be used in conjunction with logic trees. Similarly, checklists may be used in combination with structured brainstorming tools such as What If/Checklist and Hazard and Operability (HAZOP) Analysis.(P It is also a good practice to apply a tool like the 5-Whys to the root causes identified from the checklist to verify whether they are truly root causes. 

In recognition that most incidents have multiple root causes, the team is generally required to identify a minimum of three factors one from each of the following categories organizational, human, and material factors. 

HUMAN FACTORS - Most current root cause methodologies will address the human reliability and human performance aspects that are involved in the occurrence. 

Paradise, M. Root Cause Analysis and Human Factors. Human Factors Bulletin. 34(8) 1-5, 1991. 

For example, failure to follow procedures is not a root cause. Failure to follow established procedure is a common premature stopping point for incident investigation related to human factors. In many cases, the... 

Chapter 9 describes the use of human factors checklists in root cause analysis. 

Find the facts in the main sequence on the Causal Factor Chart that describe a component failure or a human error. Ensure the fact is not describing a management system failure (i.e., ensure the fact is not a root cause, near root cause, or root cause category). The identified negative events/conditions are candidate causal factors. Any candidate causal factor that is not dependent on another candidate causal factor is a valid causal factor. 

A common intermediate level finding may be that someone failed to follow established procedure. (See Chapter 6 for details on human factors considerations.) Stopping at this point would be a mistake since failure to follow established procedure is rarely a root cause. A root cause approach... 

The use of checklists to supplement another root cause analysis method can be a very powerful technique, for example, human factors checklist(s) may be used in conjunction with logic trees. The checklist may be used as a guide during development of a logic tree, or as a check after the tree has been developed. The checklist essentially acts as a memory jogger to direct the investigation team. This is especially helpful if the team lacks previous experience in the subject matter. 

With all due respect to the findings of the investigating team, the root cause appears to me to be a human factors situation. The new piping system looked simple but in fact this... 

One factor, which should always be considered when performing materials failure investigations, is the influence of human error. This section provides three examples of equipment failures due to cracking for which the root cause of failure was found to be... 

Step 6. Having identified such structural factors (the real root causes), the model must allow interpretation of these, i.e. it must suggest ways of influencing these factors, to eliminate or diminish error factors and to promote or introduce recovery opportunities in the human-machine systems and indeed in the organisation as a whole. 

With all due respect to the findings of the investigating team, the root cause appears to me to be a human factors situation. The new piping system looked simple but in fact this unique system was confusing. A check valve (valve no. 2) was installed on the vent header to prevent cross-contamination. A small block valve (valve no. 4) was installed on the vacuum relief impulse line to provide easy isolation. [5]... 

Focusing on individual error won t necessarily lead to problem identification. Mark Paradies gives this view in his article titled Root Cause Analysis and Human Factors ... 

Accept the fact that the human being is one part of a complex work system — that a complex interaction exists among the physical, psychological, psychosocial and work organization factors. Facing on one aspect, while ignoring others, will lead to an incomplete solution at best—one that treats only symptoms, not root causes. 

Pesme, H., Le Bot, R, Meyer, P. (2007). Little stories to explain human reliability assessment A practical approach of the MERMOS method. In Joint 8th IEEE HFPP Conference on Human Factor and Power Plants and 13th HPRCTAnnual Workshop on Human Performance, Root Cause, Trending, Operating Experience, Self Assessment, August 26, 2007 - August 31, 2007 (pp. 284—287). Monterey, CA, United states Institute of Electrical and Electronics Engineers Inc. 

In the industrial field, the accidents situation depends on a wide variety of causes (i.e. diversification and complexity in production processes and technologies, human factors, organizational aspects, no application of safety procedures) that are often very difficult to indentify and to analyze. This is the reason why today aproactive approach to safety problems becomes a key factor. The Risk Assessment approach is aheady known and consohdated but the problem that is not yet solved is related to the indicators used in order to identify the risk priority. Usually these indicators are based on evaluator s experience and expertise, and not necessary deriving from statistical analysis. It depends on the fact that work injuries data are often not usable to characterize a specific risk category by a statistical approach it s a fact mainly due to the amount and typology of the available data and, consequently, to the lack of relationships between injuries and root causes. 

One or more factors associated with an incident or a potential incident Causal factors may be identified as time-sequenced events or may be categorized as being related to human or environmental (e.g., equipment, machinery, atmospheric contaminant, temperature, etc.) influences and their interactions. See also Causal Factor Root Cause. Accident Chain... 

Chapter 3 presents introductory aspects of safety and human factors. Chapter 4 is devoted to methods considered useful to perform patient safety analysis. These methods include failure modes and effect analysis (FMEA), fault tree analysis (FTA), root cause analysis (RCA), hazard and operability analysis (HAZOP), six sigma methodology, preliminary hazard analysis (PFfA), interface safety analysis (ISA), and job safety analysis (JSA). Patient safety basics are presented in Chapter 5. This chapter covers such topics as patient safety goals, causes of patient injuries, patient safety culture, factors contributing to pahent safety culture, safe practices for better health care, and patient safety indicators and their selection. 

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