Training errors, human factors

Human factors, discussed in Section 4.2, enter a fault tree in the same manner as a component failure. The failure of manual actions, that prevent or mitigate an accident, are treated the same as hardware failures. The human error failure probability is conditioned by performance sluiping factors imposed by stress, training and the environment. 

Human errors may be dependent on the specific accident sequence displayed in the event tree, and, for that reason, may be included in the event tree. This requires the human-factors specialist to consider the context of the error in terms of stress, operator training in response to the accident, di.tgnosiic paiierns, environmental, and other performance-shaping factors. 

A combination of on-the-job and off-the-job methods is usually the best solution in most types of training. The following factors should be examined in order to analyze the role of training in preventing human error. Team training will be considered in the social and organizational factors which follow in other sections. 

Inspection of the HRA event tree reveals that the dominant human error is Error A the operator failing to isolate the propane valves first. The other potential human errors are factors only if a propane isolation valve sticks open. Based on these qualitative results alone, a manager rrught decide to periodically train operators on the proper procedure for isolating a failed condenser and to ensure that operators are aware of the potential hazards. The manager might... 

The human factors audit was part of a hazard analysis which was used to recommend the degree of automation required in blowdown situations. The results of the human factors audit were mainly in terms of major errors which could affect blowdown success likelihood, and causal factors such as procedures, training, control room design, team communications, and aspects of hardware equipment. The major emphasis of the study was on improving the human interaction with the blowdown system, whether manual or automatic. Two specific platform scenarios were investigated. One was a significant gas release in the molecular sieve module (MSM) on a relatively new platform, and the other a release in the separator module (SM) on an older generation platform. 

Quality of installation and the adherence to design specifications of the equipment should be evaluated to ensure that errors during shipping and installation were not made. Often overlooked at this phase are human factors considerations for the construction crew, such as selection of the contractor, training of the crew, lighting, shift work, procedures, and supervision. 

ANALYSIS DOCUMENTATION. PrHA report documentation should include the PrHA worksheets, checklists, logic diagrams, human reliability analyses, and any other analysis made to better understand the scenarios. The PSM Rule requires that human factors that impact scenarios as cause or protection be expanded to analyze the basic cause of errors or response failures. For example, a cause may identify that an operator can turn the wrong valve to initiate an accident. The PSM Rule requires that basic causes also be identified. For example, valve is not labeled the operator has not been trained on the operation or the operator forgot the step. There may be more than one basic cause. (See also Section 3.2, paragraph on Human Factors.)... 

Hall, David. 2005. The role of human factors training and error management in the aviation maintenance safety system. 58th Joint Meeting of the Flight Safety Foundation, 58th Annual IntemationalAir Safety Seminar (IASS). Moscow. November 2005. FSF 245—250. 

Carroll, J. M., Carrithers, C. Blocking learner error states in a training wheels system. Human Factors, 26, 377-389.1984. 

In addition to the initial evaluation of the credited operator action, a program should be established to ensure that all assumptions about the reliability of the operator response are maintained and improved. This would include, but is not necessarily limited to initial training, refresher training, procedures engineered to decrease the likelihood of human error, important human factors that have been identified. 

Personal factors, which affect health and safety, may be defined as any condition or characteristic of an individual which could cause or influence him to act in an unsafe manner. They may be physical, mental or psychological in nature. Personal factors, therefore, include issues such as attitude, motivation, training and human error and their interaction with the physical, mental and perceptual capability of the individual. 

These are the conditions in existence immediately prior or at the time of the incident that directly influences human and equipment performance in the workplace. These are the circumstances under which the errors and violations took place and can be embedded in task demands, the work environment, individual capabilities and human factors. Deficiencies in these conditions can promote the occurrence of errors and violations. They may also stem from an organizational factor type such as risk management, training, incompatible goals, or organization, when the system tolerates their long term existence. 

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