HFE-Human Factors Engineering- Understanding Human Failure
TATA VENKATA SURYA PRAKASH, PMP®
A Chemical Engineer with Project Management Professional (PMP®) & 26 Years of experience as Project Manager with expertise in Oil & Gas Major Projects Management from Conceptualization, FEED, EPC.
Human Failure is a very often used term in our incident/accident investigations and in todays articles we will try to understand it through the perspective of HFE.
Human Failure is basically of two types.
Inadvertent Failure(Human Error) classified as the faults/Mistakes bound by rules and Knowledge specific. Humans tend to commit mistakes which often not the primary causes of an accident.
Influenced by word of mouth and larger opinion basis most of the industrial incidents often conclude that the cause of most of accidents are human error(Personnel) and is common in a society which is driven individualism of fame and name. However, One cannot deny the fact that in every industrial accident there are almost and always several management safety systems involved which were at fault and not readily apparent.
2. Deliberate failures are Individual or a group violations happening in routine or driven by a specific situation or by exceptional circumstances.
In the case of Exceptional Failure case where an individual takes calculated risk for resolving a problem in highly unusual circumstances by breaking rules.
When we look into Active and Latent Failures which are nothing but errors and violations with immediate negative impact or consequence caused by HIGH RISK Behaviors or active failures.
Active failures basically committed by frontline workforce like Drivers, Control room Staff or Machine Operators and they do have an immediate consequence on Health and Safety.
However, Latent failures often committed by people whose tasks are removed in time and space from operational activities Viz. designers, Middle & Top Management (Decision makers) hence these are considered as failures of Health and Safety Management System. Some important examples are Poor Design of a Plant and under rated equipment, Improper Training, incompetent supervision, Poor Communication Process & un-defined roles and responsibilities.
Latent failures often pose a higher risk as they were mostly hidden within an organization until Potential Top Event has occurred which poses as Potential danger to Health and Safety as Active Failure.
When we look into Error "Error is nothing but an action which is a failed case of meeting expected outcome producing an undesired or unwanted consequence. Hence, Human Error Commonly defined as " Failure of a planned action to achieve desired result"
4 Types of Errors:
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If a person carries out a task without thinking due to familiarity to task automatically like switching on of a switch on a control panel.
Lapse is non compliance to the set of rules or procedure which is bound to be by a sequence and a step or two in sequence are missed.
Mistake is lateral realization of "Wrong doings(Actions)". Rule based mistakes happen when a series of set of rules of performing a task not been followed and a wrong rule applied.
Knowledge based mistakes happen when a person is faced with an unfamiliar situation for which one has no rules and uses ones self knowledge and works from basic principles which ends in a wrong conclusion.
The Problems or Traps which are hidden within a system are called Latent Errors or problems contributing to its occurrence. They may be in hideout for a very little moment but often based on circumstances manifest.
Violations are deliberate deviations from safe work standards and procedures which may be accidental, unintentional or deliberate and these are rule breaking actions and are deliberate failure to follow the rules. For example cutting corners to save time and effort with belief that rules are too restrictive and not enforced anyway.
These violations are classified as 1. Routine Violations. 2. Unintentional Violations. 3. Procedural Violations. 4. Exceptional Violations. & 5. Situational Violations.
The Top 10 OSHA listed Violations from 21k citations issued are:
"There is always a Safe Way of doing a task and Do it Safely or Not at all"
Prakash Tata