Human Error

Far too often the results of incident investigations lead to a final result that the cause is ‘human error’. It is very pleasant for all to declare an incident to be the result of human error. This translates that it is no one’s fault except the last individual in the domino of accident causation. It also absolves all management actions and in actions as well as any legislation that has been passed or omitted.

An acceptable practice is to try and reduce the possibility of human error by applying:

Engineering measures – Technical

Technical, or engineering, controls are those which are applied directly to the hazard itself in order to minimise and or remove the possibility of person acting inappropriately. In process safety this would be having in place trips (temperature, pressure, level, etc.) that would work automatically without any need for intervention by the person. This method is common in process safety but the problem that remains is that personnel tend to rely for too much on the output of measuring instruments record and fail to think problems through. The person has to have a complete understanding of the process because instruments do go wrong. An excellent example is the accident of Texas City Refinery in 2005 where feed was being pumped into the tower for a number of hours and nothing was leaving the tower. The instruments indicated a lowering of the level in the tower whilst in actual fact the tower was being overfilled. It is essential to have the thinking person.

Operational measures – Procedural

Procedural control will include the standards and rules set by the organization. Different procedures are developed as a result of identifying good practice and Approved Codes that are used within the organization. These procedures must be updated periodically with the input of those persons affected.

Management supervision – Behavioural

Behavioural controls relate to how the person acts. This is a weak but ultimately an excellent method but one that requires the person to identify safety not only as a target but as a way of life. Safety must be held as a value not a number.

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