Human Factor - Error Reduction Strategies

Image from: blackcloudproductions.
com
CCB4613 Human Factors for

Process Safety
Error Reduction Strategies
Presentation Title (acronym) Data Collection for Safety performance

Division Name/OPU/HCU/BU (acronym) - Chem Eng Dept. UTP
Name of Presenter Azizul b Buang
Contents
Focus for Human Error Prevention
Typical concern and generic strategy to
overcome the concern
Principles of Error Countermeasures

Remedial Measure - Some Example
Designing To Avoid Human Error

Introduction
Great deal of effort may be expended on
human error detection, identification,
delineation, and refinement,
But
no real correction of the error problem can
be attained without some specific
countermeasure to control, contain, reduce,
or eliminate the risks.


Concern: Hazards
Response:
Implement techniques by which to
recognize hazards.
Eliminate hazards.
Create barriers to prevent errors that
activate hazards, detect activated hazards,
and mitigate the effects of hazards.
Implement techniques by which to make
barriers effective.

Concern: Error-inducing conditions and
error-likely situations
Response:
Recognize error-inducing conditions and
error-likely situations.
Eliminate these conditions and situations.
Practice behaviors by which to counteract
error- inducing conditions and error-likely
situations.

Concern: Inappropriate risk-taking
Response:
Recognize the behaviors that lead to nonconservative decision-making.
Practice behaviors that lead to
conservative decision making


Concern: Recurrence of past errors
Response:
Implement a field observation and
coaching system.
Implement a problem reporting, root cause
analysis, and preventive corrective action
system.
Establish appropriate measures of
performance.

The following principles of error countermeasures serve to illustrate the intent,
function, and general level of effectiveness of various remedies:
1.
Eliminate source of human error (remove hazard) make error impossible by

design
2.
Control opportunity for error by physical means (engineering controls to

prevent error e.g. guards or barriers to prevent access to a source of
error/hazard)
3.
Mitigate consequences of an error (risk severity reduction)
4.
Ensure detectability of errors before damage occurs (foster immediate error

correction)
5.
Institute procedural pathways for guidance and to channel behavior (error

avoidance by restrictions and narrowing of conduct)
6.
Maintain supervisory control and monitoring for errors (error observation, oral
directions, and manual shutdown) useful for new tasks, new employees, new
jobs, and new equipment


The following principles of error countermeasures serve to illustrate the intent,
function, and general level of effectiveness of various remedies:
7.
Provided instructions that are written, brief, specific, and immediately available
8.
Utilize training to provide general background information, job context,

knowledge about company culture, and safety rules.
9.
Have technical manuals available for reference when questions arise or for
general self-learning useful to help avoid troubleshooting errors
10. Warnings provide an informed opportunity to avoid harm used for residual
risks after the use of other remedies
11. Specify that personal protective equipment or other safety equipment be
available when and where needed for harm or injury reduction
12. Assume intentional risk acceptance by no error prevention action and a
toleration of the results.

Specific Countermeasures
Single-error tolerance
Important principle: a single human error should not result
in appreciable harm to persons or property
Product, machine, or equipment should tolerate a simple
mistake or an honest error without giving rise to a
dangerous condition
Human fault tolerance means a system will continue to
operate despite human error, loss or failure: built-in error
override, self-correction, and retained control are important
for safety critical functions

The rule of two
Known that injuries could result from human error
or design error and the task of design engineers is
to prevent adverse results due to such errors
Through two error design rule a danger will only
ensue when at least two independent human errors
or one error and one independent equipment
malfunction occurred.
If the results could be catastrophic, increase the
rule to three error rule or more independently
occurring errors
Interposition
For a recalcitrant human error interpose
a barrier, shield, shroud or to otherwise
deny access to hazard or potential source
of harm e.g. point-of-operation guard
Interposition separates error from the
source of harm.

Remedial Measures - Example

Unfamiliarity
Time Shortage
Train operators to
be aware of
infrequentlyoccurring conditions
Simulate each
situations
Teach understanding
of consequences
Constant rehearsal
and training to
appreciate cost of
failure

Model mismatch
Spatial and
Functional
Incompatibility

Designers of system
find out/consult
users expectations
and design
characteristics into
system
Provision of
knowledge about
human engineering
for population
stereotypes

Poor Feedback
Delayed/Incomplete
Feedback

Comprehensive task
analysis will show
points at which
feedback must be
available to operators
System response
times design to
response below four
seconds & provide
sufficient information
to enable operators to
step confidently on to
next part of task

Impoverished
Information

Procedures should be
human-engineered
and tested for
operability
Procedures must not
rely on accurate
verbal transmission of
information for
success (assumed
when personnel
communicate- very
considerable
information loss will
occur)

Inadequate
Checking

Independent checks
on accuracy of task
by people and
systems that do not
have any vested
interest in success
and failure of an
individual
Job aids and
supervision should
be available to
unburden operators

Make goals and system state visible
Interfaces should make accessible, information in a
form so that system state can be easily related to
system operational goals.
Provide a good conceptual model
It is important that operators be able to develop a good
conceptual model of the plant systems from training,
from the design of the interface between the operator
and the plant, and from observations of system
operation. The information from these three sources
should be consistent and complementary to reduce the
possibility of operating errors.

Make the acceptable regions of operation visible
Directly indicating the acceptable, unacceptable, and desired
regions of system operation in process and state displays can
act as a visual aid. This reduces dependence on user memory
recall and the need for dynamic context dependent
determinations. The adequacy of plant process state can thus
be judged more readily against performance targets.
Provide appropriate feedback

Always provide feedback for an operators actions. Feedback
can take many forms. As a minimum, feedback should convey
the impact of the operators action on the overall state of the
system.

Ensure a close relationship between a control and its
function
To reduce the demand on an operators memory, there

should be a clear relationship between the location and
mode of operation of a control and its function.
Build-in constraints
The users actions should be limited to acceptable ranges of
control possibilities to guard against errors.


Make interfaces consistent
Consistency (and standardization) allows users

to apply existing knowledge to new tasks, This
reduces the burden of interface characteristics
that must be learned and remembered.
Minimizing the secondary tasks associated with
task performance can reduce the incidence of
operating error.

Addressing Human Error in the Design
First needs to characterize their potential for

occurrence and consequence for the operating
situations encompassing system operation.

Once the error environment is characterized,
particular design solutions can be selected to
achieve error reduction objectives.
By matching expected error causing situations
with appropriate design solutions, one can
address potential human error occurrences or
consequences
A design solution strategy that preferentially
deals with error occurrence first and error
consequences second

Eliminate Error Occurrence
This is the first preference, where design features known to be a

source of human error are eliminated (e.g., lack of feedback, lack of
differentiation, inconsistent or unnatural mappings). Choices:
Replacement of error inducing design features (e.g., physical
device separation, physical guards, application of validity and
range checking).
Restructuring of task so the error prevalent behaviour is no longer
performed (e.g., by information filtering, only the information
needed for the task is provided).
Automate to change the role of human involvement in support of
task performance.

Reduce Error Occurrence
Consider this approach if complete error elimination is not
possible or feasible through design choices. Design features:
Identification (e.g., device labelling).

Affordances (i.e., visually convey acceptable choices).
Constraints (i.e., build in constraints to limit operation to
acceptable ranges).
Coding (i.e., aid in choice differentiation and selection).
Consistency.
Feedback (i.e., convey device and system state directly in the

interface).

Eliminate Error Consequence
The third approach is to eliminate error consequences.
Interlocks
Margins and Delays (i.e., these features can provide

more time to unacceptable consequence realization
thus increasing the chances of error detection and
recovery prior to consequence occurrence)
Fail Safe Features
Alert of Unacceptable Device States (e.g.,

visual/auditory feedback of off-normal or unacceptable
device states).


Reduce Error Consequence
If errors and consequences can not be completely
eliminated, consider measures that enable consequence
reduction.
This may be achieved through application of additional
design features that allow operators or automation to
recognize the occurrence of an error consequence, and
to take action to mitigate the consequences


Margins (i.e., apply larger design margins to allow some
consequences to be accommodated by normal system function
and capacities).
Human Intervention / Response Teams (i.e., operations team
can
readily adapt to both predefined and undefined operating
situations, organizational structure is prepared and coordinated
to deal with the predefined consequences).
Consequence Prediction (e.g., aids can assist operations staff
in predicting the extent of consequences of operating actions
and assist in selection and execution of mitigating actions).
Thank you

Self check that, in

your own words,
you are able to:
Highlights
importance of
error reduction
strategies

Human Factor - Error Reduction Strategies

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Human Factor - Error Reduction Strategies

Încărcat de

Drepturi de autor:

Formate disponibile

Image from: blackcloudproductions.

CCB4613 Human Factors for

Presentation Title (acronym) Data Collection for Safety performance

Principles of Error Countermeasures

Presentation Title (acronym) Data Collection for Safety performance

Presentation Title (acronym) Data Collection for Safety performance

Focus for Human Error Prevention

Focus for Human Error Prevention

Focus for Human Error Prevention

Presentation Title (acronym) Data Collection for Safety performance

Focus for Human Error Prevention

Principles of Error Countermeasures

Eliminate source of human error (remove hazard) make error impossible by

Control opportunity for error by physical means (engineering controls to

Mitigate consequences of an error (risk severity reduction)

Ensure detectability of errors before damage occurs (foster immediate error

Institute procedural pathways for guidance and to channel behavior (error

Presentation Title (acronym) Data Collection for Safety performance

Principles of Error Countermeasures

Utilize training to provide general background information, job context,

Presentation Title (acronym) Data Collection for Safety performance

Presentation Title (acronym) Data Collection for Safety performance

Presentation Title (acronym) Data Collection for Safety performance

Remedial Measures - Example

Remedial Measures - Example

Presentation Title (acronym) Data Collection for Safety performance

Remedial Measures - Example

Presentation Title (acronym) Data Collection for Safety performance

Remedial Measures - Example

Presentation Title (acronym) Data Collection for Safety performance

Remedial Measures - Example

Presentation Title (acronym) Data Collection for Safety performance

Designing To Avoid Human Error

Designing To Avoid Human Error

Provide appropriate feedback

Designing To Avoid Human Error

To reduce the demand on an operators memory, there

Presentation Title (acronym) Data Collection for Safety performance

Designing To Avoid Human Error

Consistency (and standardization) allows users

Presentation Title (acronym) Data Collection for Safety performance

Addressing Human Error in the Design

First needs to characterize their potential for

Addressing Human Error in the Design

Addressing Human Error in the Design

This is the first preference, where design features known to be a

Addressing Human Error in the Design

Identification (e.g., device labelling).

Feedback (i.e., convey device and system state directly in the

Addressing Human Error in the Design

Margins and Delays (i.e., these features can provide

Fail Safe Features

Alert of Unacceptable Device States (e.g.,

Presentation Title (acronym) Data Collection for Safety performance

Addressing Human Error in the Design

Presentation Title (acronym) Data Collection for Safety performance

Addressing Human Error in the Design

Presentation Title (acronym) Data Collection for Safety performance

Self check that, in

S-ar putea să vă placă și