Addressing Human Error

Leonard G. Middleton

Asset Management Solutions

www.asset-management-solutions.com

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Agenda

• Urban Legend?

• A Brief History of Human Error

• Why People Do Things Wrong

• Improving the Odds

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Urban Legend?

• In early 1980’s a business consultant makes a presentation on addressing human error…

• "I think we can all agree that we can go for 30 seconds without making a mistake. And if we can go 30 seconds without making a mistake, we can go a minute without making a mistake. And if we can go a minute without making a mistake, we can go two minutes… 3

Urban Legend?

• At the end of the presentation the consultant asked whether anyone had any questions.

• Someone raised their hand, and asked…

• "I'm just curious, were you born stupid, or is this something you've been studying?"

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Urban Legend?

• Who is right?

• Is addressing human error as simple as hiring the right people who are conscious and can focus on ensuring the job is done right?

• Or is it much more than that?

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A Brief History of Human Error

• First instance of human error would have preceded the invention of written language.

• One of the early failures would have been likely related to tools and their construction.

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A Brief History of Human Error

• Function of an early simple one piece tool, the wood club.

– To increase the kinetic energy developed by the arm muscles, and transfer it to an object.

• Consequences of failure could be severe, even fatal.

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A Brief History of Human Error

• What could cause a wood club fail?

– Not strong enough. - Too thick

– Too long for accuracy - Too short

– Too flexible - Difficult to grip / hold

– Too heavy - Too light

– Too soft - Poorly balanced…

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A Brief History of Human Error

• Can make a higher performance club and make it more complex by tying a rock onto a stick, however the causes of failures can quickly increase…

– Materials used to fabricate.

– Assembly method and technique.

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A Brief History of Human Error

• Fast forward a few millennia, and the most complex tools that are regularly built, operated and maintained are found to fail too frequently.

• Results in the 1978 Knowlan and Heap study on failures of civilian aircraft.

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A Brief History of Human Error

• One critical finding of study is the infant mortality failure pattern is most common failure pattern.

• Factors and causes include:

– Complex systems

– Defective parts and materials

– Human error11

Why People Do Things Wrong

• Anthropometric factors relate to ergonomic issues.

• Given different body characteristics, it may be difficult, or impossible to perform certain tasks.

– Strength, size, reach, etc.

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Why People Do Things Wrong

• Human sensory factors relate to ease and ability to sense what is happening around individuals and make decisions based upon what is happening.

• Operating environment impacts ability to sense.

– Poor visibility, high ambient noise, strong odours, high vibration, etc.

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Why People Do Things Wrong

• Physiological factors relate to environmental stress that can reduce performance.

• Extreme environment situations can increase stress, causing fatigue and increase errors.

– Temperature extremes, high humidity, etc.

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Why People Do Things Wrong

• Psychological factors are divided between unintended and intended actions.

• Unintended actions are skill based errors related to distraction or preoccupation.

– Slip causing something normally done well, to be done incorrectly.

– Lapse causing a key step in sequence to be missed.

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Why People Do Things Wrong

• Intended actions can result in mistakes or violations.

• Rule based mistake

– Misapplication of a “good rule” where context is not appropriate to the rule.

– Or application of a “bad rule” that is not generally appropriate, but typically used in context.

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Why People Do Things Wrong

• Knowledge based mistake

– Inappropriate response to a situation new to the individual.

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Why People Do Things Wrong

• Violation results when knowingly and deliberately commits an error.

– Routine violation

– Exceptional violation

– Sabotage

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Improving the Odds

• Human error has been around a long time, it may not be possible to eliminate, but there are things can be done to improve the odds.

• Reliability is a result of: how suitable are the assets to their intended use; how well are they installed; how well they are operated; and how well they are maintained.

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Improving the Odds

• Design efforts can focus upon effectively reducing the probability of failures, and reducing the consequences of failures.

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Improving the Odds

• Design focus respecting “Murphy’s Law”, to reduce probability.

• Design philosophy of “making it easy to do it right, and hard to do it wrong”.

– No guarantees, just improves the odds.

• Address different physical characteristics of those performing work, and impact of the work environment. 21

Improving the Odds

• Design focus to address consequences.

• Reduce system dependencies to limit the extent of consequences.

• Evaluate compromise of adding protective systems, versus added complexity (increased probability of failure), cost, and increased maintenance requirements.

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Improving the Odds

• Use a cross functional effort in MOC process (Management of Change) to reduce potential of design changes resulting in problems not obvious to individual making the changes.

• Train all involved in MOC process to ensure they fully understand their responsibilities.

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Improving the Odds

• Focus hiring and training efforts to ensure those assigned work are competent to perform the assigned tasks.

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Improving the Odds

• Develop SOPs (Standard Operating Procedures) to provide instructions for common procedures, especially those done infrequently.

– Start up, shutdown, emergency procedures, etc.

• Ensure all required individuals are trained on procedures, and procedure documents available for their use. 25

Improving the Odds

• Develop job plans for maintenance work, especially for complex jobs, and where the failure consequences of doing the work wrong are severe.

• Given current demographics, may likely be hiring new employees, and can greatly reduce their probability of doing things wrong.

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Improving the Odds

• Violations will need to be addressed through HR policies and procedures.

• How many of your human error failures are related to violations?

– If the number is significant, there may be significant organizational issues that need to be resolved.

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References and Useful Links1. “Reliability-Centered Maintenance” by John

Moubray

2. Wikipedia http://en.wikipedia.org , see human reliability, man made disasters, human error, KISS Principle, Murphy’s Law, etc.

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Leonard G. Middleton

Asset Management Solutionswww.asset-management-solutions.com

Questions?

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Leonard G. Middleton

Asset Management Solutionswww.asset-management-solutions.com

Thank You!

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