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Types of Human Error

The document discusses different types of human failure including slips, lapses, mistakes, and non-compliance. Slips are errors in execution where the intended action is not carried out correctly. Lapses are memory failures where an intended action is simply omitted. Mistakes occur when the wrong course of action is chosen, believing it to be right. Non-compliance involves deliberate deviations from rules. To reduce human failure, performance influencing factors like task design, procedures, training, and culture should be optimized.

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Pankaj Paul
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1K views

Types of Human Error

The document discusses different types of human failure including slips, lapses, mistakes, and non-compliance. Slips are errors in execution where the intended action is not carried out correctly. Lapses are memory failures where an intended action is simply omitted. Mistakes occur when the wrong course of action is chosen, believing it to be right. Non-compliance involves deliberate deviations from rules. To reduce human failure, performance influencing factors like task design, procedures, training, and culture should be optimized.

Uploaded by

Pankaj Paul
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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#.)%*!"%'(.,&!

$/+&Human Failure

Error

Non-Compliance

Action Error

Thinking Error

Routine

Situational

Exceptional

Action-Based

Slip

Memory-Based

Lapse

Rule-Based

Mistake

Knowledge-Based

Mistake

Remember to optimise PIFs


Performance Influencing Factors (PIFs) are the characteristics of the job, the individual and the organisation that influence human performance. Optimising PIFs will reduce the likelihood of all types of human failure.

#.)%*!"%'(.,&!$/+&Characteristics $33134 "(5,10!


Associated with familiar tasks that require little conscious attention. These skill-based errors occur if attention is diverted, even momentarily. Resulting action is not intended: not doing what you meant to do. Common during maintenance and repair activities.

Failure Type
Slip
(Commission)

Examples
A simple, frequently-performed physical action goes wrong: ! flash headlights instead of operating windscreen wash/wipe function ! move a switch up rather than down (wrong action on right object) ! take reading from wrong instrument (right action on wrong object) ! transpose digits during data input into a process control interface Short-term memory lapse; omit to perform a required action: ! forget to indicate at a road junction ! medical implement left in patient after surgery ! miss crucial step, or lose place, in a safety-critical procedure ! drive road tanker off before delivery complete (hose still connected) If behaviour is based on remembered rules and procedures, mistake occurs due to mis-application of a good rule or application of a bad rule: ! misjudge overtaking manoeuvre in unfamiliar, under-powered car ! assume 20 fuel will last a week but fail to account for rising prices ! ignore alarm in real emergency, following history of spurious alarms Individual has no rules or routines available to handle an unusual situation: resorts to first principles and experience to solve problem: ! rely on out-of-date map to plan unfamiliar route ! misdiagnose process upset and take inappropriate corrective action (due to lack of experience or insufficient / incorrect information etc.) Non-compliance becomes the norm; general consensus that rules no longer apply; characterised by a lack of meaningful enforcement: ! high proportion of motorists drive at 80mph on the motorway ! PTWs routinely authorised without physical, on-plant checks Non-compliance dictated by situation-specific factors (time pressure; workload; unsuitable tools & equipment; weather); non-compliance may be the only solution to an impossible task: ! van driver has no option but to speed to complete days deliveries Person attempts to solve problem in highly unusual circumstances (often if something has gone wrong); takes a calculated risk in breaking rules: ! after a puncture, speed excessively to ensure not late for meeting ! delay ESD during emergency to prevent loss of production

Typical Control Measures ! ! ! ! !


! human-centred design (consistency e.g. up always means off; intuitive layout of controls and instrumentation; level of automation etc.) checklists and reminders; procedures with place markers (tick off each step) independent cross-check of critical tasks (PTW) removal of distractions and interruptions sufficient time available to complete task warnings and alarms to help detect errors often made by experienced, highly-trained, wellmotivated staff: additional training not valid plan for all relevant what ifs (procedures for upset, abnormal and emergency scenarios) regular drills/exercises for upsets/emergencies clear overview / mental model (clear displays; system feedback; effective shift handover etc.) diagnostic tools and decision-making aids (flowcharts; schematics; job-aids etc.) competence (knowledge and understanding of system; training in decision-making techniques) organisational learning (capture and share experience of unusual events) improve risk perception; promote understanding and raise awareness of whys & consequences (e.g. warnings embedded within procedures) increase likelihood of getting caught effective supervision eliminate reasons to cut corners (poor job design; inconvenient requirements; unnecessary rules; unrealistic workload and targets; unrealistic procedures; adverse environmental factors) improve attitudes / organisational culture (active workforce involvement; encourage reporting of violations; make non-compliance socially unacceptable e.g. drink-driving).

Lapse
(Omission)

!
! !

4
Decision-making failures; errors of judgement (involve mental processes linked to planning; info. gathering; communication etc.) Action is carried out, as planned, using conscious thought processes, but wrong course of action is taken: do the wrong thing believing it to be right

Rule-Based

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Mistake

! ! ! ! !
! !

$3313

Knowledge-Based

Mistake

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Deliberate deviations from rules, procedures, regulations etc. Also known as violations Knowingly take short cuts, or fail to follow procedures, to save time or effort. Usually well-meaning, but misguided (often exacerbated by unwitting encouragement from management for getting the job done).

Routine

Situational

Exceptional

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