HUMAN ERROR

Human Error is commonly defined as “a failure of a planned action to achieve a desired

outcome”. Error-inducing factors exist at individual, job, and organisational levels, and when
poorly managed can increase the likelihood of an error occurring in the workplace. When
errors occur in hazardous environments, there is a greater potential for things to go wrong.
By understanding human error, responsible parties can plan for likely error scenarios,
and implement barriers to prevent or mitigate the occurrence of potential errors.

Errors result from a variety of influences, but the underlying mental processes that lead to
error are consistent, allowing for the development of a human error typology. An
understanding of the different error types is critical for the development of effective error
prevention and mitigation tools and strategies. A variety of these tools and strategies must
be implemented to target the full range of error types if they are to be effective.

Errors can occur in both the planning and execution stages of a task. Plans can be adequate
or inadequate, and actions (behaviour) can be intentional or unintentional. If a plan is
adequate, and the intentional action follows that plan, then the desired outcome will be
achieved. If a plan is adequate, but anunintentional action does not follow the plan, then
the desired outcome will not be achieved. Similarly, if a plan is inadequate, and
an intentional action follows the plan, the desired outcome will again not be achieved.
These error points are demonstrated in the figure below and explained in the example that
follows.

Human error – failures in planning and execution

Example:

Failures of Plans and Actions: Sam has finished his last task for the day and his desired
outcome is to get to the accommodation module. He knows that his usual path to the
accommodation module has been barricaded off, so he plans a different route to get there.
From a human error perspective, there are three potential alternative scenarios that he may
experience when executing his plan:
Each of the failure types can be further broken down into categories and subcategories.
These will now be explained in greater detail.

Human error typology

Failures of action, or unintentional actions, are classified as skill-based errors. This error
type is categorised into slips of action and lapses of memory. Failures in planning are
referred to as mistakes, which are categorised as rule-based mistakes and knowledge-
based mistakes.

Skill-based Errors

Skill-based errors tend to occur during highly routine activities, when attention is diverted
from a task, either by thoughts or external factors. Generally when these errors occur, the
individual has the right knowledge, skills, and experience to do the task properly. The task
has probably been performed correctly many times before. Even the most skilled and
experienced people are susceptible to this type of error. As tasks become more routine and
less novel, they can be performed with less conscious attention – the more familiar a task,
the easier it is for the mind to wander. This means that highly experienced people may be
more likely to encounter this type of error than those with less experience. This also means
that re-training and disciplinary action are not appropriate responses to this type of error.
A memory lapse occurs after the formation of the plan and before execution, while the plan
is stored in the brain. This type of error refers to instances offorgetting to do
something, losing place in a sequence, or even forgetting the overall plan.

A slip of action is an unintentional action. This type of error occurs at the point of task
execution, and includes actions performed on autopilot, skipping or reordering a step in a
procedure, performing the right action on the wrong object, or performing the wrong
action on the right object. Typical examples include:

 missing a step in an isolation sequence

 pressing the wrong button or pulling the wrong lever

 loosening a valve when intending to tighten it

 transposing digits when copying numbers (e.g. writing 0.31 instead of 0.13)

Mistakes

Mistakes are failures of planning, where a plan is expected to achieve the desired outcome,
however due to inexperience or poor information the plan is not appropriate. People
with less knowledge and experience may be more likely to experience mistakes. However,
as mistakes are not committed ‘on purpose’, disciplinary action is an inappropriate
response to these types of error.

Mistakes can be rule-based or knowledge-based. The different types of mistakes are

explained below through the use of an example from NOPSA Safety Alert 28, where a
construction vessel failed to avoid a cyclone. This example demonstrates how multiple
errors at various levels of an organisation can interact to lead to a hazardous event.
Knowledge-based mistakes result from ‘trial and error’. In these cases, insufficient
knowledge about how to perform a task results in thedevelopment of a solution that
is incorrectly expected to work.

Rule-based mistakes refer to situations where the use or disregard of a particular rule or set
of rules results in an undesired outcome.

There are three types of rule-based mistakes:

 incorrect application of a good rule

 correct application of a bad rule

 failure to apply a good rule.

Some rules that are appropriate for use in one situation will be inappropriate in
another. Incorrect application of a good rule occurs when a rule has worked well on
previous occasions, so it is applied to a similar situation with the incorrect expectation that it
will work.
Sometimes rules are inappropriate or incorrect, and adherence leads to negative outcomes.
In these cases, application of a bad rule does not deliver the desired outcome. Bad rules
may be created based on incorrect knowledge (i.e. knowledge-based mistakes), or a good
rule may become bad following changes that are not managed appropriately.

Violations

Failure to apply a good rule is also known as a violation. Violations are classified as human
error when the intentional action does not achieve the desired outcome. Violations tend to
be well-intentioned, targeting desired outcomes such as task
completion and simplification. Where violations involve acts of sabotage designed to cause
damage, the planned action (violation) has achieved the desired outcome (damage). This
type of behaviour does not constitute human error and, following investigation, should be
managed through the application of appropriate disciplinary measures. There are three main
types of violations pertaining to human error: routine, situational, and exceptional.

A routine violation is one which is commonplace and committed by most members of the
workplace. For example, in a particular office building it is against the rules for personnel to
use the fire escape stairwell to move between floors, but it is common practice for people to
do so anyway.
U.S. Chemical Safety and Hazard Investigation Board (2007). Investigation Report: Refinery
Explosion and Fire, BP, Texas City, Texas, March 23, 2005.

A situational violation occurs, as its name suggests, in response to situational factors,

including excessive time pressure, workplace design, and inadequate or inappropriate
equipment. When confronted with an unexpected or inappropriate situation, personnel may
believe that the normal rule is no longer safe, or that it will not achieve the desired
outcome, and so they decide to violate that rule. Situational violations generally occur as a
once-off, unless the situation triggering the violation is not corrected, in which case the
violation may become routine over time.

An exceptional violation is a fairly rare occurrence and happens in abnormal and emergency
situations. This type of violation transpires when something is going wrong and personnel
believe that the rules no longer apply, or that applying a rule will not correct the problem.
Personnel choose to violate the rule believing that they will achieve the desired outcome.

Preventing violations requires an understanding of how motivation drives behaviour.

Planned behaviour (intentional action) is driven by an individual’s attitude towards that
behaviour. Further, individual decision-making is primarily influenced by the consequences
the individual expects to receive as a result of their behaviour, which can influence their
attitude towards that behaviour.

In most organisations, consequences associated with risk management behaviours compete

against those associated with productivity behaviours. While ‘Safe Production’ is a popular
phrase, risk management activities necessarily increase the amount of time required to
complete a task. Productivity outcomes are generally more predictable and definitive than
those associated with risk management (i.e. definitely achieving a target versus potentially
avoiding an incident). So the perceived value of productivity behaviour may be greater than
that of risk management behaviour.

Note: Violations are classified as human error only when they fail to achieve the desired
outcome. Where a violation does achieve the desired outcome, and does not cause any
other undesired outcomes, this is not human error. These types of violations may
include violation of a bad rule, such as a procedure that, if followed correctly, would trip the
plant. In such cases, a review of the rules and procedures is advisable.