Human Failure Types

Human Failure

Error Non-Compliance

Action Error Thinking Error

Routine Situational Exceptional

Action-Based Memory-Based Rule-Based Knowledge-Based

Slip Lapse Mistake 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.
 Human Failure Types

Characteristics Failure Type Examples Typical Control Measures

A simple, frequently-performed physical action goes wrong:  human-centred design (consistency e.g. up
ActionErrors

Associated with familiar tasks that

Slip  flash headlights instead of operating windscreen wash/wipe function always means off; intuitive layout of controls
require little conscious attention.
These ‘skill-based’ errors occur if (Commission)  move a switch up rather than down (wrong action on right object) and instrumentation; level of automation etc.)
attention is diverted, even  take reading from wrong instrument (right action on wrong object)  checklists and reminders; procedures with
momentarily.  transpose digits during data input into a process control interface ‘place markers’ (tick off each step)
Short-term memory lapse; omit to perform a required action:
 independent cross-check of critical tasks (PTW)
Resulting action is not intended:  forget to indicate at a road junction  removal of distractions and interruptions
‘not doing what you meant to do’. Lapse  medical implement left in patient after surgery  sufficient time available to complete task
(Omission)
Common during maintenance and  miss crucial step, or lose place, in a safety-critical procedure  warnings and alarms to help detect errors
repair activities.  drive road tanker off before delivery complete (hose still connected)  often made by experienced, highly-trained, well-
motivated staff: additional training not valid
If behaviour is based on remembered rules and procedures, mistake  plan for all relevant ‘what ifs’ (procedures for
s

Decision-making failures; errors Rule-Based occurs due to mis-application of a good rule or application of a bad rule: upset, abnormal and emergency scenarios)
of judgement (involve mental
Mistake  misjudge overtaking manoeuvre in unfamiliar, under-powered car  regular drills/exercises for upsets/emergencies
processes linked to planning; info.  assume £20 fuel will last a week but fail to account for rising prices  clear overview / mental model (clear displays;
Thinking

gathering; communication etc.)

 ignore alarm in real emergency, following history of spurious alarms system feedback; effective shift handover etc.)
 diagnostic tools and decision-making aids (flow-
Error

Action is carried out, as planned, Individual has no rules or routines available to handle an unusual
using conscious thought situation: resorts to first principles and experience to solve problem: charts; schematics; job-aids etc.)
Knowledge-Based
processes, but wrong course of  rely on out-of-date map to plan unfamiliar route  competence (knowledge and understanding of
Mistake
action is taken: ‘do the wrong  misdiagnose process upset and take inappropriate corrective action system; training in decision-making techniques)
thing believing it to be right’
(due to lack of experience or insufficient / incorrect information etc.)
 organisational learning (capture and share
experience of unusual events)
Non-compliance becomes the ‘norm’; general consensus that rules no 
Non‐Compliance

improve risk perception; promote understanding

Deliberate deviations from rules, longer apply; characterised by a lack of meaningful enforcement: and raise awareness of ‘whys’ & consequences
procedures, regulations etc. Also Routine  high proportion of motorists drive at 80mph on the motorway (e.g. warnings embedded within procedures)
known as ‘violations’  PTWs routinely authorised without physical, on-plant checks  increase likelihood of getting caught
Non-compliance dictated by situation-specific factors (time pressure;  effective supervision
Knowingly take short cuts, or fail
to follow procedures, to save time workload; unsuitable tools & equipment; weather); non-compliance may  eliminate reasons to cut corners (poor job
Situational be the only solution to an impossible task: design; inconvenient requirements;
or effort.
 van driver has no option but to speed to complete day’s deliveries unnecessary rules; unrealistic workload and
Usually well-meaning, but targets; unrealistic procedures; adverse
Person attempts to solve problem in highly unusual circumstances (often environmental factors)
misguided (often exacerbated by
unwitting encouragement from Exceptional
if something has gone wrong); takes a calculated risk in breaking rules:  improve attitudes / organisational culture (active
management for ‘getting the job  after a puncture, speed excessively to ensure not late for meeting workforce involvement; encourage reporting of
done’).  delay ESD during emergency to prevent loss of production violations; make non-compliance ‘socially’
unacceptable e.g. drink-driving).