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Focus for Human Error Prevention
Typical concern and generic strategy to
overcome the concern
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.
2.
3.
4.
5.
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
Provided instructions that are written, brief, specific, and immediately available
8.
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
Specific Countermeasures
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
Presentation Title (acronym) Data Collection for Safety performance
Division Name/OPU/HCU/BU (acronym) - Chem Eng Dept. UTP
Name of Presenter Azizul b Buang
Specific Countermeasures
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.
Train operators to
be aware of
infrequentlyoccurring conditions
Simulate each
situations
Teach understanding
of consequences
Constant rehearsal
and training to
appreciate cost of
failure
Presentation Title (acronym) Data Collection for Safety performance
Division Name/OPU/HCU/BU (acronym) - Chem Eng Dept. UTP
Name of Presenter Azizul b Buang
Designers of system
find out/consult
users expectations
and design
characteristics into
system
Provision of
knowledge about
human engineering
for population
stereotypes
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
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)
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
Interlocks
Thank you