(45c) Human Error. a Myth Eclipsing Real Causes

Human Error. A myth eclipsing real causes

For years the professionals involved in the investigation of industrial accidents have identified “human error” as common cause of a high number of major events related to process safety. However, defective actions performed by workers that lead or contribute to disaster, before or during an event, are associated to factors related to cultural, engineering, situational, psychological, procedural and organizational aspects, just to name a few, that tend to remain in the background.

The aeronautical industry have developed exhaustive research in causal factors and methodologies to mitigate risks associated with “human error”. Pilots work in complex environments and are routinely exposed to high amounts of situational stress in the workplace that can induce pilot error which may result in a threat to flight safety. As in the Oil and Gas industry, catastrophic accidents are infrequent, but they are highly visible and often involve massive loss of life.

The environment to which operators and managers of a processing plant can be exposed and that of an aircraft crew can be similar. The paper will refer to these similarities and will explore into factors and causes addressed by both industries to find commonalities and go after possible root causes.

The paper will touch a sensible topic of some cultures that use human error as cause to focus on the individuals while giving oversight to structural and systemic flaws that can be attributed to leadership or organizational factors.

Tools like the Comprehensive List of Causes (CLC) establish a number of causes associated to personal factors that are contributors to human error or flaw actions. But apart from the “5 whys” technique, it doesn’t go beyond those factors to identify root causes behind the actions of the individuals and therefore the chances of reoccurrence remain there. Also, the ability to link these factors to real root causes generally depend on the proficiency of the investigation team.

The CCPS approach with the 20 elements of Risk Based Process Safety have provided in the last years a more comprehensive framework to look into aspects that can determine behaviors of individuals that work in hazardous environments. The presentation will associate typical factors of human error with possible root causes related to the Risk Based Process Safety elements.

 

Ignacio José Alonso Mike Broadribb

Executive Director Executive Advisor

Process Safety Council - Latin America Process Safety Council - Latin America

Bogota, Colombia Genoa, Nevada, USA