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Common Components of Human Error in Design, Maintenance, or Operations

[+] Author Affiliations
Joseph P. Balkey

Charleston, WV

Paper No. IMECE2003-42761, pp. 63-70; 8 pages
  • ASME 2003 International Mechanical Engineering Congress and Exposition
  • Engineering/Technology Management: Safety Engineering and Risk Analysis, Technology and Society, Engineering Business Management, and Homeland Security
  • Washington, DC, USA, November 15–21, 2003
  • Conference Sponsors: Engineering and Technology Management Group
  • ISBN: 0-7918-3728-9 | eISBN: 0-7918-4663-6, 0-7918-4664-4, 0-7918-4665-2
  • Copyright © 2003 by ASME


Often, public reports of accidents only identify the last, obvious failure or immediate cause of the accident. If human error is the immediate cause or final failure, further assessment of accident contributors may stop, and an enhanced training program is often determined to be the primary solution for preventing further accidents of this type. However, in many cases, the accident is the final result of many inputs, decisions, actions and inactions. To demonstrate this characteristic of accidents, the 20 stories in a publication titled “Set Phasers on Stun” have been categorized into action errors and planning errors that involve designers, mechanics, or operators. For each story, the hazard and the number of simultaneous failures are listed. Then two of the 20 stories are assessed in detail; one story involves an action error and the other one involves a planning error. In each of these two stories, the system is first described as it should operate and then its risk is quantitatively assessed to identify findings, lessons learned, recommendations, analogies to the other 18 stories, and applications. This paper has three immediate goals. One, to recognize the difference between an action error and a planning error. Two, to recognize that most accidents involve 2 to 4 simultaneous failures. Three, to appreciate that quantifying the failure frequency serves two benefits. Because it is usually difficult to find out exactly what happened after an accident, the calculated frequency can help confirm what actually happened. When various alternatives are recommended, it can also help to select the most economic ones. This paper has two long term goals. One, consider assessing the failure rates of near misses. By reducing near misses, larger accidents will be reduced. Two, consider assessing the failure rates of personal near misses because you know what actually happened.

Copyright © 2003 by ASME
Topics: Maintenance , Design , Errors



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