Human Error & Human Performance

Everyone makes mistakes, including the most experienced workers. Human performance thinking accepts that and asks a better question: how do we set up the work so that when someone makes a normal mistake, nobody gets hurt?

Types of errors

TypeWhat happensExample
SlipYou meant to do the right thing but did it wrongGrabbing the wrong lever on a familiar machine
LapseYou forgot a stepForgetting to reinstall a guard after maintenance
MistakeYour plan was wrong, often from missing knowledgeChoosing the wrong sling for a load
Violation (shortcut)Knowingly skipping a rule, usually to save time or because the rule seems unworkableNot tying off for “just a minute”

Error traps

When you notice two or more traps at once, slow down and pay extra attention. See Situational Awareness.

Tools that catch errors

Fix the system, not just the person

Telling people to “be more careful” doesn’t prevent the next mistake. Better controls make errors less likely or less harmful: interlocks, guardrails, color coding, better lighting, simpler procedures, enough time and people. When something goes wrong, ask what made the error easy and what failed to catch it. See Incident Investigation and Hierarchy of Controls.

Learn from normal work. Ask crews where the plan doesn’t match reality, and what they do to make it work. Those workarounds show where the next incident could come from.

Standards & references

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