Tel: (+44) 01492 879813 Mob: (+44) 07984 284642

andy@abrisk.co.uk
www.abrisk.co.uk
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Identifying the causes of human
failure
Andy Brazier
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Overview
Common themes in accidents
What to consider when investigating human
failures
Causal trees
Practical exercise.
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Common themes in major accidents
All involve at least one fatal error
But several factors made those errors more likely
Multiple contributory factors
Increasing probability of disaster
Increasing severity of consequences
Always information available before the event
warning of disaster
Including similar near-misses
Multiple management failures.
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Near Miss
Yes
Accident
No
Adequate
Recovery?
Return
to normal
Yes
Incident
Developing
No
Adequate
Defences?
Hazardous
Situation
Human
Failure
Technical
Failure
Organisation
Failure
Incident model
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Dealing with real life human failures
You need to consider what influences peoples
behaviour and performance
If you cannot identify management and/or
systems failures you are accepting that little can
be done to prevent the failure recurring
If you think an error is caused by lack of
attention what can you do to prevent it?
If you think the cause was failure to follow a
procedure you must identify why this occurred.
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Error analysis
Human error is NOT a root cause
You need to understand why errors or violations
occur
Telling people to be more careful is not a
solution
Neither is writing more procedures
Or repeating more of the same training
If you cant find the cause of the error or violation
you are saying it will happen again
Be very wary of taking disiplinary action.
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Example - Piper Alpha
Valve blank only finger tight
De-isolated and started Pump A
Fire water pumps on manual
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Blank not leak tight
Causal tree 1
Why?
Poor awareness
of hazards
Why?
Risk
assessment
failure
Organisation
failure
Why?
High
workload
Why?
Overtime not
allowed
Why?
PSV job
over-ran
Knew pump would
not be operated
Why?
Why?
Ill defined channel
of communication
Communication
failure
Pump due for
overhaul
Why?
Not informed
that job
postponed Why?
Risk
assessment
failure
No review of job
status at end of day
Risk
assessment
failure
New policy
Why? Why?
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Pump A started without PSV
Why?
Hydrates
Why?
Unresponsive
to complaints
Design
failure
Why?
Causal tree 2
Why?
Attitude
failure
Why?
Attitude
failure
Why?
Why?
Procedure
failure
No
procedure
Organisation
failure
No one in
permit office
Why?
Permit not
handed back
Why?
Poor handover
practice
PSV removal not
covered in handover
PSV not
visible
Pump B
Tripped
Production
pressure
Monitoring
failure
Lack of
supervision
Why?
Why?
Why?
Routine
violation
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Inadequate emergency response
Causal tree 3
Why?
Why?
Poor hazards
awareness
Risk
assessment
failure
Why?
Routine
procedure
Why?
Design
failure
Why?
Frequent false
alarms
Unprepared
Why?
Extreme
threat
Why?
Why?
Inadequate
procedures
Emergency
response
failure
Why?
No regular
practice
Emergency
response
failure
Why?
Slow response
to gas alarms
Fire pumps on
manual
Lack of
command
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