Whose fault is it anyway? A practical illustration of human factors in process safety

Major process accidents have typically occurred not through a single failure, but through a combination of events, some of which had contributors from past actions and failures (latent or unrevealed failures). People are integral and key features of business systems; therefore systems, tools, and equipment should be designed with the potential capabilities and limitations of people in mind. This paper demonstrates the benefits of using human factors approaches to improve system safety and reliability. Practical examples from past experience are quoted and a framework for human error prediction is described. Guidance is given on the practicalities of deriving recommendations from these types of studies.