Operator error (or human error) is broadly defined as the cause of an unintended consequence due to a bad decision, distraction, voluntary deviation from the procedure and so on. More simply, it is “a failure of a planned action to achieve a desired outcome.” Operator error is the subject of much research, particularly as it relates to health & safety, quality assurance, and productivity in industrial, manufacturing and construction contexts. In fact, it has been designated as the main cause of multiple disasters and accidents. Generally, it can be broken down into different categories:
Performing the task incorrectly or over the expected time allotted
Most operator tasks in a process or manufacturing plant are described in procedures. Procedures detail the sequence of steps the operator needs to perform (to clean a piece of equipment for example), indicate the risks and hazards to be expected while performing the tasks, the necessary personal protective equipment (PPE), lockout/tag out requirements and more. In this particular case, the operator is either missing the correct knowledge or know-how to perform the task correctly, and training is the primary solution.
Failing to perform or omitting a task
A failure to perform or omit task may indicate a lack of adherence to the procedure. This could be because omitting the task is de facto normalized in the plant (because it’s faster, safer, easier, cheaper or any other reason). These violations are also known as shortcuts, workarounds or non-compliance, depending on which side of the task execution you are sitting. They are extremely common and are difficult to get rid of. They may require a process or procedure redesign, review of the plant culture for normalizing violations, review of safe work rules and much more. While training can play a part, it is typically not the leading fix.
Performing an extra or non-required task or tasks out of sequence
These are considered slips or lapses, or unintended actions. They are more prevalent in situations where the operator is familiar with the task and lacks concentration or focus during its execution. Training is of limited use in these cases which require improving the context of the task execution (encouraging focus and concentration) or improving the procedure/system so that slips and lapses are less probable.
Failing to respond adequately to a contingency
This is most frequently encountered when the operator faces an unexpected situation and will incorrectly apply a familiar (but ultimately incorrect) response. In other words, the incorrect task is applied while believed to be the correct one. These errors in decision-making can be attributed to a lack of experience and/or training. An interesting strategy here is to build into the training a number of plant cases (and their correct response) which the operator is not expected to encounter frequently, thereby compensating for the long floor experience required to actually witness those cases.
Making a training response irrelevant
When doing root-cause analysis, the common reflex is to stop investigating upon reaching the “operator error” stage. While this may be accurate, it is not enough to take a correct decision on what needs to be fixed, so the situation doesn’t happen again. Training may or may not be a correct response, and even if it is, not all types of training will apply.
Here are five steps to ensure training is indeed relevant:
- Perform full root-cause analysis, using the 5-whys method or other, until the ultimate root is uncovered
- Determine if the corrective action requires training (or a process, procedure or system redesign)
- Determine if training applies to all operators, a specific team or individual and if training should be about reviewing the basics or providing further practice
- Keep in mind training itself may be part of the issue and need improvements, either in content, structure or application
- Monitor and confirm the results of the corrective training, as a continuous improvement best practice