| dc.description.abstract | Process Safety aims to prevent and control incidents that have the potential to release hazards that could result in serious undesired outcomes. It has been widely agreed for some time now that human error is a causal factor in most accidents. Therefore, adequate human error management is indispensable for comprehensive Process Safety Management. Regulatory requirements to consider human factors in Safety and Environmental Management Systems have motivated companies to address human error; and so, efforts dedicated to the analysis of human factors in investigations have been increasing. However, these efforts are generally not effective at reaching the root causes of the errors, leaving organizations with the false sense of security that human error is being adequately managed. We are not learning enough, particularly from offshore incidents, and as a result, we keep having incidents that would have been preventable and organizations are not able to continuously improve. Human factors needs to be taken more seriously as a discipline that requires not just a basic understanding and some tools with guidance, but competency; i.e., deep knowledge and skills that have been developed through effective practice. This paper provides an overview of the incident investigation process, and overview of the fundamentals of human error, and discusses why, in the experience of the presenter, many organizations, while investing time and effort, don’t learn enough from incidents. | en |
