166: Skill-based Behavior Issue

Definition/Typical Issues

Was the issue caused by the automatic response of a worker to a situation?

Examples

Example 1

• An operator was distracted during a startup process when a mechanic came by to discuss last week's football game. As a result, he performed the steps for shutting down the equipment instead of starting up the equipment.

Example 2

• Although the parts were not the same color, as they should be, assembly line personnel continued to assemble vegetable cutters. As a result, they assembled 227 half-red/half-blue vegetable cutters.

Example 3

• When acknowledging an alarm, an operator read the alarm as High Outlet Temperature T303, when the alarm actually said, High Outlet Temperature T803. T303 had been alarming frequently over the last few days and required no action. When T803 alarms, numerous local actions are required. As a result of the operator doing nothing in response to the alarm, a fired heater (i.e., a heater that uses a flammable gas as the heat source) was damaged.

Typical Recommendations

• Avoid situations that appear similar but require different actions to be taken.
• Provide error-proofing to alert operators that their actions are incorrect.
• Provide a means to automate the task.
• Provide clear, unambiguous feedback.