168: Error Mitigation Issue
Definition/Typical Issues
Were personnel unable to detect errors (by way of alarms or instrument readings) during or after the occurrence? Was the system designed such that personnel were unable to recover from errors before a failure occurred?
Examples
Example 1
- An operator was simultaneously filling two large vessels with gasoline. While attending to one of the vessels, he allowed the other one to overflow because no level alarms or indicators were provided to let him know that the vessel was reaching its capacity.
Example 2
- An operator thought he closed a valve on the feed line to a tank. However, the valve stem was binding and the valve was half-open. No position indicator was provided for the valve, and no flow indication was provided for the line.
Typical Recommendations
- Ensure that important safety- and quality-related equipment is adequately equipped with error-detection systems.
- Provide feedback to the operator so that he/she can tell whether procedure steps are performed correctly.
- Design tasks and equipment to allow time to detect and correct errors for safety- and quality-critical tasks and equipment.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 160 | Intolerant System |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 175 | Intolerant System |