214: Sensory/Perceptual Abilities Issue*

Node Sensory/Perceptual Abilities Issue*

*This node is for descriptive purposes only. Code only to Personnel Performance; Individual Issue (#213).

Definition/Typical Issues

Was the problem a result of less than adequate vision (e.g., poor visual acuity, color blindness, tunnel vision)? Was the problem a result of some limitation in hearing (e.g., hearing loss, tone deafness)? Was the problem a result of some sensory limitation (e.g., poor sense of touch or smell)?

Note 1: The Personnel Performance Issue; Individual Issue (#213) node should only be used when the problem is isolated to one individual. If other personnel have difficulty performing the same task under similar circumstances, then other portions of the Root Cause Map™ should be used to code the issue.

Note 2: There should be management systems in place to detect and correct most (if not all) individual performance issues BEFORE an incident occurs. Therefore, the failure or absence of the management systems should be coded as well.

Note 3: Consider coding under the Personnel Hiring Issue (#209) node because there should be management controls to ensure that employees possess the required job capabilities prior to being hired. Also consider coding under the Supervision During Work Issue (#192) or Detection of Individual Performance Issue (#212) nodes because supervision should detect this problem.

Note 4: Code as Personnel Performance Issue; Individual Issue (#213) only. The 10 nodes beneath Individual Issue (#213) are included to provide the investigator with an understanding of the types of problems that might be categorized as Personnel Performance Issue; Individual Issue (#213). However, the investigator should NOT include these cause nodes in the investigation report.

Examples

Example 1

  • An operator read the wrong temperature on a chart that recorded temperatures for several tanks. The chart was color-coded. The operator was partially color blind and confused the readings. He recorded a temperature that was in range when the actual temperature was out of range.

Example 2

  • An operator failed to hear an evacuation alarm. The operator's hearing was poor, and the alarm was not loud enough for the operator to hear.

Example 3

  • An older operator needed to wear reading glasses to read the computer display. However, he refused to wear his glasses because it made him look "old." As a result, he misread the computer display and prematurely stopped a batch.

Typical Recommendations

  • Ensure that job requirements are complete, including required physical/perceptual capabilities.
  • Provide reasonable accommodations for coworkers with sensory/perceptual limits.

    Note 1: A review of the human factors engineering for the process (see Human Factors [#146]) is also appropriate to accommodate a wider spectrum of mental capabilities. For example:
    • Can the displays be redesigned so that lights that indicate "closed" conditions of valves are always in the same relative location on the panel?
    • Can more chart recorders be installed with fewer points per chart to eliminate the need for color-coding?
    • Can visual indicators (strobe lights) be used in addition to the audio alarms?

Cross-References

Version 10 Element(s)
Node ID Node Name
210 Sensory/Perceptual Capabilities LTA

 

Maritime Element(s)
Node ID Node Name
250 Inadequate Sensory/Perceptual Abilities
Back to top