Case Studies in Human Factors: When Trust Goes Awry

摘要

This paper presents three examples of how suboptimal consideration of human factors in the design of procedures, equipment, and warehouse storage locations contributed to costly human errors. In each case, the wrong raw material was added to a batch despite opportunities by other employees to detect the error and prevent the mischarge. A culture of verbal communication and "trust" in other operators resulted in less than rigorous adherence to procedures to verify that the correct material was being used. Latent conditions, such as warehouse location design, inadequate raw material identification, and equipment layout made it difficult for the operators to detect an error once it was made. The paper includes the results of root cause analyses and practical recommendations to reduce human error in these types of situations.