Operational error

‘Operational error has occurred whenever unplanned and undesired results stem from the acts or decisions of supervisory management.’

Reference: D.A. Weaver. Symptoms of Operational Error. http://www.safetyawakenings.com/wp-content/uploads/2013/07/Weaver_1071_PS.pdf

‘Operator errors may be exacerbated by poor system/equipment design or by the complexity of operations.’

Reference: Adapted from CCPS(1989) Guidelines for Technical Management of Chemical Process Safety)

‘Operator actions are classified by psychologists into skill-based (those which require repetitive action such as hitting the right button), rule-based (in which the action is dictated by some clearly specified directive) and knowledge-based (which require some thought in order to decide on what action to take). Thus deviations can result from simple physical errors, often made worse by bad design, errors in following rules or operating instructions and errors due to operators misinterpreting situations and formulating incorrect plans of action.’

Reference: Skelton, B., Process Safety Analysis: An Introduction, Butterworth-Heinemann, Feb 27, 1997, ISBN-13: 978-0884156666