Human failure types

A Hearts and Minds resource

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 Human failure types
What?
- This resource gives an overview of human failure types, and provides a taxonomy and supporting
information to help you to better understand the various types of human failure, and the factors that make
each type more likely to occur, and remedies to prevent their occurrence.

How?
- It uses a taxonomy flowchart to illustrate human failure types and causes.
- It can be used in conjunction with the Hearts and Minds tools Managing rule breaking, Risk assessment
matrix and Improving supervision, but is also a good general resource when exploring and reacting to human
failure.
- It is illustrated with examples and includes a simple knowledge test.

Why?
- To be of assistance when exploring the possibility of human failure in risk assessments and in identifying
barriers to reduce risks.
- To be of assistance when exploring human failure causation in incident and accident investigations (see EI
Guidance on investigating and analysing human and organisational factors aspects of incidents and
accidents).
- To help manage rule breaking and identify relevant remedies to address the particular human failure type.

ACKNOWLEDGEMENTS Next Slide

 How to use this resource

The resource should be viewed in slide show mode

The human failure taxonomy illustrated in this resource is shown in three stages so
that you can focus on specific areas at a time.

The completed taxonomy diagram contains embedded links to additional guidance

and examples. If you hover the cursor over the highlighted text boxes a dialogue
box will appear that describes the additional material available. Use the ‘Next
Slide’ and ‘Go back’ buttons to navigate from screen to screen and to return to the
human failure taxonomy chart.

You can refer to the taxonomy when you complete the knowledge test at the end of
the resource.

Go back Click Here to Start

 What this resource provides

This resource provides information about

• Different types of errors.
• Different types of non-compliances.
• Remedies for errors and non-compliances.

Examples are used throughout the resource to illustrate the various types of Error and Non-
compliance.

A simple knowledge test is included at the end of the resource which will enable you to
assess how well you have understood the material presented.

Go back Next Slide

Human Error and Non-Compliance
Human errors and non-compliances are how people cause accidents.

Errors
Errors are intentional or unintentional actions – or inactions – that deviate from what would
have been expected.

Non-Compliances
Non-compliances, also called Violations, are intentional actions or inactions that do not
conform with agreed rules or procedures.

• The term non-compliance is used here as a less threatening alternative to Violation

and refers specifically to (apparently) deliberate failure to follow known rules or
procedures.

Go back Next Slide

 Human failure taxonomy Go back Next Slide

Human failures

Intended actions Unintended actions

The solution to an Non-compliances - Intended consequences Errors - Unintended consequences

unworkable
situation to get the Non- Unintentional Non-
job done Mistakes Lapses Slips
compliances compliances

When the person A special case when the rule When the person When the person
When official When the person
decided to act or procedure is not known or does what they does something,
solutions to novel meant to, but forgets to do
without complying well understood. A form of but not what they
problems are hard should have done something
with a known rule mistake by the individual who meant to do
to follow, or old something else
or procedure didn’t know better
habits take over
Rule-based Memory Attention
When rules are Situational
broken to get the
job done and Knowledge-based Attention Competition
Exceptional
make the boss
happy • Choosing a standard Performing highly skilled and routinised tasks that
solution for a known problem require:
Breaking the rules Organisational benefit (rule-based behaviour) 1) occasional checks on accuracy and progress and
for solely personal Or 2) remembering what to do next. Will be made more
• Solving a problem from first likely by other task demands that take attention or
gain Personal benefit principles (knowledge-based memory, such as being in a hurry, having too many
behaviour) tasks, insufficient information, hard to see.
When knowingly And
dangerous and performed • Getting the wrong solution; or Strong but wrong - doing what worked last time - is the
Reckless the right solution for the most common error. If there is a possibility of such a
without any care or
wrong problem (mistake) reversion to previous behaviours, this can be predicted
consideration of oneself
when other conditions make errors more likely
or others, whether for
organisational or personal
goals
Routine non-compliance Routine errors
Routine non-compliance may be personal (a Routine errors by an individual may be
habitual rule breaker) or common (“everyone due to temporary personal factors (e.g.
does it that way”) stress). If many people make the same
Non-compliance Error error there may be a problem with
The question that has to be asked is: Did
design, workload, training etc. Does
management know this non-compliance was remedies remedies management know that errors are being
routine? If not, how could they be made more
made frequently? If not, why not?
aware of it?
 Human failure taxonomy Go back Next Slide

Human failures

Intended actions Unintended actions

The solution to an Non-compliances - Intended consequences Errors - Unintended consequences

unworkable
situation to get the Non- Unintentional non-
job done Mistakes Lapses Slips
compliances compliances

When the person A special case when the rule When the person When the person
When official When the person
decided to act or procedure is not known or does what they does something,
solutions to novel meant to, but forgets to do
without complying well understood. A form of but not what they
problems are hard should have done something
with a known rule mistake by the individual who meant to do
to follow, or old something else
or procedure didn’t know better
habits take over
Rule-based Memory Attention
When rules are Situational
broken to get the
job done and Knowledge-based Attention Competition
Exceptional
make the boss
happy • Choosing a standard Performing highly skilled and routinised tasks that
solution for a known problem require:
Breaking the rules Organisational benefit (rule-based behaviour) 1) occasional checks on accuracy and progress and
for solely personal Or 2) remembering what to do next. Will be made more
• Solving a problem from first likely by other task demands that take attention or
gain Personal benefit principles (knowledge-based memory, such as being in a hurry, having too many
behaviour) tasks, insufficient information, hard to see.
When knowingly And
dangerous and performed • Getting the wrong solution; or Strong but wrong - doing what worked last time - is the
Reckless the right solution for the most common error. If there is a possibility of such a
without any care or
wrong problem (mistake) reversion to previous behaviours, this can be predicted
consideration of oneself
when other conditions make errors more likely
or others, whether for
organisational or personal
goals
Routine non-compliance Routine errors
Routine non-compliance may be personal (a Routine errors by an individual may be
habitual rule breaker) or common (“everyone due to temporary personal factors (e.g.
does it that way”) Non-compliance Error stress). If many people make the same
error there may be a problem with
The question that has to be asked is: Did
design, workload, training etc. Does
management know this non-compliance was remedies remedies management know that errors are being
routine? If not, how could they be made more
made frequently? If not, why not?
aware of it?
 Human failure taxonomy Go back Next Slide

Human failures

Intended actions Unintended actions

The solution to an Non-compliances - Intended consequences Errors - Unintended consequences

unworkable
situation to get the Non- Unintentional Non-
job done Mistakes Lapses Slips
compliances compliances

When the person A special case when the rule When the person When the person
When official When the person
decided to act or procedure is not known or does what they does something,
solutions to novel meant to, but forgets to do
without complying well understood. A form of but not what they
problems are hard should have done something
with a known rule mistake by the individual who meant to do
to follow, or old something else
or procedure didn’t know better
habits take over
Rule-based Memory Attention
When rules are Situational
broken to get the
job done and Knowledge-based Attention Competition
Exceptional
make the boss
happy • Choosing a standard Performing highly skilled and routinised tasks that
solution for a known problem require:
Breaking the rules Organisational benefit (rule-based behaviour) 1) occasional checks on accuracy and progress and
for solely personal Or 2) remembering what to do next. Will be made more
• Solving a problem from first likely by other task demands that take attention or
gain Personal benefit principles (knowledge-based memory, such as being in a hurry, having too many
behaviour) tasks, insufficient information, hard to see.
When knowingly And
dangerous and performed • Getting the wrong solution; or Strong but wrong - doing what worked last time - is the
Reckless the right solution for the most common error. If there is a possibility of such a
without any care or
wrong problem (mistake) reversion to previous behaviours, this can be predicted
consideration of oneself
when other conditions make errors more likely
or others, whether for
organisational or personal
goals
Routine non-compliance Routine errors
Routine non-compliance may be personal (a Routine errors by an individual may be
habitual rule breaker) or common (“everyone due to temporary personal factors (e.g.
does it that way”) stress). If many people make the same
Non-compliance Error error there may be a problem with
The question that has to be asked is: Did
design, workload, training etc. Does
management know this non-compliance was remedies remedies management know that errors are being
routine? If not, how could they be made more
made frequently? If not, why not?
aware of it?
 Human failure taxonomy Go back Next Slide
Click the flashing boxes for Human failures
more information
Intended actions Unintended actions

The solution to an Non-compliances - Intended consequences Errors - Unintended consequences

unworkable
situation to get the Non- Unintentional non-
job done Mistakes Lapses Slips
compliances compliances

When the person A special case when the rule When the person When the person
When official When the person
decided to act or procedure is not known or does what they does something,
solutions to novel meant to, but forgets to do
without complying well understood. A form of but not what they
problems are hard should have done something
with a known rule mistake by the individual who meant to do
to follow, or old something else
or procedure didn’t know better
habits take over
Rule-based Memory Attention
When rules are Situational
broken to get the
job done and Knowledge-based Attention Competition
Exceptional
make the boss
happy • Choosing a standard Performing highly skilled and routinised tasks that
solution for a known problem require:
Breaking the rules Organisational benefit (rule-based behaviour) 1) occasional checks on accuracy and progress and
for solely personal Or 2) remembering what to do next. Will be made more
• Solving a problem from first likely by other task demands that take attention or
gain Personal benefit principles (knowledge-based memory, such as being in a hurry, having too many
behaviour) tasks, insufficient information, hard to see.
When knowingly And
dangerous and performed • Getting the wrong solution; or Strong but wrong - doing what worked last time - is the
Reckless the right solution for the most common error. If there is a possibility of such a
without any care or
wrong problem (mistake) reversion to previous behaviours, this can be predicted
consideration of oneself
when other conditions make errors more likely
or others, whether for
organisational or personal
goals
Routine non-compliance Routine errors
Routine non-compliance may be personal (a Routine errors by an individual may be
habitual rule breaker) or common (“everyone due to temporary personal factors (e.g.
does it that way”) stress). If many people make the same
Non-compliance Error error there may be a problem with
The question that has to be asked is: Did
design, workload, training etc. Does
management know this non-compliance was remedies remedies management know that errors are being
routine? If not, how could they be made more
made frequently? If not, why not?
aware of it?
 How dangerous are human
failures and why?
Slips
• Simple slips are usually benign and most people quickly spot that they have made such an error.
Slips can be very dangerous under certain conditions, such as flying at low altitude or heart
surgery, but such situations should have been recognised and prepared for in advance.

Lapses
• Lapses are more dangerous than slips because they are harder to recognise, and other people
may assume that the necessary action has in fact been taken. Lapses are the main errors in
maintenance and can lead to hidden problems.

Mistakes
• Mistakes are even more dangerous because people often refuse to believe that they are wrong,
despite evidence to the contrary, and may go beyond the point where safe recovery is possible.

Non-compliance
• Non-compliances are usually successful adaptations to real or imagined problems. When they
combine with an error they are suddenly extremely dangerous. People breaking the rules assume
everything else will go safely so they will get away with it, but errors are unexpected and the
combination can suddenly become lethal.

Go back Next Slide

 Safety Culture and dealing with
errors and non-compliances
The organisational response to errors and non-compliances is an indicator of the organisational culture.
This is determined by what people see as the causes of such behaviours. People often explain their own
errors and non-compliances in terms of the situation in which they found themselves, but see the same
types of behaviour by others as the result of personal failings of those individuals.

• Pathological and Reactive cultures subscribe to explanations in terms of individual weaknesses and
look to identify error-prone individuals. Reporting one’s own errors and non-compliances is seen as
personally dangerous – Messengers of bad news are reprimanded.

• Calculative cultures are heavily procedure-based and so may tolerate errors but have difficulty with
non-compliances. People find it hard to report their own errors, and non-compliances may still be kept
hidden if possible – Messengers of bad news are tolerated.

• Proactive and Generative cultures teach people to recognise errors and how to identify their causes
so that they can be prevented. Errors provide information that can be used for improvement –
Messengers of bad news are trained and rewarded.

Go back Next Slide

 The Safety Culture Ladder
GENERATIVE
(High Reliability Orgs.)
HSE is how we do business round
here

PROACTIVE
Safety leadership and values drive
continuous improvement
Increasingly
informed
CALCULATIVE
we have systems in place to manage
all hazards

REACTIVE
Safety is important, we do a lot every
time we have an accident

Increasing
Trust/Accountability
PATHOLOGICAL
who cares as long as we’re not caught

Go back Next Slide

 Knowledge quiz
Set out on the next slide are a series of statements which represent different types of
human failure. Decide which type of human failure each statement belongs to.

If you are unsure go back to the Human Failure Taxonomy flowchart and review the
information presented again.

Click the ‘answer’ button to reveal which type of human failure each statement belongs to.

Go back Next Slide

 Go back Human failure End Quiz
Knowledge quiz taxonomy flowchart

Which type of human failure?

Because of their lack of knowledge of the procedures, operators are found to have been Unintentional
Answer
working without the correct PPE specified for the process. Non-Compliance

A fuel tanker driver knows that lack of attention can cause an accident but still uses a Reckless Non-
Answer
mobile phone while driving at high speed on a busy highway. Compliance

Because of using out of date drawings, a maintenance worker caused a gas release that
Answer
Mistake
led to a fire.

During a start-up, a refinery operator discovers they have omitted a step in a lengthy
Answer
Lapse
procedure.

In order not to cause any production losses a maintenance worker decides to fix a broken Organisational
Answer
relay without turning off the electricity supply. Benefit
Because they were in a hurry to get home early, instead of asking for a scaffold, a Personal
Answer
construction worker used his own ladder to tighten a screw at 5 m height. Benefit
During maintenance a technician discovered that the torque wrench they were supposed Situational Non-
Answer
to use cannot be used in the space available. They used a drilling wrench instead. Compliance

While filling out a report, a maintenance worker accidentally marked the wrong checklist
item, indicating a check has been done, when it hadn’t. Answer
Slip
What now?
The knowledge gained from this resource can be used in a number of ways:

- It can be used to help managers make better decisions regarding rule breaking behaviour (for more
information, please see the M anaging rule-breaking tool)
- When should behaviour be punished?
- Can we learn from people’s non-compliance?

- It can be used when taking human failure into account when assessing risks (for more information,
please see the Risk assessment matrix tool)
- What is the risk of someone making an error/non-compliance?

- It can be used to improve supervision (for more information, please see the Improving supervision
tool)
- Why are people making errors or non-compliances?
- Can supervisors detect and solve them?

- It can be used when investigating accidents (see EI Guidance on investigating and analysing human
and organisational factors aspects of incidents and accidents).
- What was the root cause of human failure? (Non-compliances also have root causes)

Next Slide
Replay Quiz Return to Start End Presentation
Errors Next Slide

Errors are always unintended.

Slips (doing what you didn’t mean to do) and lapses (not doing what you meant to do) are
unintended poor actions that are deviations from skilled performance.
Mistakes (doing what you thought you ought to do, but wouldn’t have chosen with
hindsight) are unintended poor solutions to problems that individuals think are adequate
under the circumstances.
• Skilled performance requires a pre-programmed plan of action that is activated by an
intention (1) to act, that itself is defined by the intention (2) to achieve a goal – so there
are at least two levels of intention required.
• Slips & lapses = failure to carry out plan of action (1): A good plan that goes wrong
– good plan, lousy execution.
• Mistakes = failure to create good plan to achieve goal (2): Not having a good plan
to start with, but carrying it out anyway – lousy plan, seemed a good idea at the
time.

NB: Perception (Detection) errors are a fourth error type used in other human error taxonomies. They
occur when an individual misperceives or fails to perceive something. For example an individual could
mishear an instruction from a colleague or read the wrong pressure from a computer screen. Being able
to distinguish this fourth error type is important as different solutions are required.
Errors Next Slide

Factors both internal and external to an individual make it more or less likely that
an error will occur. Such factors are called Performance Influencing (Shaping)
Factors (PIFs / PSFs). These can be identified and fixed. These include (from J.
Williams) :

Unfamiliarity with task (x17) Poor feedback from system (x4)

Time shortage (x11)
Poor signal:noise ratio (x10)
Poor human-system interface (x8)
Designer-user mismatch (x8)
Irreversibility of errors (x8)
Information overload (x6)
Negative transfer between tasks (x5)
Misperception of risk (x4)
Inexperience (not lack of training) (x3)
Poor instructions or procedures (x3)
Inadequate checking (x3)
Educational mismatch (x2)
Disturbed sleep patterns (x1.6)
Hostile environment (x1.2)
Monotony and boredom (x1.1)

Key: (x1) = probability of error occurring

 Human failure
The skill-, rule-, and knowledge-based taxonomy

classification
Skill-, rule- and knowledge-based information processing refers to the degree of conscious control
exercised by an individual over their tasks.
• In skill-based mode, highly practised largely physical actions are performed smoothly and with
little conscious monitoring, e.g. a competent driver can drive from A to B with little conscious
thought.
• In rule-based mode an individual applies rules learnt through training or from experience.
Here the level of conscious control is intermediate between knowledge- and skill-based mode.
• In knowledge-based mode the individual carries out a task in largely conscious mode, e.g. a
learner driver or process operator presented with a novel situation.
Skill-based Automatic
Automatic
Automated routines with
little conscious attention

Rule-based

IF symptom X THEN cause is Y

IF the cause is Y THEN do Z

Knowledge-based
No routines or rules available for handling
situation Conscious
Errors Human failure
taxonomy

Slips and Lapses are caused mainly by problems with attention,

perception and memory.
• Lapses are typically failures of memory that cause us to forget to carry out an
action, to lose our place in a task or even forget what we intended to do.
e.g. A busy maintenance worker, even though he meant to do so, forgot to notify the
control room about an unusual noise that he heard while inspecting one of the new
pumps in the unit.
e.g. A busy operator forgets to re-order a reserved stock of production material.
Errors Human failure
taxonomy

Slips and Lapses are caused mainly by problems with attention,

perception and memory.
• Slips occur when a person does something, but not what they meant to do.
e.g. Instead of isolating Pump 1, a maintenance worker closed the suction and
discharge valves on Pump 2. When asked later he said he had no idea why he
had done so. He knew that he was supposed to isolate Pump 1 instead of Pump 2
and actually had intended to do so.
Errors Human failure
taxonomy

Mistakes occur when a solution for a problem is incorrect. They come in two types
• Rule-based - using a rule-of-thumb experience to solve a problem
• Knowledge-based - solving a problem from first principles when there is no standard
solution

Rule-based mistakes either involve recognising a situation too quickly, overlooking or not
knowing about different situations, or accepting the first rule that promises to achieve the
goal.

Knowledge-based mistakes usually result from taking either too little or too much
information into account. An individual may not have been given essential information by
others. When under time stress or lack of sufficient information people tend to use
assumptions.
Remedies for Errors Human failure
taxonomy

Errors are unintentional, so just telling people not to make them does not work.
The notion of the error-prone individual has always proved very difficult to prove
in practice – some people go through periods when they make more errors, but
this is temporary. The problem of people making errors is not solved by looking
for error-prone individuals and removing them; effective solutions lie in
recognising error-provoking environments and fixing them.

• Mistakes are failures to select the correct course of action, often because a diagnosis
was wrong. They can be prevented by providing useful information, training in decision
making, team support processes (e.g. Crew Resource Management [CRM]) etc.
Because people find it hard to accept that they are wrong, recovery is often too late and
most attention should be paid to prevention.

• Slips are failures of highly automated human processes, so it is necessary to ensure

that attention is not captured elsewhere when it is necessary to perform a check on
progress, that the design does not invite the wrong response, that there is sufficient time
to perform the task and no competing demands. Warning people of a mismatch between
expected and actual outcomes is effective in prompting recovery actions.

• Lapses are typically memory failures but may also be due to working in a hurry, to
design, and to competing prompts. Providing effective external memory cues such as
checklists works well.
Non-Compliance
Next Slide

Non-compliance can only be understood in a social context where rules and procedures
are agreed (or imposed) ways of working; these may range from detailed work instructions,
procedures and guidelines up to the laws of physics and chemistry.

When a major assumption of the Safety Management System is broken, the chances of
bad consequences become significantly greater because other individuals will work with the
expectation that the rules and procedures are being followed. Wider experience has shown
this may also involve going past the point where the chances of an accident become
greater than is acceptable.

Non-compliances are influenced by the social and personal norms - “This is how far we go”
– “This is how far I go”.
Typical examples (each of which may be any one of the types) are:
• Speeding or not wearing a seatbelt
• Not isolating a hazardous system to avoid shutting it down
• Giving a manager a task without the appropriate required training (e.g. Journey
management)
Non-Compliance
Next Slide

Five different types of non-compliance

1. Unintentional non-compliance is a form of mistake. The person either does not know
about a rule or procedure or understands it differently.
e.g. Because of a failure to follow a procedure, an incident occurred. After
investigation, it turned out that the rule had been changed recently but the workers
had not yet been properly informed about the revision.

2. Situational non-compliances occur when it is not possible to get the job done by
following the procedures strictly.
e.g. During maintenance a technician discovered that the torque wrench they were
supposed to use cannot be used in the space available. They used a drilling
wrench instead.

3. Organisational benefit non-compliances occur when people want to meet

organisational goals, which they may believe are what their managers and supervisors
actually want.
e.g. During the conceptual design evaluation of a project, a number of environmental
considerations are dropped in order to reduce costs and speed up the work.
Non-Compliance
Next Slide

Five different types of non-compliance, continued

4. Personal benefit non-compliances are when individuals achieve purely personal goals.
e.g. A mechanic is working up on the derrick, while there is a crew down on the drill
floor. No permit-to-work was raised, the drilling supervisor was not informed and
the derrick access procedures were ignored. The mechanic wanted to ‘just
quickly’ grease the crown block so he could go home early.

5. Exceptional non-compliances occur when people have to solve problems for the first
time and fail to follow good practice.
Non-Compliance Human failure
taxonomy

Non-compliances are made more likely by the dangerous mixture of 4 ingredients:

• The Expectation that rules will need to be bent or broken

• The feeling of Powerfulness – one has the skills and experience to get away with it
• The lack of detailed Planning, making short-cuts necessary
• The existence of Opportunities to take short-cuts that are recognised, often by the
most highly motivated individuals

Non-compliances may also be Reckless if they are known to be dangerous and are
performed without care or consideration of oneself or others.
e.g. To show off in front of his colleagues, a worker is seen working while under the
influence of alcohol.

Any non-compliance (except exceptional) may also be Routine.

e.g. In a plant there are often large periods (> 30 minutes) with many plant alarms (more
than one per minute). An operator has accepted an alarm and did not take any
further action which resulted in a poor quality product run. During the last few weeks
this had happened several times to other operators as well.
Remedies for Non-Compliances Next Slide

Non-compliances are usually intentional, but it is necessary to understand which type of

non-compliance has been committed because every type has a different remedy. Simply
telling people to be compliant is not effective and may result in people mindlessly following
poor or inappropriate rules and procedures. Rules and procedures exist to ensure safe
work, but may be out of date, hard to follow, or felt to slow the work down. People break the
rules if they have had to do it before to get the job done, if they feel they know how to do it,
if they recognise an opportunity and there is a poor plan of action.

• Unintentional non-compliances. The solution is to make sure everyone knows

exactly what the rules and procedures are (Awareness and Distribution) and that their
understanding is correct (Training and Testing).

• Situational non-compliances may be caused by change, with procedures that were

previously correct, or were written without consulting users in the field on feasibility.
Situations should be recognised and procedures altered accordingly. People should be
trained to report such situations without fear of reprisal/negative consequences.
 Human failure
Remedies for Non-Compliances taxonomy

• Exceptional non-compliances need to be discovered by requiring people to think the

unthinkable and practice what feels difficult or personally dangerous
(e.g. H2S rescue).

• Organisational benefit non-compliances: Expectations should be made completely

clear by managers and supervisors. This should come from the very top of the
organisation. A professional risk-based approach, taking a measured account of the
local situation and competences, may allow local variances to be applied.

• Personal benefit non-compliances can often be avoided by supervisors who know

their workforce well enough and who make their expectations sufficiently clear.

• Reckless non-compliances require understanding about just how dangerous they are,
with a knowledge of sanctions and the belief that they will be applied.

If any type of non-compliance is routine it is necessary to ascertain if only one individual is

breaking the rules or if it is common practice. In all cases it is necessary to find out if
management knows and condones or even expects and tells people to break the rules (and
is creating the problem) or does not know (and is failing in their duty to manage).
Routine Errors Human failure
taxonomy

All errors may be committed routinely. If this is the case then there is a serious
problem for the organisation

• If an error is routine then either there is a systemic problem, independent of the

individuals who make the error, or an individual has a specific problem

• Routine errors made by many people may be caused by problems such as

instruments that are easily confused, rows of identical switches, complicated
sequences and repetitions, stressful conditions inherent in the task, etc.
• The Substitution Test (Would another individual with the same competence, in
the same situation, be likely to make the error?) can be used to test if an individual
or the task is the problem.
• Individual routine errors may be made because an individual lacks the required
level of skill to perform the task or because they were in a particular situation, e.g.
personal stress or medical conditions like diabetes leading to poor decision
making.

Routine errors are first and foremost a supervisory problem:

• Supervisors and managers who actively go in search of routine issues should be
rewarded, those who ignore them should be reminded of their responsibilities.
Routine Non-Compliance Next Slide

All non-compliances (apart from exceptional) may be committed routinely. If this is

the case then there is a serious problem for the organisation

• Routine non-compliances by many people may be caused by poor or impossible

procedures, or poor setting of standards by supervisors

• Two questions should be asked

1. Did supervisors know, and condone?
2. If supervisors did not know, why not?

• Supervisors and managers who actively go in search of routine issues should be

rewarded; those who ignore them should be reminded of their responsibilities.

• Routine non-compliance by a single individual requires assessing that individual’s

attitudes. They may have a history of disregard for the rules in general.
Routine Non-Compliance Next Slide

Reckless non-compliances and Sabotage

Individuals who deliberately choose to act in ways that are intended to cause harm or
disruption, sabotaging plant or activities, form a distinct group and need to be treated
separately.

Individuals who pursue a course of action knowing it to be unacceptably risky, bringing

themselves or others into danger, are acting recklessly. While many actions may appear
reckless at first sight, careful investigation is necessary. Investigators should be aware of
hindsight bias, since the individual may well have failed to see the hazard or assessed the
risk completely inappropriately. Road transport non-compliances are more likely to be
reckless.
 Human failure
Routine Non-Compliance taxonomy

Sheep and Wolves

People are to be found along a continuum between extreme Sheep – people who dislike
cutting corners or breaking rules – and outright Wolves – people who only see rules and
procedures as guidance for others, if they get in the way of achieving their goals. In a
major study the majority of offshore workers, and management, were classified as wolves.
Wolves’ and Sheep’s clothing can indicate whether individuals have broken the rules
recently. The largest single group were Wolves in Sheep’s clothing, individuals
predisposed to finding rule-breaking easy to justify, but lacking the opportunity, especially in
environments with many alternatives so that often any action could be justified.
 Human failure taxonomy
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Human failures

Intended actions Unintended actions

The solution to an Non-compliances - Intended consequences Errors - Unintended consequences

unworkable
situation to get the Non- Unintentional non-
job done Mistakes Lapses Slips
compliances compliances

When the person A special case when the rule When the person When the person
When official When the person
decided to act or procedure is not known or does what they does something,
solutions to novel meant to, but forgets to do
without complying well understood. A form of but not what they
problems are hard should have done something
with a known rule mistake by the individual who meant to do
to follow, or old something else
or procedure didn’t know better
habits take over
Rule-based Memory Attention
When rules are Situational
broken to get the
job done and Knowledge-based Attention Competition
Exceptional
make the boss
happy • Choosing a standard Performing highly skilled and routinised tasks that
solution for a known problem require:
Breaking the rules Organisational benefit (rule-based behaviour) 1) occasional checks on accuracy and progress and
for solely personal Or 2) remembering what to do next. Will be made more
• Solving a problem from first likely by other task demands that take attention or
gain Personal benefit principles (knowledge-based memory, such as being in a hurry, having too many
behaviour) tasks, insufficient information, hard to see.
When knowingly And
dangerous and performed • Getting the wrong solution; or Strong but wrong - doing what worked last time - is the
Reckless the right solution for the most common error. If there is a possibility of such a
without any care or
wrong problem (mistake) reversion to previous behaviours, this can be predicted
consideration of oneself
when other conditions make errors more likely
or others, whether for
organisational or personal
goals
Routine non-compliance Routine errors
Routine non-compliance may be personal (a Routine errors by an individual may be
habitual rule breaker) or common (“everyone due to temporary personal factors (e.g.
does it that way”) stress). If many people make the same
Non-compliance Error error there may be a problem with
The question that has to be asked is: Did
management know this non-compliance was design, workload, training etc. Does
routine? If not, how could they be made more
remedies remedies management know that errors are being
aware of it? made frequently? If not, why not?
 Acknowledgements
This resource was developed by Patrick Hudson (Consultant) and was commissioned by the Energy Institute’s Human and
Organisational Factors Working Group, which comprised during the project:

Fiona Brindley, Health and Safety Executive

Dr Robin Bryden, Shell International Exploration and Production B.V.
Suzanne Croes, Shell International Exploration and Production B.V.
Bill Gall, Kingsley Management Limited
Pete Jefferies, ConocoPhillips
Rob Miles, Health and Safety Executive
Allen Ormond, ABB
Go back to Introduction
Gareth Parkes, EI
Graham Reeves, BP plc
Helen Rycraft, Magnox North Sites
Dr Mark Scanlon, EI
Dr John Symonds, ExxonMobil Corporation Publications Information
John Wilkinson, Health and Safety Executive

Their contributions to the project’s technical direction are gratefully acknowledged. In addition, the EI gratefully acknowledges the
valuable contributions made by others who reviewed and commented on drafts of the resource during its development.

Affiliations refer to the time of participation.

This project was funded through the Winning Hearts and Minds toolkit research and development fund, which is managed by the EI on behalf
of Shell International Exploration and Production B.V. For further information see www.energyinst.org.uk/heartsandminds

Mark Scanlon coordinated the project and technical editing was carried out by Gareth Parkes and Mark Scanlon. Formatting was carried out by
Stuart King and assisted by Shell International Exploration and Production B.V.
 Publication information
Publications information
© Energy Institute
1st edition, December 2009
The information contained in this resource is provided as guidance only and while every
reasonable care has been taken to ensure the accuracy of its contents, the Energy Institute
cannot accept any responsibility for any action taken, or not taken, on the basis of this
information. The Energy Institute shall not be liable to any person for any loss or damage
which may arise from the use of any of the information contained in any of its publications.

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Acknowledgments