The petroleum industry fails to uncover valuable human error lessons from incidents – Are you making the same mistakes?

Abstract

Problems occur even when individual system components function correctly; therefore, we must carefully evaluate what happens at the interfaces between those components, as well as the resulting effect of their interactions. Human factors design and human-machine integration, which assess interfaces affecting humans and overall system performance respectively, have been consistently pursued in an integrated fashion for decades now in space programs. Unfortunately, reliability engineering and other approaches used in industries with very different requirements than those in aerospace have been replacing many of the National Aeronautics and Space Administration (NASA) successful system safety practices over recent years.This paper highlights Root Cause Analysis (RCA) practices traditional in the space industry's investigations that have been found absent or not thoroughly applied in the petroleum industry. The purpose is to stress their value and their need by showing how their absence hinders learning from incidents. The scope was limited to human factors integration into incident investigations.