This document outlines different types of human errors and violations that can occur. It describes errors as unplanned actions like using the wrong object or transposing numbers. Errors can be slips from forgetting tasks or lapses from easily diverted attention. Violations are deliberate breaks of rules that can be routine from believing incorrect actions are normal, situational due to lack of resources, or exceptional when risks are known. Nine root causes of human factor issues are identified, including poor organizational change management, inappropriate staffing levels, insufficient training, fatigue, poor procedures, lack of human factors in risk assessment and investigations, poor communication, lack of human factors in design, and poor organizational culture.

1. Human Factors Root Cause Analysis
Error (unintentional) or Violation (deliberate) Violations
(Breaking the Rules)
Errors
What Best describes the error
Do an unplanned action
e.g. use wrong object,
transpose numbers wrongly
Slip
Forget to carry out task
(often occur during
periods of waiting)
Lapse
These occur if the attention is diverted easily
Believed doing the
right thing
Knowledge based
• Experience
• Information or
understanding
Rule Based
• Expect to conform to rule
Mistake
Errors occur due to:
• Environment – noise, light, heat, distractions, etc
• Extreme task demands – high workload, monotonous tasks, disruptions
• Social or organisational factors – low numbers, conflicts, peer pressure
• Individual factors: training ,fatigue, illness, attitude, personal issues
(work/home), drugs
• Equipment – poor design, poor procedures
How Does this Best describe the violation?
Has Become the Normal
Way of Working
Routine
Violation
Looking to cut corners, often
due to:
• A perception that rules are
too restrictive
• Believe rules no longer
apply
• Lack of enforcement
• New starter believes it is
the normal way to work
Pressure of the job
Situational
Violation
Often due to a lack of:
• Time
• Numbers
• Right equipment
Human Factor Root Causes
1. Poor Organisational Change or
Transition Management
2. Inappropriate Staff levels and
Workload
3. Insufficient Training and
Competence
4. Fatigue (shift work and
overtime)
5. Poor Procedures (not just
SOPs)
6. Lack of Human Factors
consideration in risk
assessment and investigations
7. Poor Communication
8. Lack of Human Factor
considerations in design
9. Poor Organisational Culture
Exceptional
Violation
• Rare
• Knowledge of risk
• False belief benefit >
risk