OTO 053/2001

Preventing the propagation of error and misplaced reliance on faulty systems: A guide to human error dependency

This guide is aimed at managers, analysts and designers. Human error dependency is particularly serious because it can "defeat" multiple independent safety defences, thereby undermining safety in what would otherwise be a high reliability system. This is demonstrated by cases where independent safety systems have failed simultaneously, teams of operators have misdiagnosed emergency situations and staff have relied on inoperative warning systems. The guide draws on practical examples of error defences and accident case studies to show that it is practical to guard against these types of errors.

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Updated 2021-04-14