(68a) Humans Make Mistakes...Which Cause Events

When reviewing investigations reports associated with Loss of Primary Containment (LOPC) events, it is not uncommon to find human error identified as a cause. However, if you take a closer look at these human errors, it appears most of these errors are being made by a single group of humans – namely, operators. But are these really the only humans making errors contributing to or causing LOPC events? This paper seeks to answer this question by reviewing all the identified causes of a set of LOPC events within a company to identify errors being made by other groups of humans which may not be adequately addressed within these investigations.