machine shop

The most common prescription to correct the cause of an accident or mistake is training. Training in itself is not a total solution. It is important that the operators or maintenance technicians understand the proper operation of the equipment. The maintenance technicians must understand the precautions and methods of conducting maintenance safely and effectively. However, this type of human error is more of a mistake due to ignorance.

What if an operator performed an equipment startup so many times that they forgot to check the procedures or displayed messages during the startup?  Or they became so distracted that the wrong machine was shut down?  Sometimes complacency causes the error.

Can training help in this situation?

The US Department of Energy DOE-HDBK-1028-2009 outlines a process for human performance improvement that has been implemented at DOE facilities and commercial nuclear plants to reduce errors.

The tools identified for individuals are:

-Task review

-Job site review

-Questioning attitude at activity level

-Questioning attitude during work planning and preparation

– Pause when unsure

-Self checking

-Procedure use and adherence

-Validate assumptions


-Effective communications

-Place keeping


These tools have been developed into training programs to “drill” the processes and mindsets into individuals through exposure and repetition.

For additional information, refer to DOE-HDBK-1028-2009 or contact