Version: February 2016

1. Introduction

1.1 Purpose of this Handbook

This Handbook is provided to help the demining community understand human error. It
describes the theoretical underpinnings of the subject and provides information on ways of
predicting error probabilities. Most importantly, it suggests ways of reducing the frequency
and the mitigating the consequences of human error.
The Handbook is intended for two groups of readers:
 Developers of demining Tools and techniques. It is hoped that the information it
contains will be valuable in the design of demining equipment to identify and
reduce the errors that might occur when it is used in the field.
 Demining project managers and deminers. The Handbook also contains
recommendations for reducing the number of errors that occur during all phases
of a demining project.

1.2 Acknowledgements
The Handbook was created by Dave Usher of CBRNE Ltd (www.cbrneltd.com) and Stewart
Grainger of BACTEC International Ltd (www.bactec.com).
The research leading to these results has received funding from the European Union Seventh
Framework Programme 2007-2013 under grant agreement n° 284996. Project D-BOX – A
demining tool-box for humanitarian clearing of large-scale areas from anti-personnel
landmines and cluster munitions.

This document reflects only the authors’ views and the European Union is not liable for any
use that may be made of the information contained herein.

1.3 Contacts
If you have any queries or comments regarding the content of this Handbook, please contact
Dominic Kelly, Managing Director, CBRNE Ltd.

Human Error Analysis for Deminers Page 1 of 37

 2. Contents
1. Introduction ................................................................................................................. 1
1.1 Purpose of this Handbook ...................................................................................1
1.2 Acknowledgements .............................................................................................1
1.3 Contacts ...............................................................................................................1
2. Contents ...................................................................................................................... 2
3. Human Error ................................................................................................................ 4
3.1 What Is Error .......................................................................................................4
3.2 What Is Not Error.................................................................................................5
4. Predicting Error Probability ......................................................................................... 6
4.1 Information processing .......................................................................................6
4.2 Quantification ......................................................................................................7
4.2.1 HEART .............................................................................................................7
4.2.2 THERP ..............................................................................................................7
4.2.3 Absolute Probability Judgement ....................................................................8
4.3 Dependence ........................................................................................................8
4.4 Recovery ..............................................................................................................9
4.5 Safety Analysis .....................................................................................................9
4.6 Accident data .......................................................................................................9
4.7 Accuracy ..............................................................................................................9
5. Demining Error Data .................................................................................................. 11
5.1 RAPID .................................................................................................................11
5.2 Database of Demining Accidents ......................................................................12
5.3 SME Opinion ......................................................................................................12
5.3.1 End user platform .........................................................................................12
5.3.2 Online survey ................................................................................................15
6. Current Error Mitigation in Demining ....................................................................... 16
6.1 Standards ...........................................................................................................16
6.2 Procedures.........................................................................................................16
6.3 Accreditation .....................................................................................................17
6.4 Personnel ...........................................................................................................17
6.4.1 Recruitment ..................................................................................................17

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 6.4.2 Briefing ......................................................................................................... 18
6.4.3 Understanding of error ................................................................................ 18
6.5 Supervision ........................................................................................................ 18
6.6 Safety Check ...................................................................................................... 18
6.7 Equipment ......................................................................................................... 19
6.7.1 Hand protection ........................................................................................... 19
6.7.2 Depth gauge ................................................................................................. 19
6.7.3 Detection ...................................................................................................... 19
6.7.4 Signage ......................................................................................................... 19
6.8 PPE .................................................................................................................... 20
6.9 Accident reporting ............................................................................................ 20
6.10 The Role of Management ................................................................................. 21
7. Reducing error in demining Tools .............................................................................. 22
7.1 Human-HAZOPS ................................................................................................ 22
7.2 Standards .......................................................................................................... 22
7.3 Operability assessment ..................................................................................... 23
8. Conclusions ................................................................................................................ 24
8.1 General .............................................................................................................. 24
8.2 Error Reduction ................................................................................................. 25
8.3 Recommendations ............................................................................................ 26
8.4 Finally ................................................................................................................ 26
9. Further information ................................................................................................... 28
9.1 Abbreviations .................................................................................................... 28
9.2 HEART ................................................................................................................ 29
9.2.1 The process .................................................................................................. 29
9.2.2 The tables ..................................................................................................... 29
9.2.3 An example................................................................................................... 32
9.3 Human-HAZOPS suggested guidewords ........................................................... 32
9.4 Safety checklist ................................................................................................. 33
9.5 References ........................................................................................................ 36

Human Error Analysis for Deminers Page 3 of 37

 3. Human Error
People make errors throughout their daily lives. It is part of being human, and we are all
familiar with what is involved. However, the concept of human error is difficult to define.
Indeed, some analysts go as far as to deny its existence in industrial contexts, maintaining that
if an action has an undesirable outcome it is the inevitable consequence of a combination of
poor ergonomics, poor training and poor procedures [Ref 1].
The term ‘human reliability’ sometimes appears in the published literature. However, we will
not use it in this Handbook because of the implication that it includes other human
characteristics such as dependability, punctuality and willingness.

3.1 What Is Error

The following definitions of error have been used extensively in the published literature:
 Any member of a set of human actions or activities that exceeds some limit of
acceptability, i.e. an out of tolerance action [or failure to act] where the limits of
performance are defined by the system [Ref 2]
 An identifiable human action that in retrospect is seen as being the cause of an
unwanted outcome [Ref 3]
 Something done that was not intended by the actor, that was not desired by a
set of rules or an external observer, or that led the task or system outside its
acceptable limits [Ref 4]
We will use the third of these definitions in this Handbook, because of its important inclusion
of inadvertence, which is absent from the others.
Examples of actions that can be considered errors in the demining domain include:

 Unintentionally disturbing an explosive device

 Misreading a map
 Using a misleading, unclear or offensive word in speech or writing
 Mishearing spoken commands
 Mistranslating written procedures
 Misreading a gauge, dial, clock-face or computer printout
 Entering incorrect data in a database or report.
Actions such as these are the physical, observable manifestation of the error. They are termed
‘external error modes’, which reflects the internal cognitive processes that will have preceded
them, as shown in Figure 1. As discussed further in Section 5, these underlying processes must
be addressed if error is to be mitigated.

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 Causes
external events
excessive task demand Mechanisms
operator incapacitated discrimination
human variability input information
processing
recall
inference
physical co-ordination

Internal Error Mode External Error Mode

detection omission of task
identification inaccurate performance of task
decision incorrect timing
commission of erroneous task
commission of extraneous task

Figure 1: Processes leading to error

It is important to distinguish errors from hazardous events. Most errors are harmless; most
are recovered immediately; most result only in delay. Of interest is the tiny minority of errors
with serious consequences.

3.2 What Is Not Error

It is also instructive to consider what does not fall into the definition of error:
 malevolent acts. Deliberate actions taken by people with destructive effect,
such as vandalism, sabotage and physical attacks.
 deliberate departure from procedures. These behaviours (sometimes called
‘violations’) are surprisingly common. They usually arise from poorly written
procedures, in which the importance of carrying out a particular step is not made
sufficiently clear. Often however the user will depart from a procedure because
they believe it to be wrong – they consider it to contain pointless and time-
wasting steps, perhaps, or they have little confidence in the abilities of its author.
There is great debate in the aviation industry about whether flight crew should
follow Standard Operating Procedures (SOPs) slavishly, or should elect to diverge
from them from time to time. However well-intentioned, such behaviour would
still technically constitute a 'violation' rather than an error [Ref 5].
 equipment malfunction. Despite the all-too-familiar messages arising from
fragile software, machines cannot be described as making errors – they
malfunction or fail.
Events of these types can be expected to occur, but their frequency cannot be predicted. They
can be prevented only by removing the human from the system. This is seldom practicable.

Human Error Analysis for Deminers Page 5 of 37

 4. Predicting Error Probability

4.1 Information processing

In the standard ‘S-R-K model’ established by Rasmussen [Ref 6], people are considered to
process information at three levels:
 Skill-based. This is the automatic, rehearsed, unconscious processing needed to
perform activities that cannot be verbalised and that can be grasped only after
practice. An obvious example is riding a bicycle.
 Rule-based. Behaviour based on following rules and
procedures, without necessarily understanding the
underlying reasoning. The importance of SOPs to
demining projects cannot be overstated
 Knowledge-based. This is the conscious, thoughtful
application of experience, training, logic and reason.
The choice of a course of action from competing
alternatives, for example. In the demining context,
determining the type of mine would fall into this
category
These three categories are distinguished by the type of cognition involved. It is by no means
clear that riding a bicycle involves less cognition than making a deduction. The distinction is
based more on the extent of consciousness.
Errors can be made at all these levels. An experienced deminer might misidentify the type of
munition that has been uncovered; a step can be missed from a procedure; a demining
operator can move outside the safe area.
However, the ability to quantify the probability of such errors is restricted to tasks in which
information is processed at the rule-based and skill-based levels. It is not feasible to attempt
numerical prediction in knowledge-based activities, such as determining courses of action or
diagnosing faults, because of the overwhelming (and incalculable) influence of factors such as
training, visual clues, intuition, intelligence, evidence, history and precedent.
Another important model was developed by James Reason [Ref 7], in which errors are
classified into:
 Slips. These can be thought of as actions not carried out as intended or planned,
such as ‘finger trouble’ on a keyboard or a ‘Freudian slip’ when speaking. Slips
typically occur at the task execution stage.
 Lapses are missed actions or omissions, such as when somebody has failed to do
something due to a failure of memory or attention. Lapses usually occur at the
storage (memory) stage.

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  Mistakes. A mistake is a specific type of error brought about by a faulty plan or
intention. This leads to an action that was believed to be correct but turns out to
have been wrong. Mistakes are associated with the planning stage.

4.2 Quantification
Over 150 different methods of quantifying Human Error Probability (HEP) predictions have
been developed and published in the last 50 years. Although at least 35 of them have been
considered sufficiently rigorous for the UK nuclear industry [Ref 8], most have not stood the
test of time and are no longer supported by their developers.
The three techniques for predicting HEPs described in this Section are the most commonly
used in safety engineering. Only these have been validated against error rates observed in
the real world.
4.2.1 HEART
The most well-known and popular method of predicting HEPs is the Human Error Assessment
and Reduction Technique (HEART) [Ref 9]. HEART has little theoretical underpinning but can
nevertheless produce plausible results. Its popularity rests on its breadth of application and
its simplicity.
The process involves selecting from a Table the ‘Generic Task’ that most closely resembles the
task under scrutiny. The ‘nominal human unreliability’ value of the chosen GT is then modified
by the effect of Error Producing Conditions, which are selected from a list of 38 and applied to
a suitable extent. The result is an estimate of the probability of committing the error at each
opportunity.
Section 9.2 provides the HEART Tables and an example of the calculation of a HEP.
4.2.2 THERP
The Technique for Human Error Rate Prediction (THERP) [Ref 10] was developed in the US
nuclear industry over 50 years ago for assessing the safety of Pressurised Water Reactors.
Unlike HEART, it has a thorough theoretical grounding in psychology, mathematics and
statistics. As a result, the rate at which errors are committed is assumed to follow a ‘log-
normal’ frequency distribution – that is, it is the logarithm of the HEP (rather than the HEP
itself) that is assumed to follow a normal distribution.
The prediction process is based on the THERP handbook – a large paper volume containing
tables of information about the frequencies of the errors that might occur in the tasks typically
carried out at nuclear power stations. For example, the Table concerning Check reading of
displays contains items such as Digital indicators and Analogue meters without limit marks. A
‘Basic HEP’ and an ‘Error Factor’ is given for each item. Multipliers are then applied for the
‘Performance Shaping Factors’ stress, experience, ergonomics and whether Personal
Protective Equipment (PPE) is worn. The result is an estimated HEP per opportunity, with an
associated range of accuracy.

Human Error Analysis for Deminers Page 7 of 37

The THERP handbook has not been published electronically, but computer applications to
support the process are now available [Ref 11].
4.2.3 Absolute Probability Judgement
The final method of predicting error probability is to rely on the knowledge and experience of
Subject Matter Experts (SMEs). It has been shown that HEPs estimated by SMEs – based on
their understanding of the process, the people involved, the equipment used and the training
provided – are at least as accurate as HEART or THERP [Ref 12].

4.3 Dependence
The probability of error also depends on preceding events. For example, an earlier error
(whether by the same operator or another) might cause greater vigilance (reducing the HEP)
or cause greater nervousness (raising the HEP).
The concept of dependence extends to supervisory tasks, in which the probability of error
depends on the relationship between the people involved. The effectiveness of supervision is
reduced if both operators have the same training, have the same cultural background, have
worked together for many years and socialise outside work. They no longer act
independently. The growth of trust between them – so important to the effectiveness of an
organisation – can actually increase the probability of errors of supervision.
HEART does not model dependence. THERP provides the algorithm shown in Table 1, where
HEPA and HEPB are the probabilities of error in Task A and the subsequent Task B respectively.
Table 1: Error dependence

Dependence Combined HEP for Task A and Task B

Zero HEPA × HEPB
Low HEPA × (1 + 19  HEPB)/20
Moderate HEPA × (1 + 6  HEPB)/7
High HEPA × (1 + HEPB)/2
Complete HEPA

The Table shows that THERP is a conservative technique – the second error only increases the
combined HEP. However, the contribution made by the second error reduces as the
dependence increases. Indeed, bearing in mind that HEPs are typically around 0.001, the
result of applying this rather simplistic algorithm is that the combined HEP is effectively HEP A
divided by the denominators in the right-hand column of the table.

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 4.4 Recovery
Many of the factors leading to error have been discussed above. However, the probability of
the error leading to an accident is affected by still more factors – principal among which is that
most errors are discovered and corrected before they propagate. This is known as error
recovery. Unless the potential for recovery is understood and modelled, the HEP will be
grossly over-estimated. There are currently no widely accepted means of modelling recovery.

4.5 Safety Analysis

In safety engineering, the extent of risk is a combination of the probability of an accident and
its severity. The accident probability is the product of the probabilities of the events leading
to it. One or more of these events can be human error. Thus the analysis of error can be seen
as part of a broader risk assessment process.
This being so, it should be remembered that the HEP – however derived – represents the
probability per opportunity, while the other probability data used in the safety analysis are
usually expressed per annum. That is to say, for safety-case purposes, a HEP must be
multiplied by the annual frequency of the associated task, bearing in mind the number of
people who perform it. For example, if an error with a HEP of p can occur in a task performed
twice every working day by two people, its annual probability is p × 2 × 2 × 225 = 900p. Thus
an error with a probability of one in a thousand (p = 0.001) can be expected to occur every
year of operations.

4.6 Accident data

An additional problem in the area of human error analysis is the lack of data. In some
industries, such as aviation and nuclear, few errors occur because of very high standards of
safety and training, and an effective safety culture. In other industries, errors are not recorded
because there is no commercial advantage in doing so. The lack of reliable error data makes
it difficult to validate and enhance the HEP prediction methodologies described above.
To provide value, to research or to industry, error-recording systems must be blame-free. This
can be achieved by anonymity, but the natural tendency to avoid controversy means that
employees might need to be incentivised to contribute their observations.

4.7 Accuracy
Great approximation is involved in the prediction of HEPs. In HEART, the analyst must choose
the GT, the EPCs and their proportions of effect. In THERP, the analyst chooses the table, item
and moderating factors. Despite the best of intentions, these choices are likely to be fraught
with uncertainty and personal bias. The HEP data are estimates. The algorithms for combining
them are crude. The modelling of the error and the treatment of dependence and recovery
are matters of personal judgement.

Human Error Analysis for Deminers Page 9 of 37

To reflect the inherent approximation and inter-analyst variability involved, predicted HEPs
should be expressed only to one significant figure (for example, 0.03 or 0.1). Sometimes the
best that can be achieved is the correct order of magnitude.

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 5. Demining Error Data
In this Section of the Handbook, we describe data and opinions regarding error and accidents
in demining. The theoretical background set out above implies that to reduce the likelihood
that any of the errors discussed will cause an accident we must address the precursors, or
‘internal error modes’ shown in Figure 1.

5.1 RAPID
The RAPID database, maintained by the Geneva International Centre for Humanitarian
Demining (GICHD), records the accidents that have been reported in demining projects
worldwide since 1977 [Ref 13]. The causation data are shown in Figure 2. The categories that
relate to error – ‘Staff negligence’, ‘Procedure failure’, ‘Supervision failure’ and ‘Training
failure’ – together account for 36% of the total.

Staff negligence,
193, 9%

Equipment
malfunction, 233,
11%

Other, 30, 2%
Unknown, 961,
46%
Procedure failure,
195, 9%

Supervision failure,
231, 11%

Training failure,
138, 7% Support failure,
105, 5%

Figure 2: Accident causation data from the RAPID database (since 07-Jun-77)

However, the value of the RAPID database to research is limited by the absence of a recorded
cause for nearly half of the accidents. The situation is deteriorating: 64% of the accidents
recorded since 01-Jan-2000 have no information about causation.

Human Error Analysis for Deminers Page 11 of 37

 5.2 Database of Demining Accidents
The Database of Demining Accidents (DDAS) is a valuable resource of information on
humanitarian demining accidents, independent of the principal demining agencies [Ref 14]. It
is an Access database with records going back to 1999. The information has been obtained
from sources worldwide, including the United Nations Mine Action Service (UNMAS).
DDAS does not offer Human error as a causation term. But 81 of the records have Victim
inattention, 439 have Field control inadequacy and 289 have Management control inadequacy
in at least one of the fields relating to causation (Accident Classification, Primary Cause and
Secondary Cause). When multiple-counting has been eliminated, 667 unique records remain,
some 83% of the total. If these causations are considered forms of error, it can be said that
human error has contributed to a significant majority of the accidents recorded.
The following deductions can be made from the DDAS data:
 Human error plays a part in most demining accidents
 AP mines cause the most casualties to deminers
 Most accidents occur during the excavation of AP mines
 Supervisors are involved in 12% of the recorded accidents.
 10% of accidents are fatal and about 40% severe
 Only 2% of injuries are to the foot
 Most injuries are to the hands. The implications of this finding are discussed in
Section 6.7.

5.3 SME Opinion

In addition to these recorded data, the D-BOX project also gathered the opinions of demining
experts on the sources of error in a demining project.
5.3.1 End user platform
The D-BOX End User Platform (EUP) consisted of around 20 experienced deminers from
around the world. Figure 3 shows the proportion of errors they attributed to:
 Equipment (incorrect choice, incorrect use, faulty, poorly maintained) – 29%
 Procedures (failure to follow SOPs, faulty procedures) – 71%
The distribution of errors is altered only slightly by including the SurveyMonkey results
described in Section 5.3.2. Well over twice as many errors are attributed to the use of
procedures as to the use of equipment.

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 Equipment, 8,
29%

Procedures, 20,
71%

Figure 3: Errors by source (EUP opinion)

Figure 4 shows the EUP opinion regarding causation, in the following categories:
 Psychological (boredom, poor concentration, complacency, over-confidence,
fatigue) – 39%
 Management (supervision, training) – 35%
 Socio-cultural (status, ‘face’) – 6%
 External pressures (funding, time pressure, targets) – 7%
 Practical (terrain, equipment) – 13%
Thus, the most significant ‘internal error mode’ is seen to be the combination of the
psychological factors that affect the deminer. This is not surprising, as error is primarily a
psychological phenomenon. Perhaps more notable is that 35% of errors are thought to arise
from poor supervision or training – despite the fact that the respondents had some
responsibility for these activities.

Human Error Analysis for Deminers Page 13 of 37

 Practical, 6, 13%

Psychological,
External 18, 39%
pressures, 3, 7%

Socio-cultural, 3,
6%

Management,
16, 35%

Figure 4: Errors by cause (EUP opinion)

Better
procedures, 15,
25% Enhanced
training, 22, 37%

Better
equipment, 4, 7%

Better supervision, 18,

31%

Figure 5: Suggested solutions (EUP opinion)

Figure 5 shows the types of solutions the EUP put forward. It is notable that no solutions are
suggested explicitly for the psychological causes of error, despite their predominance. The
most frequent suggestion is improved training (37%) followed by better supervision (31%),
which reflects of course the observations regarding training and supervision noted above. The
next most frequently suggested solution (25%) is to enhance the SOPs. This subject is
discussed in Section 6.7.

Page 14 of 37 Human Error Analysis for Deminers

5.3.2 Online survey
The raw results from an on-line survey of SMEs are summarised in Table 2.
Table 2: Summary of on-line SME opinion data

Error type Incidence

1. Failure to follow SOPs 12
2. Incorrect designation and control of un/cleared land. 10
3. Incorrect use of equipment 7
4. Paperwork/reporting errors 6
5. Equipment faults 1

Human Error Analysis for Deminers Page 15 of 37

 6. Current Error Mitigation in Demining
Because of the level of international interest, the economic and social penalties of accidents
and the need for efficiency, the demining industry has developed many hazard mitigation
measures. The principal ones are described in this Section.

6.1 Standards
The International Mine Action Standards (IMAS) aid safety and efficiency during many
demining activities. They are maintained by GICHD. A team of experienced demining
managers, based in Geneva, holds regular meetings with active demining managers to
promulgate their work and to gather feedback to ensure that standards and procedures are
kept in harmony with experience in the field.

6.2 Procedures
Produced by the demining operators, the SOPs provide guidance on the conduct of specific
actions to complete the demining project. They are derived from the IMAS but take into
account the local conditions, the types of deminers employed and the particular techniques
required by the ordnance and its location.
The opinions expressed by the SMEs (and the accident data recorded) indicate that the SOPs
are one of the most fertile areas for error reduction. This is a very common finding in the field
of Human Factors, because good procedures are very difficult to produce. A well-designed
procedure embodies more than the correct technical content: it reflects the capabilities and
limitations of its readers.
For maximum usability, a procedure should meet the following criteria:
 The medium of publication is suitable for the task being undertaken. Insofar as
deminers cannot practically have access to their procedures in the field, the
range of possible media includes paper-based, computer application, video and
aide mémoire
 The content is presented in the most accessible format. Text, diagrams,
photographs, tables and flowcharts should each be considered for their impact
on the reader
 Warnings are indicated by an eye-catching icon
 The reason underlying a procedural step is provided, particularly one involving a
warning. This will allow the reader to accept and internalise the importance of
following the step
 The readability of the text suits the literacy of the readers. A Flesch-Kincaid score
[Ref 15] of at least 90 is appropriate for demining SOPs
 The procedures are all presented in the same format. This will allow the user to
find particular information quickly

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  The design of the procedures complements that of the training. To maximise the
information transfer, the training and the procedures should be developed in
tandem.
These considerations are complicated in the demining industry by the variety of languages
spoken, the cultural differences within the workforce and the practical difficulty of accessing
the procedures when they are most needed.
In order to improve the effectiveness of demining SOPs, it would seem valuable to develop
them in close collaboration with specialists in the field of Human Factors and technical
authorship. Also, the close engagement of the end-users is vital.

6.3 Accreditation
Accreditation is the practical testing of competence to secure high quality, safe demining. The
process has two parts:
 Organisational Accreditation in which a demining organisation earns formal
recognition as being competent to plan and manage at project effectively and
efficiently. Such accreditation will be awarded to the headquarters of an
organisation, normally for a period of two to three years
 Operational Accreditation. Conveyed “in country”, this formally recognises that
an organisation is competent to carry out demining activities such as surveying,
manual clearance or the use of mine detecting dogs. The process, which is
usually supervised by the Mine Action Centre (MAC), covers individuals and
teams.
Demining is a small community and individuals are likely to be known to the project manager
personally or by recommendation. The managers’ performance will be seen and tested during
mobilisation, training and accreditation. In this way, personal deficiencies leading to error will
be identified and remedial actions can be taken before operations begin.

6.4 Personnel
The quality, attitudes and experience of project managers strongly influence the efficiency
and safety of demining projects through their attitude to personnel matters.
Recruited managers will carry out the training for a particular contract. It will be based on the
SOPs but its quality and content will depend on the manager’s skills and experience. Demining
manager training courses are run by GICHD and several national agencies, attendance at which
should form part of the accreditation process.
6.4.1 Recruitment
Normally, demining recruits will be selected from those with basic training and some
experience. If the project includes local volunteers with no experience (in accordance with
the requirements set out in the Cultural Guidelines [Ref 16]), selection tests will be

Human Error Analysis for Deminers Page 17 of 37

administered and basic training provided during the mobilisation phase. Many supervisors
and team leaders, particularly from countries such as Lebanon, Mozambique and Zimbabwe,
will have contacts with deminers from earlier contracts.
6.4.2 Briefing
Briefing is the process of alerting personnel to immediate issues or local changes in
circumstances, and reminding them of their training. The accuracy of briefing for demining
tasks is essential for safety because a missed word or an inaccurate location reference can
lead to an accident.
6.4.3 Understanding of error
It would appear that the subject of human error is poorly understood in the demining
community. Little distinction was made in the questionnaire responses between cause and
effect, and between hazards and accidents. For example, in answer to the question ‘What is
the cause of the error?’ several respondents stated ‘Human Error’.
We can conclude that the training of deminers should include elements of the theory and
practice of error identification and reduction.

6.5 Supervision
Deminers must be focused, competent and confident to safeguard themselves and their
teams against accidents. That demands good health and attitude and an absence of mental
or physical distractions. Managers and supervisors will monitor the health, rest, nutrition and
accommodation of their employees to ensure they are fit for work.
Once at work, the supervisors and team leaders will monitor the deminers in the field to check
that they are working on the correct task, in defined areas and to the SOPs. Supervisors and
team leaders will be nearby to provide advice and encouragement. Whilst risk assessments
and SOPs will cover the threat, situation, procedures and inspections, it is unusual to find
specific procedures to reduce human error. This matter is discussed further in Section 6.6.

6.6 Safety Check

At the beginning of the working day and each new demining task, the team leader will carry
out a “Ready for Work” assessment, as specified in the SOPs of the demining organisation.
This differs from a risk assessment, in which (as described in Section 4.5) the severity of an
accident is combined with the frequency of its occurrence to obtain a level of risk. The safety
check ensures that all practicable safety measures are in place.
It has been shown in many industries, from aviation to surgery, that the effectiveness of a
safety check of this type is greatly enhanced by the use of a checklist [Ref 17]. A checklist
reduces the opportunity to omit items and allows the results to be recorded
contemporaneously.

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The demining safety checklist must cover a broad range of subjects, but from the perspective
of reducing error, it should include a consideration of any conditions that might affect the
precursors to error. Section 9.4 contains a suggested checklist, covering the following
subjects:
 The health and state of mind of the deminers
 The condition of the equipment provided for the tasks, its calibration, sensitivity
and state of its power supply
 The availability and condition of the PPE
 The safe working distances between team members
 The presence, serviceability and readiness of medical support and evacuation
vehicle
 Special conditions increasing the probability of error.

6.7 Equipment

6.7.1 Hand protection

It is clear from the DDAS results given in Section 5.2 that most of the injuries arising in
demining are to the hand. Only 2% are to the foot. This information helps to identify the
more hazardous tasks, and the hazard could be mitigated in a number of ways, including task
redesign.
It might also be possible to develop better hand protection for demining activities. The
conflicting requirement for both blast protection and flexibility (to permit fine movement)
adds to the challenge.
6.7.2 Depth gauge
To compound the usual errors associated with measuring the depth of munitions, deliberate
depth variations might be part of the layers’ psychological plan. The high risk associated with
failing in this task suggests that automation should be considered.
6.7.3 Detection
The EUP did not express many views about their equipment. But there was a call for metal
detectors with a higher probability of detection, and more ‘intuitive equipment with alarms
fitted for incorrect use’. The latter comment reflects the need for the inclusion of Human
Factors and error analysis in the design process.
6.7.4 Signage
In and around the demining site, signs are often displayed to warn of danger, to prohibit entry,
to advise alternative routes and so on. Such signs must be designed carefully if they are to

Human Error Analysis for Deminers Page 19 of 37

influence people’s behaviour in the direction intended. This problem was underlined in the
Petrified Forest National Park in Arizona (US) where the theft of wood increased after signs
were put up telling visitors not to steal wood [Ref 18].

Figure 6: Confusing signs

Errors can be made both by the designer of a sign and by its interpreter. Figure 6 shows
extreme examples of poor design, in which there is conflict between the text and the image.
The cognitive load imposed on the interpreter of the sign by the need to resolve this conflict
might cause delay, incorrect action and a loss of confidence in signage generally. Of course,
even if the sign is well designed, clear and wholly unambiguous, the interpreter might simply
misunderstand it or fail to see it.
In general, research suggests that the most effective signs align ‘descriptive’ and ‘injunctive’
messages [Ref 18, 19] – that is, the sign should imply that people are already doing what they
should be doing.

6.8 PPE
It is of course an error, in a hazardous environment, not to wear PPE or to wear it incorrectly.
But it should be remembered that in itself the error does not cause accidents. Instead, it
reduces the mitigation of the severity of some accidents – those against which the PPE is
intended to protect.
It is notable that in the THERP methodology (Section 4.2.2), the HEP is doubled if PPE is worn.
This reflects the difficulty of carrying out a delicate manual task wearing thick gloves or a
facemask. Therefore, the risk assessment of a task in which PPE is mandated must include the
extent of mitigation achieved by the PPE as well as the probability of it not being worn.

6.9 Accident reporting

We saw in Section 5 that many of the records in the RAPID database do not contain the cause
of the accident. If they did, it would be possible to analyse the part played by the many factors
involved in an accident.
To ensure a constructive accident investigation, organisations need to adopt a blame-free
culture. This has much to offer in terms of improved relationships between employees and

Page 20 of 37 Human Error Analysis for Deminers

with employers, better co-operation and communications and a readiness to participate in
measures designed to improve safety [Ref 20]. Accordingly, a well-designed accident
reporting system allows the incident to be described anonymously.
Also, the database should include near misses, as these types of incident provide enormously
valuable information. Many comprehensive software packages are available to support
blame-free accident and incident reporting and investigation, such as i-sight [Ref 21] and SHE
Incident Management [Ref 22].

6.10 The Role of Management

Management in demining is the key factor in reducing errors and accidents. This is because
management covers:
 Selection, training and accreditation of managers, supervisors, team leaders and
deminers
 Mobilisation of projects
 Assessment of hazards, climate and terrain
 Assessment of risks
 Selection of tools
 The design of clearance and neutralisation plans
 Provision of accommodation, feeding, recreation, equipment and vehicles
 Supervision of health and welfare of all personnel
 Supervision of safe working practices, and
 Briefing and reporting.

Human Error Analysis for Deminers Page 21 of 37

 7. Reducing error in demining Tools
The discussion above has focused on reducing the errors that can occur during the demining
process. The other principal area that can benefit from the study of human error is the design
of demining Tools. In this context, the term Tool includes equipment, systems, products and
procedures.

7.1 Human-HAZOPS
The first step in human error assessment of a Tool is to identify the errors that might credibly
be made by its users. The best method of doing this is based on the Hazard and Operability
Study (HAZOPS) methodology used in engineering [Ref 23] and is known as a Human-HAZOPS
[Ref 24].
The process is carried out by SMEs, preferably around six in number, one of whom acts as a
scribe. Together, the team should:
 Identify the tasks undertaken. A task hierarchy is the ideal format – where the
tasks are broken down (‘redescribed’) into their subtasks.
 Identify guidewords, representing deviations from the correct performance of
the task. The guidewords should be based on experience of how demining tasks
are usually performed. Section 9.3 gives a list to start from.
 Apply the guidewords to each of the tasks in the task hierarchy. This will
generate ideas for how errors might occur, and the scribe should record the
credible ones.
 For each of the recorded errors, consider its effects on safety, prioritising those
with the greatest safety significance.
 Discuss and record possible ways of reducing the probability of the error or the
severity of its consequences (or both). Identify the most practicable method and
consider how it might be implemented.
The result of the Human-HAZOPS is a list of possible modifications to the design of the Tool,
each of which will help to reduce human error.

7.2 Standards
Another important way of reducing error in the use of equipment is to design the equipment
in accordance with recognised international standards. Many Human Factors standards have
been published, for application to all types of work. The following are the most relevant to
demining:
 EN ISO 6385:2004 – Ergonomic principles in the design of work systems
 EN ISO 14738:2002 Safety of machinery — Anthropometric requirements for
the design of workstations at machinery

Page 22 of 37 Human Error Analysis for Deminers

  EN ISO 1005-2:2003 Safety of machinery — Part 2: Manual handling of
machinery and component parts of machinery
 EN ISO 9241 – Ergonomic requirements for office work with VDTs
 EN ISO 60601 Parts 1 - 6 – medical equipment design. General requirements
for safety
 Defence Standard 00-250 – UK Ministry of Defence Human Factors Standard
(Parts 0 – 3)
 UK Health and Safety (Display Screen Equipment) Regulations 1992 as
amended by the Health and Safety (Miscellaneous Amendments) Regulations
2002

7.3 Operability assessment

It is always invaluable to obtain an assessment of the operability of a Tool from a Human
Factors expert, independent of the design team. He or she will be more capable of viewing
the design from the user’s perspective – and identifying the potential for error – than someone
who has been involved in the decisions taken and the trade-offs made as the design has
matured.

Human Error Analysis for Deminers Page 23 of 37

 8. Conclusions
This Handbook has described the theory underpinning human error analysis. An
understanding of the root causes of error should enable measures to be put in place to reduce
the number of errors on the minefield.

8.1 General
In this Handbook, we have shown that:
 Human error is an important factor in most demining accidents.
 The understanding of human error among deminers is generally poor. This
indicates a need to include the subject in demining training.
 demining accident data are few and of poor quality, which frustrates research
into demining safety and the role played by human error.
 The greatest danger is in the routine excavation of landmines and ERW in
preparation for neutralisation.
Table 3: The main causes of error

Poorly written procedures, poorly followed Management or supervision failure

Error in selecting or providing equipment Incorrectly adjusted equipment

Page 24 of 37 Human Error Analysis for Deminers

 Poor training, poor briefing Loss of concentration

Incorrect information, inaccurate reporting Poor evidence (inaccurate, not current,

(particularly grid references) poorly interpreted).

8.2 Error Reduction

Although of value to everyone involved in demining activities, this Handbook has two
particular groups of readers – demining Tool developers and demining project managers.
Accordingly, there are two forms of error reduction methodology.
The first one is directed at the developers of the D-BOX Tools. We believe the use of the
Human-HAZOP process will help identify possible user errors so that they can be reduced or
eliminated in the next design iteration. The Tool developers might also employ the error rate
prediction methods (particularly HEART) in the development of a safety case for a demining
project in which the D-BOX Tools are used.
The second methodology of error reduction is directed at demining managers. It consists of
the following administrative measures:
 including a checklist in the SOP that describes the safety check to be undertaken
before work commences and new tasks are started
 improving SOPs to aid understanding and implementation

Human Error Analysis for Deminers Page 25 of 37

  enhancing deminer training, consistently with the SOPs, to include a discussion of
error
 ensuring a blame-free incident reporting system, to include near-misses
 ensuring that all signage is clear and unambiguous.

8.3 Recommendations
The following recommendations have emerged from the research leading to this Handbook.
1. Demining managers should attend the courses run by GICHD (and other national
agencies) to enhance their training skills. Where practicable, the courses
attended should be accredited by a professional teaching body, such as the UK’s
National College for Teaching & Leadership [Ref 25]
2. Specialists in Human Factors and technical authorship should collaborate with
demining managers in developing demining SOPs
3. Research should be conducted into ways of mitigating the psychological sources
of error, such as boredom and over-confidence
4. Funding should be made available for research and development into improved
demining equipment, as described in Section 6.7
5. D-BOX Tool designers should follow the Human HAZOPS methodology to reduce
the likelihood of error in the use of their Tools. Feedback on the usability and
value of the methodology should be used to enhance the process
6. Research should be initiated into improved hand protection for deminers
7. A safety check such as that given in Section 9.4 should be considered an essential
part of the operators’ SOPs and used every day (and whenever a new task is
started)
8. The RAPID database maintained by GICHD should be revised along the lines set
out in Section 6.9. There should be greater emphasis on the importance of
entering information about causation
9. Deminer training, particularly for managers, should include error identification
and reduction techniques
10. Signage in and around the minefield should meet the intelligibility criteria set out
in Section 6.7.4.

8.4 Finally
This Handbook has explored the subject of human error in demining, from the viewpoints of
Tool developers and Tool users. The intention has been to increase the safety and productivity
of humanitarian demining projects in the EU and outside, by raising awareness of the ways in

Page 26 of 37 Human Error Analysis for Deminers

which error can be identified and mitigated. Remember: human error is unavoidable, but we
can reduce the chances of it happening.

Human Error Analysis for Deminers Page 27 of 37

 9. Further information

9.1 Abbreviations
Abbreviation Meaning
AP Anti-Personnel
CBRNE Chemical, Biological, Radiological, Nuclear and Explosive
DDAS Database of Demining Accidents
EDEN End-user driven DEmo for cbrNe
EPC Error Producing Condition
ERW Explosive Remnants of War
EU European Union
EUP End User Platform
GICHD Geneva International Centre for Humanitarian Demining
GT Generic Task
HAZOPS Hazards and Operability Study
HEART Human Error Assessment and Reduction Technique
HEP Human Error Probability
IMAS International Mine Action Standards
ISO International Organization for Standardization (Greek: iso=same)
MAC Mine Action Centre
PPE Personal Protective Equipment
RAPID Reporting, Analysis, and Prevention of Incidents in Demining
SME Subject Matter Expert
SOP Standard Operating Procedure
THERP Technique for Human Error Rate Prediction
UK United Kingdom
UNMAS United Nations Mine Action Service
US United States
VDT Visual Display Terminal

Page 28 of 37 Human Error Analysis for Deminers

 9.2 HEART

9.2.1 The process

The Human Error Assessment and Reduction (HEART) process is as follows:
1. Choose the ‘Generic Task’ from Table 4 below that is most similar to the task
under scrutiny.
2. Obtain the nominal HEP value (HEPnom) from the Table. The three figures in the
HEPnom column can be interpreted as follows: out of the tasks to which the GT is
the most similar, 5% will have a HEP below the 5th%ile value, 50% will have a HEP
below the 50th%ile value and 95% will have a HEP below the 95th%ile value. Thus
the figure to choose depends on how conservative you need to be.
3. Choose an applicable Error Producing Condition (EPC) from the list of 38 in Table
5 and obtain its maximum Predicted Nominal Factor (PNF).
4. Consider the conditions under which the task is conducted and estimate the
Proportion of Effect (PoE) of this EPC, between 0 and 1.
5. Calculate the value of the EPC from the expression E = [(PNF - 1) × PoE] + 1.
6. Include up to 3 EPCs, by repeating from step 3.
7. The final HEP is HEPnom multiplied by all of the EPC values calculated.

9.2.2 The tables

Table 4: HEART Generic Tasks

Generic Task Description HEPnom

50 %ile (5th%ile – 95th%ile)
th

GT(A) Unfamiliar Totally unfamiliar, performed at speed with no 0.55 (0.35 - 0.97)
real idea of likely consequences.
GT(B) Shift without Shift or restore system to new or original state 0.26 (0.14 - 0.42)
procedures on a single attempt without supervision or
procedures
GT(C) Complex Complex task requiring high level of 0.16 (0.12 - 0.28)
comprehension and skill.
GT(D) Simple Fairly simple task performed rapidly OR given 0.09 (0.06 - 0.13)
scant attention.
GT(E) Routine, low Routine, highly-practised, rapid task involving 0.02 (0.007 - 0.045)
Skill relatively low level of skill.

Human Error Analysis for Deminers Page 29 of 37

 Generic Task Description HEPnom
50th%ile (5th%ile – 95th%ile)
GT(F) Restore with Restore or shift system to original or new state 0.003 (0.0008 - 0.007)
procedures following procedures, with some checking.

GT(G) Familiar, Completely familiar, well-designed, highly 0.0004 (0.00008 - 0.009)

practised practised, routine task occurring several times
per hour, performed to highest possible
standards by highly-motivated, highly trained
and experienced persons, totally aware of
implications of failure, with time to correct
potential error, but without the benefit of
significant job aids.
GT(H) Respond Respond correctly to system command even 0.00002 (0.000006 - 0.0009)
correctly when there is an augmented or automated
supervisory system providing accurate
interpretation of system state.

Table 5: HEART error producing conditions

Predicted
Error Producing Condition Description Nominal
Factor
EPC01 Unfamiliarity Unfamiliarity with a situation which is potentially ×17
important but which only occurs infrequently or which is
novel.
EPC02 Time shortage A shortage of time available for error detection and ×11
correction.
EPC03 Low signal/noise A low signal to noise ratio. (when really poor) ×10
EPC04 Features override A means of suppressing or over-riding information or ×9
features, which is too easily accessible.
EPC05 Incompatibility No means of conveying spatial and functional ×8
Information to operators in a form that they can readily
assimilate.
EPC06 Model mismatch A mismatch between an operator's model of the world ×8
and that imagined by a designer.
EPC07 Irreversibility No obvious means of reversing an unintended action. ×8
EPC08 Channel overload A channel capacity overload, particularly one caused by ×6
simultaneous presentation of non-redundant
Information
EPC09 Technique unlearning A need to unlearn a technique and apply one which ×6
requires the application of an opposing philosophy.
EPC10 Knowledge transfer The need to transfer specific knowledge from task to ×5.5
task without loss

Page 30 of 37 Human Error Analysis for Deminers


Error Producing Condition
EPC11 Performance
ambiguity
EPC12 Risk misperception
EPC13 Poor feedback
EPC14 Poor cue
EPC15 Inexperience
EPC16 Impoverished
information
EPC17 Little checking
EPC18 Objective conflict
EPC19 No diversity
EPC20 Educational
mismatch
EPC21 Dangerous incentive
EPC22 Lack of exercise
EPC23 Unreliable
instruments
EPC24 Absolute judgements
EPC25 Unclear allocation
EPC26 Lack of progress
tracking
EPC27 Physical capability
EPC28 Low meaning
EPC29 Emotional stress
EPC30 Ill-health
EPC31 Low morale
EPC32 Inconsistency
EPC33 Poor environment
EPC34 Low loading
Human Error Analysis for Deminers
Predicted
Description Nominal
Factor
Ambiguity in the required performance standards. ×5
A mismatch between perceived and real risk. ×4
Poor, ambiguous or ill-matched system feedback ×4
No clear, direct and timely confirmation of an intended ×4
action from the portion of the system over which
control is to be exerted.
Operator inexperience (e.g. a newly qualified tradesman ×3
but not an expert).
An impoverished quality of information conveyed by ×3
procedures and person/person interaction.
Little or no independent checking or testing of output. ×3
A conflict between immediate and long-term objectives. ×2.5
No diversity of Information input for veracity checks. ×2.5
A mismatch between the educational achievement level ×2
of an individual and the requirements of the task.
An incentive to use other more dangerous procedures. ×2
Little opportunity to exercise mind and body outside the ×1.8
immediate confines of a job.
Unreliable instrumentation (enough that it is noticed). ×1.6
A need for absolute judgements which are beyond the ×1.6
consistent capabilities of an operator.
Unclear allocation of function and responsibility ×1.6
No obvious way to keep track of task progress whilst ×1.4
performing it.
A danger that finite physical capabilities will be ×1.4
exceeded.
Little or no intrinsic meaning in a task. ×1.4
High-level emotional stress. ×1.3
Evidence of ill-health amongst operatives, especially ×1.2
fever
Low workforce morale ×1.2
Inconsistency of meaning of displays and procedures. ×1.2
A poor or hostile environment (below 75% of health or ×1.15
life-threatening severity)
Prolonged inactivity or highly repetitious cycling of half ×1.1
hour low mental workloads. (×1.05 each
Page 31 of 37
 Predicted
Error Producing Condition Description Nominal
Factor
hour
thereafter)
EPC35 Sleep disruption Disruption of normal work-sleep cycles. ×1.1
EPC36 Task pacing Task pacing caused by the intervention of others. ×1.06
EPC37 Supernumeraries Additional team members above those necessary to ×1.03
perform task normally and satisfactorily.
EPC38 Age Age of personnel performing perceptual tasks. ×1.02

9.2.3 An example
As an example, Generic Task E is a routine, highly practised, rapid task involving relatively low
level of skill. Its HEPnom is 0.02 at the 50th%ile level. Next, if there is little time available for
error detection and correction, then EPC02 (with PNF = 11) should be chosen. A PoE of 0.5
might be suitable if the operator has no control over the pace of the work and there is a strict
deadline for completion.
So, if no further EPCs are relevant, the HEP is given by:
0.02 × [((11 - 1) × 0.5) + 1] = 0.02 × (10 × 0.5 + 1) = 0.02 × 6 = 0.12
That is to say, HEART predicts that in 50% of the cases in which these conditions apply, the
task will be done incorrectly in up to 12% of attempts – one in every eight.

9.3 Human-HAZOPS suggested guidewords

Keyword Example
1. omission Action in procedure not carried out.
Necessary action not in procedure
2. commission Action not in procedure carried out
3. repetition Action carried out too often
4. extent Action carried out too much/little/long/quickly/slowly
5. order Action carried out at the wrong point in procedure.
Action carried out in the wrong direction
6. identification Action carried out on the wrong object
7. data acquisition Inaccurate reading of gauge/display/printout.
Incorrect interrogation of database, query design error
8. interpretation Incorrect interpretation of image/information/signal
9. application Choice of inappropriate Tool, operation of Tool outside scope.
Incorrect application of data/Tool

Page 32 of 37 Human Error Analysis for Deminers

 Keyword Example
10. confidence Over-dependence on Tool output, misunderstanding of
accuracy/reliability.
Reluctance to admit lack of understanding
11. stress Fear of injury/sanctions/ridicule, time pressure
12. motivation Poor opinion of Tool. Perception of wasted effort/time.
Lack of reward/job satisfaction
13. situational awareness Tool distracts attention from hazards.
Overconfidence in output, cognitive lock-up
14. fatigue Excessive effort, long/unsocial hours
Conflict with circadian rhythm
15. workload Mental/physical overload/underload
Boredom, monotony
16. usability Tool has poor learnability/effectiveness/affect/flexibility
Conflict with expectations, inconsistency
17. communications Missed visual/acoustic cues
Speech misunderstood/misheard/mis-spoken
18. domino effects Downstream/'knock-on' effects
Incomplete/incorrect consequence analysis
19. supervision Failure to monitor conduct of work/adherence to
procedures/worker health/competence/testing/refresher
training
20. procedure Incomplete/incorrect steps, unclear explanations, translation
errors
Unexplained abbreviations/units, divergence from style guide
21. dependence Shared training/culture/experience/assumptions
Changed probability of subsequent error

9.4 Safety checklist

DEMINING TEAM LEADER’S SAFETY CHECK LIST

The purpose of these checks is to reduce human error by ensuring that deminers are fit
for work and that they have correct and serviceable tools.

Human Error Analysis for Deminers Page 33 of 37

 Company/NGO:
Location: Task:
Date: Time:
SOPs for Task:
Team Leader (Name):

Team Members (Names):

1. 2.
3. 4.
5. 6.
7. 8.
9. 10.
11. Medic/Ambulance:

Mine Detectors (Serial Numbers):

1. 2.
3. 4.
5. 6
Serial Topic Check Done

1. Team Members Fitness – Looks normal and is moving well

2. Mood – Alert and interested
3. Dress – Approved clothes and boots
4. Task – Briefed and knows their task
5. Procedures – Knows procedures to be used
6. Knows Safety Distances.
[Normally minimum distance between working deminers is 15m. For
demolitions AP 60m and for AT 200m]
7. Detectors Working in metal free pit
8. Working in mined pit
9. Battery OK
10. Spare Battery OK
11. Acceptable wear on Detector Pad
12. PPE Helmet, Visor, Body, Gloves
13. Fitting
14. Serviceable
15. Clean
16. CASEVAC Medic: Name and Location:
17. Ambulance: Locations and Keys

Page 34 of 37 Human Error Analysis for Deminers

 18. Error Factors Topsoil Condition - Wet/slippery, frozen, hard, rocky
19. Light level – Cloud, low light, driving rain/snow
20. Fatigue – Heat, time of day, hours of work, time in PPE
21. Urgency – Pressure to complete, peer competition, imminent holiday

Human Error Analysis for Deminers Page 35 of 37

 9.5 References

1 Accidents are normal and human error does not exist: a new look at the creation of
occupational safety
S W Dekker
International Journal of Occupational Safety and Ergonomics 2003 9(2) p211-8

2 Comparative evaluation methods for human reliability analysis

A D Swain (1989)

3 Human reliability assessment in context

E Hollnagel
Nuclear Engineering and Technology, 37(2) April 2005

4 Human Error: Cause, Prediction and Reduction

J W Senders, N P Moray (1991)
Lawrence Erlbaum Associates, p.25. ISBN 0-89859-598-3

5 Slips, Lapses, Mistakes and Violations

Crew Resource Management
http://www.crewresourcemanagement.net/4/26.html

6 Skills, rules and knowledge: Signals, signs, and symbols and other distinctions in
human performance models
IEEE Transactions on Systems, Man, and Cybernetics, SMC-13, p257-267
Jens Rasmussen, 1982

7 Human Error
J. Reason, Cambridge University Press, 1990
ISBN-0-521-31419-4

8 Review of human reliability assessment methods

Julie Bell & Justin Holroyd
Health and Safety Laboratory for the Health and Safety Executive 2009

9 Human Error Assessment and Reduction Technique

J C Williams and J Willey
Institution of Chemical Engineers, Symposium Series No. 93, 1985, p353-366

10 Technique for Human Error Rate Prediction

A D Swain and H E Guttman NUREG/CR-178 1983

11 THERP Calculator
InterAction of Bath Ltd, 2010

12 A Guide to Practical Human Reliability Assessment

B Kirwan, Taylor and Francis, 1994, p202

13 RAPID_Accident_Causes_May2014.xls
Supplied by Fiaz Paktian, GICHD

14 Database of Demining Accidents

http://ddasonline.com Maintained by Andy Smith www.nolandmines.com

15 Flesch-Kincaid readability tests

Page 36 of 37 Human Error Analysis for Deminers

 en.wikipedia.org/wiki/Flesch-Kincaid_readability_tests

16 D-BOX D3.2 Cultural Guidelines for demining managers

February 2014, D Usher (CBRNE), S Grainger (BACTEC)

17 The Checklist Manifesto: How to Get Things Right

Atul Gawande
Metropolitan Books, December 22, 2009
ISBN 0805091742

18 Crafting normative messages to protect the environment

Cialdini, R B (Department of Psychology, Arizona State University)
Current Directions in Psychological Science, August 2003

19 EDEN D83.2 Communication Kit

Issue: 1.0
Irina Stănciugelu (CBRNE), Holly Carter (PHE)
22/10/2014

20 Human Factors and Behavioural Safety

Jeremy Stranks
Routledge 2011
ISBN: 978-0-7506-8155-1

21 Risk & Safety Tracking Software

i-sight.com/case-management-software/safety-tracking-software

22 SHE Health and Safety Software

www.shesoftware.com/incident-management

23 Hazard and Operability Studies in engineering

BS IEC 61882:2002

24 Guidance on Human Factors Safety Critical Task Analysis

Energy Institute, London, Registered Charity Number 1097899
1st edition March 2011, ISBN 978 0 85293 603 0

25 National College for Teaching & Leadership

https://www.gov.uk/government/organisations/national-college-for-teaching-and-leadership

Human Error Analysis for Deminers Page 37 of 37

 Published by CBRNE Ltd
Printed by XXXXX XXXX

ISBN XXXX XXXX XXX

February 2016
Price: US$ 25

This project has received funding from the European Union’s

Seventh Framework Programme for research, technological
development and demonstration under grant agreement no
284996”