ABSTRACT
This chapter describes some accidents which occurred because someone forgot to carry out a simple, routine task such as closing or opening a valve, or carried it out wrongly that is, he closed or opened the wrong valve. Those interested in the psychological mechanisms by which slips and lapses of attention occur should read J. Reason and C. Mycielska's book on everyday errors. The examples that follow illustrate some of the ways to prevent or reduce slips and lapses of attention or recover from their effects. They include better displays of information, interlocks that prevent an incorrect action being performed, warnings that it has been performed, trips which prevent serious consequences and reducing stress or distraction. Behavioural safety training will have little if any effect as slips and lapses of attention are not deliberate. A trade union leader is quoted as saying that the management team members were more tired than the operators as the managers were working 12-hour shifts.
