Difference between revisions of "Human error"
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Similarly to human performance, the ''Errors'' can be categorized in many ways. | Similarly to human performance, the ''Errors'' can be categorized in many ways. | ||
| − | === | + | ===Action Errors=== |
:While making the ''Error'', a human being is performing either: | :While making the ''Error'', a human being is performing either: | ||
:#An incorrect task, which is commonly categorized as a mistake; OR | :#An incorrect task, which is commonly categorized as a mistake; OR | ||
:#A correct task incorrectly, which is commonly categorized as a slip. | :#A correct task incorrectly, which is commonly categorized as a slip. | ||
| − | + | ===Failure-timing Errors=== | |
| + | :J.T. Reason developed the classification of unsafe acts that distinguishes between two types of errors: | ||
| + | :#Active failures, whose effects are felt immediately in a system. | ||
| + | :#Latent failures, whose effects may lie dormant until triggered later, usually by other mitigating factors. | ||
| + | |||
| + | (2)The presence of defenses or safeguards in a system can usually prevent theeffects of latent failures from being felt by closing the window of opportunity duringwhich an active failure may be committed. For example, consider the case of amechanic who assembled a component incorrectly which eventually led to a plane crashdays or even weeks later. The defenses that should have normally caught this mistakewere not in place. These defenses include proper training (the mechanic was taught to fixthis particular component very informally and on-the-job), good situational awareness(the mechanic was tired from a double shift the night before), and independent inspection(the job was “pencil-whipped” to save time.)(3)Active failures are usually the result of actions taken (or not taken) by front-line operators such as pilots, air traffic controllers, or anyone else with direct access tothe dynamics of a system. Latent failures, on the other hand, are caused by thoseseparated by time and space from the consequences of their actions in the dynamics ofthe system. Personnel working in vocations such as architectural design, hardwaredesign and equipment maintenance are more prone to cause latent failures than activefailures. | ||
AC 120-729/28/00Par 8Page 8(4)Both active and latent failures may interact to create a window for accidentsto occur. Latent failures set the stage for the accident while active failures tend to be thecatalyst for the accident to finally occur. A good way to think of this model of accidentcreation is as slices of Swiss cheese. Each slice can be thought of as a defense to anaccident (training, good management, teamwork, etc.) and each hole is a failure in thatdefense. The last slice is the final action which could serve as a defense before theaccident event. The failure in that defense would constitute the active failureprecipitating the accident. If the defenses to a situation contain a sufficient number offailures, which allow the holes to “line up,” an accident will occur.(5)Differences between active and latent failures cannot be over emphasized;each type of error helps to shape the type of training required to correct them. Forexample, because of the immediate demands and consequences of their actions, flightpersonnel require training that includes the psychomotor aspects of physical skills such asimproving reaction time in emergency training. The strict physical requirements foremployment as a flight officer demonstrate this emphasis clearly. On the other hand,maintenance personnel may require human factors and operations training to account fortheir susceptibility to latent failures. In addition, the range of physical activities ofmaintenance personnel on the job also requires emphasis on workplace ergonomics. Forexample, maintenance personnel may be asked to lift heavy objects, work in awkwardpositions, or perform tasks in extreme weather conditions. These difficult workconditions all require knowledge of ergonomics to ensure safe, error-free performance.Though CRM and MRM share the basic concepts of error prevention, the content of whatis taught is specific to what is actually performed on the job. | AC 120-729/28/00Par 8Page 8(4)Both active and latent failures may interact to create a window for accidentsto occur. Latent failures set the stage for the accident while active failures tend to be thecatalyst for the accident to finally occur. A good way to think of this model of accidentcreation is as slices of Swiss cheese. Each slice can be thought of as a defense to anaccident (training, good management, teamwork, etc.) and each hole is a failure in thatdefense. The last slice is the final action which could serve as a defense before theaccident event. The failure in that defense would constitute the active failureprecipitating the accident. If the defenses to a situation contain a sufficient number offailures, which allow the holes to “line up,” an accident will occur.(5)Differences between active and latent failures cannot be over emphasized;each type of error helps to shape the type of training required to correct them. Forexample, because of the immediate demands and consequences of their actions, flightpersonnel require training that includes the psychomotor aspects of physical skills such asimproving reaction time in emergency training. The strict physical requirements foremployment as a flight officer demonstrate this emphasis clearly. On the other hand,maintenance personnel may require human factors and operations training to account fortheir susceptibility to latent failures. In addition, the range of physical activities ofmaintenance personnel on the job also requires emphasis on workplace ergonomics. Forexample, maintenance personnel may be asked to lift heavy objects, work in awkwardpositions, or perform tasks in extreme weather conditions. These difficult workconditions all require knowledge of ergonomics to ensure safe, error-free performance.Though CRM and MRM share the basic concepts of error prevention, the content of whatis taught is specific to what is actually performed on the job. | ||
Revision as of 17:59, 14 October 2019
A human error (hereinafter, the Error) is any unintentional act of a human being working on a system that can potentially degrade this system. The Error is one of the many contributing causes of risk events and a significant cause of disasters and accidents in industries such as nuclear power, aviation, space exploration, and medicine.
Prevention of the Errors and/or their impact is a major contributor to reliability and safety of complex systems. Studies of human factors that allow for reduction of the Errors are the focus of several disciplines such as maintenance resource management.
Categories
Similarly to human performance, the Errors can be categorized in many ways.
Action Errors
- While making the Error, a human being is performing either:
- An incorrect task, which is commonly categorized as a mistake; OR
- A correct task incorrectly, which is commonly categorized as a slip.
Failure-timing Errors
- J.T. Reason developed the classification of unsafe acts that distinguishes between two types of errors:
- Active failures, whose effects are felt immediately in a system.
- Latent failures, whose effects may lie dormant until triggered later, usually by other mitigating factors.
(2)The presence of defenses or safeguards in a system can usually prevent theeffects of latent failures from being felt by closing the window of opportunity duringwhich an active failure may be committed. For example, consider the case of amechanic who assembled a component incorrectly which eventually led to a plane crashdays or even weeks later. The defenses that should have normally caught this mistakewere not in place. These defenses include proper training (the mechanic was taught to fixthis particular component very informally and on-the-job), good situational awareness(the mechanic was tired from a double shift the night before), and independent inspection(the job was “pencil-whipped” to save time.)(3)Active failures are usually the result of actions taken (or not taken) by front-line operators such as pilots, air traffic controllers, or anyone else with direct access tothe dynamics of a system. Latent failures, on the other hand, are caused by thoseseparated by time and space from the consequences of their actions in the dynamics ofthe system. Personnel working in vocations such as architectural design, hardwaredesign and equipment maintenance are more prone to cause latent failures than activefailures. AC 120-729/28/00Par 8Page 8(4)Both active and latent failures may interact to create a window for accidentsto occur. Latent failures set the stage for the accident while active failures tend to be thecatalyst for the accident to finally occur. A good way to think of this model of accidentcreation is as slices of Swiss cheese. Each slice can be thought of as a defense to anaccident (training, good management, teamwork, etc.) and each hole is a failure in thatdefense. The last slice is the final action which could serve as a defense before theaccident event. The failure in that defense would constitute the active failureprecipitating the accident. If the defenses to a situation contain a sufficient number offailures, which allow the holes to “line up,” an accident will occur.(5)Differences between active and latent failures cannot be over emphasized;each type of error helps to shape the type of training required to correct them. Forexample, because of the immediate demands and consequences of their actions, flightpersonnel require training that includes the psychomotor aspects of physical skills such asimproving reaction time in emergency training. The strict physical requirements foremployment as a flight officer demonstrate this emphasis clearly. On the other hand,maintenance personnel may require human factors and operations training to account fortheir susceptibility to latent failures. In addition, the range of physical activities ofmaintenance personnel on the job also requires emphasis on workplace ergonomics. Forexample, maintenance personnel may be asked to lift heavy objects, work in awkwardpositions, or perform tasks in extreme weather conditions. These difficult workconditions all require knowledge of ergonomics to ensure safe, error-free performance.Though CRM and MRM share the basic concepts of error prevention, the content of whatis taught is specific to what is actually performed on the job.
