Dealing with Human Error


Dealing with Human Error


So what should we do with knowledge of individual actions which appear to have contributed to an accident? Clearly, we cannot ignore the information, but we do need a better process if we want to get to the root causes and prevent similar events in the future.

Some of the key points to consider in future investigations include:

  • Complexity is the enemy of safety - simplify any instructions or signage which is unduly long or confusing.
  • We all know what is extremely unsafe or very safe - minimise “grey” areas. Ensure clear guidance for marginal circumstances eg Go & No Go criteria.
  • Demands for quick incident investigations (as opposed to prompt incident reporting which is OK) may prevent gaining a deeper understanding – resist pressure to conclude investigations prematurely, but OK to provide interim reports.
  • Look for weaknesses in the system – strengthen the system, not punishment, to minimise future errors.
  • Reserve “punishment” for those who deliberately and repeatedly break our rules, or are grossly negligent.
  • Procedures can’t describe all circumstances and prescribe every action, so we do need good intent - implement a process of controlled authority to allow the exercise of judgement by trained and authorised personnel e.g. “Our policy is to do the right thing”. 
Note: Article adapted by Gary Rowe from the principles contained in the book Behind Human Error by Sidney Dekker et al (2010).

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