Error management competencies

The interview data provided a range of insights into the processes of error management employed by expert pilots. The scope of this chapter allows only for abrief discussion of the major categories of error management competencies identified by the expert pilots in the interview data A more detailed exploration of each of these categories is provided in the full report (Thomas and Petrilli, 2004). 

The approaches described in this chapter can be regarded as complementary rather than competing methodologies. They all have a part to play in an integrated approach to the management of human error to reduce accidents in the CPI. Having said this, we will place rather more emphasis on approaches other than the traditional safety approach in this book. 

Safety and risk management research in healthcare has adopted as its dominant trend the systems oriented approach, modelled largely on previous research in safely critical industries such as aviation and nuclear power. The systems view entails that the focus is not primarily on the mechanisms of individual human error but on the factors that shape human performance (Rasmussen 1986 Reason 1993,1997). In an organisational context, such factors are, of course, those that are within the control of the organisation. For instance, it has been suggested that quahty and safety are affected not only by operators professional and technical competence and skills, but also by their attitudes to and perceptions of their job roles, their organisation and management (Helmreich and Merritt 1998). Such employee attitudes and views are important elements which shape safety cirlture - and its related notion safety climate . Indeed, survey studies have shown that staff attitudes are important indices of safety performance not only in human-machine system domains such as railway operations and constmction (e.g. Itoh and Andersen 1999 Itoh et al. 2004 Silva et al. 2004) but also in healthcare (e.g. Colla et al. 2005 Itoh and Andersen 2010). 

The management of process plant engineering resource costs and schedule durations is frequently problematical and occasionally disastrous. Often the problems stem from a technical error, or series of errors, which are discovered too late and require remedial action. Equally often, however, the problems stem from management failure, that is, from failure to plan the work and control its execution according to the plan. The plan may be unachievable because the project team is not sufficiently competent to meet the challenge, or because irresistible (or insufficiently resisted) external factors dictated an over-optimistic commitment. 

The second new topic is that of competence. Given that most accidents occur because of human error, or safety failures in systems of work, the management of competence is of fundamental importance. 

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