Error management study

The book begins with a discussion of the theories of error causation and then goes on to describe the various ways in which data can be collected, analyzed, and used to reduce the potential for error. Case studies are used to teach the methodology of error reduction in specific industry operations. Finally, the book concludes with a plan for a plant error reduction program and a discussion of how human factors principles impact on the process safety management system. 

In the second case study, variation tree analysis and the events and causal factors chart/root cause analysis method are applied to an incident in a resin plant. This case study illustrates the application of retrospective analysis methods to identify the imderlying causes of an incident and to prescribe remedial actions. This approach is one of the recommended strategies in the overall error management framework described in Chapter 8. 

Van Dyck, C., Frese, M., Baer, M. and Sormentag, S. 2005. Organizational error management culture and its impact on performance A two-study replication. Journal of Applied Psychology, 90(6), 1228-40. 

The study adopted an interview-based approach to the investigation of the core components of effective error management, and error management training within the commercial aviation environment. As an explicit objective of the study was to collect data with respect to the tacit knowledge of domain experts, the study was designed within an interpretive framework. 

The Critical Decision Method, as adapted for this study, involves an interview of approximately one-hour duration for each participant. The interview proper was broken into three major sections, with the Critical Decision Method being used three times to ejqrlore different aspects of the management of error in normal operations as well as training. The three sections of the interview were broadly 1) the management of shps and lapses 2) the management of mistakes and 3) error management from an instructional perspective. 

As the objective of the study was to explore and document the error management strategies used by expert pilots, in order to inform the syllabus and ciuriculum structure of an error management training package, the analysis of interview data was undertaken with explicit reference to the interpretive research design. Accordingly, the study did not seek to test pre-defined hypotheses or adopt any detailed quantitative analysis of data. 

This study has provided a detailed account of error management, through the analysis of experts imderstanding of error avoidance, detechon and resolution. From the results of this study, it is evident that elements of error management share much in conunon with our current understanding of Crew Resource Management (CRM). 

The findings of this study reinforce a model of error management that emphasizes the process of mismatch emergence as the driver of error detection, problem identification and error resolution (see Figitre 15.1). 

This model of error management, as first proposed by Rizzo, Ferrante and Bagnara (1995) and subsequently expended in this study, has several unique features that suggest it offers considerable explanatory power in relation to the detection of safety breaches in dynamic real-world contexts. 

In addition to these formal studies of human error in the CPI, almost all the major accident investigations in recent years, for example, Texas City, Piper Alpha, Phillips 66, Feyzin, Mexico City, have shown human error as a significant causal factors in design, operations, maintenance or the management of the process. Figures 4.4-1 and 4.4-2 show the effects of human error on nuclear plant operation. 

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