Errors culture

Airservices Austraha technicians also undeigo training in HF and the management of human error. This HF training is similar to that outlined in the ICAO Human Factors Training Manual (199S) and incorporates HF fundamentals such as conceptual models of error, cultural and oiganizational factors, human performance, communication, teamwork and environmental issues. 

Chapter in Book) Review Human Error Culture... 

Organizational factors create preconditions for errors, At the operational level, plant and corporate management inadvertently support conditions for errors. The safety culture of the... 

Error-Inducing Conditions 1.7.1.3. Design and Culture Factors... 

The last area addressed by the systems approach is concerned with global issues involving the influence of organizational factors on human error. The major issues in this area are discussed in Chapter 2, Section 7. The two major perspectives that need to be considered as part of an error reduction program are the creation of an appropriate safety culture and the inclusion of human error reduction within safety management policies. 

As discussed earlier in this chapter, the main requirements to ensure an appropriate safety culture are similar to those which are advocated in quality management systems. These include active participation by the workforce in error and safety management initiatives, a blame-free culture which fosters the free flow of information, and an explicit policy which ensures that safety considerations will always be primary. In addition both operations and management staff need feedback which indicates that participation in error reduction programs has a real impact on the way in which the plant is operated and systems are designed. 

Sociotechnical approach (control of error through changes in management policy and culture) Occupational/process safety Effects of organizational factors on safety Policy aspects Culture Interviews Surveys Organizational redesign Total Quality Management More frequent in recent years... 

Many organizations that have evolved over a long period of time come to believe that the system of safety rules that they have developed is invulnerable to human error. The existence of a "rule book" culture can produce a complacent attitude which assumes that if the rules are followed then accidents are impossible. This is based on the belief that a rigid set of rules will cover every contingency and that interpretation by individuals to cover imanticipated situations will never be required. Of course, all rules will at some time require such interpretation, and the need for this should be accepted and built into the system. 

The model of human error held by management and the plant culture constitutes the environment in which the data collection system operates. Within this environment, all data collection systems need to address the topics listed in Figure 6.1. These topics, from the types of data collected, to the feedback systems that need to be in place, will be addressed in subsequent sections of this chapter. 

The first area focuses on the cultural and organizational factors that will have a major influence on the effectiveness of a human error data collection system and how well the information derived from such a system is translated into successful error reduction strategies. Regardless of how effectively the technical issues are dealt with, the system will not be successful imless there is a culture in the organization which provides support for the data gathering process. No data collection system aimed at identifying human error causes of accidents will be workable without the active cooperation of the workforce. 

The type of data collected on human error and the ways in which these data are used for accident prevention will vary depending upon the model of error and accident causation held by the management of an organization. This model will also influence the culture in the plant and the willingness of personnel to participate in data collection activities. In Chapters 1 and 2 a number of alternative viewpoints or models of human error were described. These models will now be briefly reviewed and their implications for the treatment of human error in the process industry will be discussed. 

The two categories of data described above relate to immediate causes of error. However, the question of how these factors came to be as they are, involves a consideration of the effects of organizational, and management and cultural issues. 

Workforce Support for Data Collection and Incident Analysis Systems Few of the incident investigation and data collection systems reviewed provide any guidelines with regard to how these systems are to be introduced into an organization. Section 6.10 addresses this issue primarily from the perspective of incident reporting systems. However, gaining the support and ownership of the workforce is equally important for root cause analysis systems. Unless the culture and climate in a plant is such that personnel can be frank about the errors that may have contributed to an incident, and the factors which influenced these errors, then it is unlikely that the investigation will be very effective. 

Management must modify the culture and develop human factors awareness in the hazard identification teams so that they will be capable of identifying the potential for human error. A good practice is to involve operators in the hazard identification team. 

Development of programs to create an appropriate culture to support the error management system... 

Development of a Plant Culture to Support the Error Management Program... 

The general approach that has been advocated in this chapter is that it is the responsibility of an organization, through its safety management policies, to create the systems, environment, and culture that will minimize human error and thereby maximize safety. 

Figure 6. Effect of maitotoxin (MTX, 3 x 10 g/mL) on the beating rate of cultured rat myocardial cells in the absence ( ) or presence (o) of verapamil (10 M). Verapamil was administered 5 min before the application of MTX, Vertical lines indicate the standard error of mean (n=5). (Reproduced with permission from Ref. 20. Copyright 1987 Elsevier)...

Whole cell OPH activity was measured by following the increase in absorbancy of p-nitrophenol from the hydrolysis of substrate (0.1 mM Paraoxon) at 400 nm (sm = 17,000 M cm ). Samples of culture (1 ml) were centrifuged at 10,000 g and 4 C for 5 min. The cells were washed, resuspended with distilled water, and 100 pi was added to an assay mixture containing 400 pi 250 mM CHES [2-(N-cyclohexylamino)ethane-sulfonic acid] buffer, pH 9.0, 100 pi 1 mM Paraoxon, and 400 pi distilled water. One unit of OPH activity was defined as pmoles Paraoxon hydrolyzed per min. Each value and error bar represents the mean of two independent experiments and its standard deviation. 

---