Human error inevitability

Management policies are the source of many of the preconditions that give rise to systems failures. For example, if no explicit policy exists or if resources are not made available for safety critical areas such as procedures design, the effective presentation of process information, or for ensuring that effective communication systems exist, then human error leading to an accident is, at some stage, inevitable. Such policy failures can be regarded as another form of latent human error, and will be discussed in more detail in Section 2.7. 

Human error analysis This method is used to identify the parts and the procedures of a process that have a higher than normal probability of human error. Control panel layout is an excellent application for human error analysis because a control panel can be designed in such a fashion that human error is inevitable. 

Error Reduction Without automation, data needs to be entered and reentered at several stages in the process. This inevitably introduces clerical error. With electronic data exchange, the data is only entered once and reused in all subsequent steps. Thus, human error in data entry can be significantly reduced. 

Identification is a major problem in clinical laboratories, and serious untoward events can occur with misidentified specimens. Unambiguous identification is possible today with bar-coding and similar machine-labeling techniques (31). The model discussed here is for testing patient-derived materials in a clinical laboratory the model can, of course, be extended to other applications. A machine-readable label on every specimen is the contemporary standard of modern equipment. Keying in identifiers to an instrument is less desirable owing to the inevitable human errors. In our experience with bar-code readers, they read the label correctly or don t work at all. The topic, automated specimen identifications, is described in more detail in Section 8.2 here (32). 

Human behavior is always influenced by the environment in which it takes place. Changing that environment will be much more effective in changing operator error than the usual behaviorist approach of using reward and punishment. Without changing the environment, human error cannot be reduced for long. We design systems in which operator error is inevitable, and then blame the operator and not the system design. 

The design principles in section 9.3 apply when the controller is automated or human, particularly when designing procedures for human controllers to follow. But humans do not always follow procedures, nor should they. We use humans to control systems because of their flexibility and adaptability to changing conditions and to the incorrect assumptions made by the designers. Human error is an inevitable and unavoidable consequence. But appropriate design can assist in redudng human error and increasing safety in human-controlled systems. 

No amount of behavior observation will create an error-free, injury-free workplace. The Chemical Manufacturers Association explains in a CMA publication that enlightened managers realize that... most mistakes are committed by skilled, careful, productive, well-meaning employees. Human error is a natural and inevitable result of human variability in our interactions with a system. (Lorenzo, pp. 4-5)... 

There is no doubt that this approach to error management resulted in significant enhancements to safety. However, this approach failed to emphasize the inevitability of error and its spontaneous occurrence even within the best-designed systems. The next step was developing an approach that accepted both the ubiquity and inevitability of human error and therefore focnssed not only on error reduction, but also on the subsequent management of error to either mitigate or ameliorate any effects of error on system performance. 

The investigators work with clients to design and implement customized solutions based on their company strategies, structure and culture to enhance performance and optimize costs. A fundamental concept of ICAM is the acceptance of the inevitability of human error. As stated by Reason (2000), an organization carmot change the human condition, but they can change the conditions imder which humans work, thereby making the system more error tolerant. 

Most of the time, the humans in the system act as a key defence against incidents and accidents due to their abihty to make complex decisions and maintain flexibility in a changing situation. This is in contrast to comparatively rigid technical systems that lack the extent of real time flexibflity available to humans. However, sometimes people make mistakes. Human error is inevitable. The discipline of human factors is aimed at understanding human behaviour and how we can optimize the performance of humans in the system to maximize safe operations. 

Popular assumptions about human error are that it is inevitable and there is little we can do and that people are careless, have a bad attitude, and do not pay attention. Many feel that the only solution is intensive training or some sort of negative reward (e.g., losing your job). The truth is that most people need to go through a trial-and-error period to learn. As our systems become more and more complex, an individual understands them less and less, and therefore, mistakes are likely to increase. So, to decrease the amount or significance of human errors that can lead to a hazard, you need to make the safe operation of your systems less dependent on how well people can operate them. 

The systems approach seeks to identify situations or factors likely to contribute to human error. James Reason s analysis of industrial accidents revealed that catastrophic safety failures almost never result from isolated errors conunitted by individuals. Most incidents result from smaller and multiple errors in components and environments with underlying system flaws. Reason s Swiss Cheese Model describes this phenomenon. Errors made by individuals can result in disastrous consequences due to flawed systans that are represented by the holes in the cheese. Reason believed human error would happen in complex systems. Striving for perfection or punishing individuals who make errors does not appreciably improve safety. A systems approach stresses efforts to catch or anticipate human errors before they occur. Reason used the terms active errors and latent errors to distinguish individual errors from system errors. Active errors almost always involve frontline personnel. They occur at the point of contact between a human and some element of a larger system. Latent errors occur due to failures of the organization or designs that allow inevitable active errors to cause harm. The terms sharp end and blunt end correspond to active error and latent error. The systems approach provides a framework for analysis of errors and efforts to improve safety. 

Human error is an inevitable part of any operation. The influence of human performance becomes crucial in cases where operators directly guide the skimmers through the oil slick. Human performance itself is adversely affected by the severe climatic conditions in the Arctic region. Low ambient temperature, combined with winds can decrease the felt temperature by operators (i.e. wind chill effect) (Bluestein Quayle 2003, Osczevski Bluestein 2005). Extremely cold weather may cause some health issues for the operators and thus deteriorate their performance. 

The tasks of hazard identification and risk assessment are closely linked— both require the assessors to visualize the operation (Cooper and Chapman 1985). In a complex situation, particularly one that does not yet exist in reality, it may be difficult to visualize all the factors that affect the risk, which leads to a greater likelihood of human error. Therefore, staff must be trained in how to perform a risk assessment. The skills needed wiU often be fuUy developed only after some considerable period of working in the real environment. Training is obvionsly extremely important, bnt the conventional classroom-based training is often ineffective (Bransford et al. 1986) and training in the real environment will inevitably expose inexperienced personnel to the very risks that companies are aiming to minimize. 

Human error is and always will be inevitable. However, to accept that its consequences are always an inevitability would be both foolish and dangerous. 

The Safe System approach is a fundamental shift from traditional traffic safety thinking. It reframes the ways in which traffic safety is viewed and managed. Its aim is to support development of a transport system better able to accommodate inevitable human error. The recognition that humans do make, and will continue to make, errors of judgement as road users is one of the core shifts in thinking. 

Adapting our road transport system to respond to inevitable human error can best be achieved through better management of crash energy, so that when an error that leads to a crash occurs, no individual road user is exposed to a level of crash forces that exceeds the capacity of the human body to withstand. 

Methodological studies inevitably lead to some revision and even rejection of past work. Archaeologists who were too readily persuaded to accept scientific results as absolute facts may be a little dismayed to find that some of these facts are now being questioned. They must remember that no discipline has a corner on infallability and that knowledge, in the sciences as well as in the humanities, advances slowly by a kind of iterative process in which error is gradually reduced to reach an approximation of truth. Uninhibited self-criticism is the surest indication that archaeometry is coming of age. 

Research is by its nature exploratory, and honest mistakes may occur. Errors due to human fallibility are unfortunate, but not unethical. Research inevitably... 

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