Human error organizational levels

From the organizational view of accident causation presented in the previous section, it will be apparent that the traditional approach to human error, which assumes that errors are primarily the result of inadequate knowledge or motivation, is inadequate to represent the various levels of causation involved. These contrasting views of error and accident causation have major implications for the way in which human error is assessed and the preventative measures that are adopted. 

This section illustrates some of the more global influences at the organizational level which create the preconditions for error. Inadequate policies in areas such as the design of the human-machine interface, procedures, training, and the organization of work will also have contributed implicitly to many of the other human errors considered in this chapter. 

Several references were made in Chapter 3, Serious Injury Prevention, to human errors as the causal factors for accidents. And it was said that many serious injuries result from recurring but potentially avoidable human errors, and that organizational, cultural, technical, and management systems deficiencies often lead to those errors. Emphasizing human error reduction above the worker level, although proposed many years ago as a preventive measure, is not prominent in the work of safety professionals. 

Another of James Reason s books—Managing the Risks of Organizational Accidents—is a must read for safety professionals who want an education in human error reduction. It was published in 1997 and has been reprinted five times. Reason writes about how the effects of decisions accumulate over time and become the causal factors for incidents resulting in serious injuries or damage when all the circumstances necessary for the occurrence of a major event come together. This book was referenced in Chapter 3, Serious Injury Prevention, because it stresses the need to focus on decision making above the worker level to prevent major accidents. Reason writes this ... 

Over and over, writers and researchers have reiterated that errors are made at an organizational, managerial and design levels, that they form a distinctive corporate culture and create error-producing factors within the occupational setting. Minimizing the probability of such human errors occurring is the new frontier for safety professionals. 

To avoid hazard-related incidents resulting in serious injuries, human error potentials must be addressed at the cultural, organizational, management systems, design, and engineering levels, and with respect to the work methods prescribed. 

Discussions in the Professional Safety article (Manuele, 2011) addressed issues such as moving the preventive efforts from a focus on the employee to improving the work system the design of the work system and the work methods the complexity of causation and human errors occurring at organizational levels above the worker. 

Safety professionals should view the following highlights as generic and broadly applicable. They advise on where human errors occur, who commits them and at what level, the effect of organizational culture, and where attention is needed to reduce the occurrence of human errors. These highlights, taken from the Guidelines, apply to organizations of all types and sizes. 

Human factors errors within aviation maintenance industry can be more effectively managed by applying proactive monitoring and early error detecting techniques at both organizational and individual levels ... 

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