‘Learning Objectives of Error and Risk’ Give a critical account of generic models of error Understand the conceptual difficulties involved in the use of the term error To begin to be able to plan error prevention/minimisation strategies in organisations Give a critical account of two models of risk taking behaviour Evaluate the utility of models of risk taking behaviour in the workplace.
Reading
Error Conceptual Issues Generic models Prevention
Conceptual Issues What is an error? Can you make an error while you are asleep? Can you make an error by doing nothing? If there are no negative outcomes from an ‘error’, has there been an error?
Conceptual Issues (cont.) Does an error involve intent? What do you do to people who make errors? How do organisational factors impinge on error? Can one persons error be another's intended action?
To What Extent is ‘blame’ useful Is it fair? Who might apportion blame? Operators normally get blamed - this is cheap. Allocation of individual responsibility removes moral responsibility from management
Blame (cont.) Does blame have a certain utility? The term ‘error’ precipitates a mantle of causality around around those proximate to an event
Emerging Themes Errors are rarely issues of personal responsibility. Errors are completely dependent on context. Errors are normally distributed system failures not the result of one persons actions Errors are multi-causal.
Models of Error Many variants Slips vs. Mistakes Omission vs. Commission Skill, Rule and Knowledge based errors Generic Error Modelling Systems
Some Problems with these models Generic models, by their nature play down the importance of context The distinction between slips and mistakes - e.g... valve operation The role of intention The difficulty in distinguishing between skills rules and knowledge
Problems (cont.) Tend to be non falsifiable Tend to be post hoc and descriptive, not prospective (this would allow effective planning) The baby disappears with the bath water.
Error Prevention Not possible So we try to –Reduce the probability of error –Design systems that degrade gracefully, rather than fail catastrophically –Allow error recovery
What can be done to mitigate ‘error’ (general) View errors as distributed failures of systems Appreciate the complex causality of ‘error’ Operate a blame free culture - errors are very useful ways of learning about organisations and system performance
Mitigation (gen.) cont... Be flexible and responsive Plan Distinguish between prevention e.g... by design, and recovery Recognise operators are part of system not separate from it.
What can be done to mitigate ‘error’ (particular) Train and inform designers, trainers, procedure writers, managers as well as operators - ensure very one has domain specific knowledge and is not far removed. Train operators in dealing with unusual or unexpected systems configurations, not just in routine operations. Ensure procedures are congruent with system characteristics
Mitigation (particular - cont.) Ensure management style is consistent and has no hidden agendas (q. is this possible) Pay attention to communication between different professional groups Pay attention to communications both within and between operations
Continued Learn from past mistakes in general terms Institute operational feedback systems –e.g... CHIRPS –e.g... Operational feedback officers Train ( properly) Attend to organisational safety culture Have management commitment to safety
Automation - a particular issue Creeping de-skilling Opaque systems Complex and unpredictable systems states Additional reading on this topic ‘Ironies of Automation’ by Lisanne Bainbridge, in ‘New Technology and Human Error’ eds, Rasmussen, Duncan and Leplat’ LEA, Also Chapter by Brehmer.