Human Error
Presented by
Capt. Prita Widjaja
Overview
“To err is human .....”
……. but can be minimized
HOW
Understand
the Process of the Process Accident/Incident
Human Performance of Human Error
Objective
• At the end of this presentation, participants
will have awareness of:
– issue of error as a failure in human
performance,
– the concepts of human error,
– how errors can happen, and
– how to manage the errors.
Introduction
What is important to know about
human error?
Human error is a natural part of life.
Human error, although not expected, in fact, is
common and widespread.
Errors are not the results of a type of aberrant
behavior but a natural by-product of virtually all
human endeavors.
con’t
If an operator can perform a task with ease, they
never will be wrong in doing the job, but operators
may at a certain time make an error as a
consequence of variation in task, environment, and
individual factors.
All to often, these errors are committed by normal,
healthy, qualified, experienced, and well-equipped
personnel.
Human error is not random. This is systematically
related to aspects of the service equipment, tasks,
and operating environment.
Human Error in Aviation Accidents
Environment Factor 6%
Human Factors 60%
Technical Factors 34%
In 2007 - 2013 there were 169 national aviation accidents (civil/ commercial)
or ± 24 times accidents per year.
(www.dephub.go.id/knkt/ntsc-aviation/ aaic.htm).
Definition of Human Error
Human error can be defined as the failure of the activities
/ actions planned to achieve the expected goals.
(Reason, 1990)
Error and “Human Performance”
Human Error Taxonomies
Error of omission (not doing the required thing)
• Forgetting to do it
• Ignoring to do it deliberately
Error of commission (doing the wrong thing)
• Slips in which the operator has the correct motivation or
intention, but carries out the wrong execution (sequence or
wrong order of execution ; timing/to fast or low).
• Errors based in erroneous expectations and schema.
con’t
Cognitive Task Errors
• Forming an incorrect diagnosis (faulty data processing,
flawed logic, improperly interpreted information.
• Making an decision unsupported by available information
( “leaping to conclusion”; reliance on flawed intuitive skills).
Error Models and Theories
• Design vs operator-induced errors
• Variable vs constant errors Var vs Cons.ppt
• Reversible vs irreversible errors
• Slips, lapses, and mistakes
• Skill-, rule-, knowledge-based behaviors and
associated errors
• The ‘Swiss Cheese Model’ Swiss Cheese Model.ppt
Generic Error-Modeling System
Reason, 1990
Basic error SKILL – BASED
types
ATTENTIONAL Inattention
Slip FAILURES
Over attention
Unintended
Action
MEMORY
Lapse FAILURES
Unsafe
action RULE Misapplication
of good rule
Mistake KNOWLEDGE-
BASED Application
Intended MISTAKES of bad rule
Action
KB/RB
Violation ROUTINE
EXCEPTIONAL
The Classification of Unsafe Acts
• Error
Failure of planned action in achieving
the expected goals
• Violation
Deliberately, intended, intention deviation
from procedure, standards, or operational
rules safe.
Error Type
Slip or Lapse : Acts or omissions of memory in familiar
situations (Unintended; based on ability-attentional or
memory failures)
SLIP LAPSE
Attention failure Memory failure
Intrusion Omitting planned items
Omission Place losing
Reversal Forgetting intension
Mis-ordering
Mis-timing
con’t
Error Type
Mistake: Insufficient planning for achieve the
desired results (Intended; based on rules or
knowledge)
RULED BASED MISTAKE KNOWLEDGE BASED MISTAKE
Misapplication of Generally happens in novice
good rule that just learning or limited
knowledge, and many
Application of
variable form
bad rule
Error Distinctions
Review
The Basic Error Type and Performance Level
Error Management Strategies
• Error Prevention aims at avoiding the error all-together.
This is possible only in some specific cases and, almost
without exception, requires design-based solutions.
• Error Reduction aims at minimizing both the likelihood
and the magnitude of the error.
Shaping Factors v2.pptx
Error Management Strategies
Error Detection aims at making errors apparent as fast and
as clearly as possible, and therefore enabling recovery.
An error can be:
Detected by the person that committed the error
(self-monitoring), or Cued by the environment, or
Detected by another person.
Error Management Strategies
• Error Recovery aims at making it easy to rapidly recover the
system to its safe state after an error has been committed.
• Error Tolerance aims at making the system as tolerant as
possible towards error, i.e. minimizing the consequences of
errors.
Summary
• error is a failure in human performance (the error taxonomies
are omission or commission),
• there are several theories and models to understand human
error,
• errors can be happen when individual have failure in attention,
memory and/or rule-knowledge mistake and violation,
• to manage errors, there are some strategic to implement error
prevention, reduction, detection, recovery, and tolerance.
