Civil Engineering Reference
In-Depth Information
design. For example, design the controls of a fighter aircraft so that the aircraft is easier
to use, and pilot will not have to train so much.
TABLE 18.3
Implications of Reason's Error
Model for Training and Redesign
Knowledge-based mistakes Train the operator
Rule-based mistakes
Training and redesign
Slips
Redesign the task/environment
Lapses and mode errors
Redesign the task
ERRORS IN AN ORGANIZATIONAL CONTEXT
Human errors in organization may be blamed on organizational deficiencies (Reason,
1997). Accidents, because they are so visible, are often analyzed, but less visible
organization errors are not analyzed. Accidents represent the tip of the iceberg.
Underneath the surface there are many organizational deficiencies that limit productivity
as well as quality. Such deficiencies may be due to poor communication policies and
poor operating procedures. The same organizational characteristics that cause unsafe acts
and accidents will also decrease productivity and quality. We may note the analogy with
poor usability of software, which goes hand in hand with poor quality and poor software
definition (see Chapter 7).
Table 18.4 shows the results of analysis of errors committed by operators of mining
equipment (Conway et al., 1981). In addition to slips and mistakes, there was also
violation of company procedures. The implications of these are noted in terms of redesign
of the operator's compartment, training, organizational changes, and management
enforcement. Note that depending on the error type there are different implications for
design, training, and disciplinary measures.
Human errors are commonplace. Many of the errors that people commit in operating
equipment systems are the results of poor design and poor organizational structure, rather
than irresponsible action (Reason 1997; Woods and Cook, 1999). Although human errors
are statistically identified as a contributing cause to most accidents, we must consider that
the human errors are accompanied by organizational errors. Before the human error
occurred there were several mechanical and organizational errors. But the organizational
errors are more difficult to identify. They are abstract and not so visible. They affect the
system and weaken its defenses (Perrow, 1984). The notion that the operator should be
punished or personally made responsible is unwarranted, unless of course there is a clear
violation of regulations. The
TABLE 18.4
Analysis of Errors Committed by
the Operators of Mining Equipment
Potential Error
Error Type
Action
Hauler not returned for service according to schedule
Violation
Management
Setting off with parking brake on
Slip
Design
Operator driving machine while sitting on rear bumper
Violation
Design/Training
Misreading of displays
Slip
Design
