Human error is an action that has been done but that was "not intended by the actor; not desired by a set of rules or an external observer; or that led the task or system outside its acceptable limits".[1] Human error has been cited as a primary cause contributing factor in disasters and accidents in industries as diverse as nuclear power (e.g., the Three Mile Island accident), aviation, space exploration (e.g., the Space Shuttle Challenger disaster and Space Shuttle Columbia disaster), and medicine. Prevention of human error is generally seen as a major contributor to reliability and safety of (complex) systems. Human error is one of the many contributing causes of risk events.
Human error refers to something having been done that was "not intended by the actor; not desired by a set of rules or an external observer; or that led the task or system outside its acceptable limits".[1] In short, it is a deviation from intention, expectation or desirability.[1] Logically, human actions can fail to achieve their goal in two different ways: the actions can go as planned, but the plan can be inadequate (leading to mistakes); or, the plan can be satisfactory, but the performance can be deficient (leading to slips and lapses).[2][3] However, a mere failure is not an error if there had been no plan to accomplish something in particular.[1]
Performanceedit
Human error and performance are two sides of the same coin: "human error" mechanisms are the same as "human performance" mechanisms; performance later categorized as 'error' is done so in hindsight:[3][4] therefore actions later termed "human error" are actually part of the ordinary spectrum of human behaviour. The study of absent-mindedness in everyday life provides ample documentation and categorization of such aspects of behavior. While human error is firmly entrenched in the classical approaches to accident investigation and risk assessment, it has no role in newer approaches such as resilience engineering.[5]
Categoriesedit
There are many ways to categorize human error:[6][7]
exogenous versus endogenous error (i.e., originating outside versus inside the individual)[8]
situation assessment versus response planning[9] and related distinctions in
'slips' occurring when the physical action fails to achieve the immediate objective
'lapses' involve a failure of one's memory or recall
active error - observable, physical action that changes equipment, system, or facility state, resulting in immediate undesired consequences
latent human error resulting in hidden organization-related weaknesses or equipment flaws that lie dormant; such errors can go unnoticed at the time they occur, having no immediate apparent outcome
equipment dependency error – lack of vigilance due to the assumption that hardware controls or physical safety devices will always work
team error – lack of vigilance created by the social (interpersonal) interaction between two or more people working together
personal dependencies error – unsafe attitudes and traps of human nature leading to complacency and overconfidence
Sourcesedit
The cognitive study of human error is a very active research field, including work related to limits of memory and attention and also to decision making strategies such as the availability heuristic and other cognitive biases. Such heuristics and biases are strategies that are useful and often correct, but can lead to systematic patterns of error.
Misunderstandings as a topic in human communication have been studied in conversation analysis, such as the examination of violations of the cooperative principle and Gricean maxims.
Organizational studies of error or dysfunction have included studies of safety culture. One technique for analyzing complex systems failure that incorporates organizational analysis is management oversight risk tree analysis.[13][14][15]
Controversiesedit
Some researchers have argued that the dichotomy of human actions as "correct" or "incorrect" is a harmful oversimplification of a complex phenomenon.[16][17] A focus on the variability of human performance and how human operators (and organizations) can manage that variability may be a more fruitful approach. Newer approaches, such as resilience engineering mentioned above, highlight the positive roles that humans can play in complex systems. In resilience engineering, successes (things that go right) and failures (things that go wrong) are seen as having the same basis, namely human performance variability. A specific account of that is the efficiency–thoroughness trade-off principle,[18] which can be found on all levels of human activity, in individual as well as collective.
^Hollnagel, E. (1983). "Human error. (Position Paper for NATO Conference on Human Error, August 1983, Bellagio, Italy".
^Hollnagel, E. and Amalberti, R. (2001). The Emperor's New Clothes, or whatever happened to "human error"? Invited keynote presentation at 4th International Workshop on Human Error, Safety and System Development.. Linköping, June 11–12, 2001.
^Hollnagel, Erik (2009). The ETTO principle : efficiency-thoroughness trade-off : why things that go right sometimes go wrong. Farnham, England Burlington, VT: Ashgate. ISBN978-0-7546-7678-2. OCLC 432428967.
External linksedit
Autrey, T.D. (2015). . Human Performance Association. Archived from the original on 2021-04-11. Retrieved 2020-08-21.
November 12, 2023
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For other uses see Human Error disambiguation Human error is an action that has been done but that was not intended by the actor not desired by a set of rules or an external observer or that led the task or system outside its acceptable limits 1 Human error has been cited as a primary cause contributing factor in disasters and accidents in industries as diverse as nuclear power e g the Three Mile Island accident aviation space exploration e g the Space Shuttle Challenger disaster and Space Shuttle Columbia disaster and medicine Prevention of human error is generally seen as a major contributor to reliability and safety of complex systems Human error is one of the many contributing causes of risk events Contents 1 Definition 2 Performance 3 Categories 4 Sources 5 Controversies 6 See also 7 References 8 External linksDefinition editHuman error refers to something having been done that was not intended by the actor not desired by a set of rules or an external observer or that led the task or system outside its acceptable limits 1 In short it is a deviation from intention expectation or desirability 1 Logically human actions can fail to achieve their goal in two different ways the actions can go as planned but the plan can be inadequate leading to mistakes or the plan can be satisfactory but the performance can be deficient leading to slips and lapses 2 3 However a mere failure is not an error if there had been no plan to accomplish something in particular 1 Performance editHuman error and performance are two sides of the same coin human error mechanisms are the same as human performance mechanisms performance later categorized as error is done so in hindsight 3 4 therefore actions later termed human error are actually part of the ordinary spectrum of human behaviour The study of absent mindedness in everyday life provides ample documentation and categorization of such aspects of behavior While human error is firmly entrenched in the classical approaches to accident investigation and risk assessment it has no role in newer approaches such as resilience engineering 5 Categories editThere are many ways to categorize human error 6 7 exogenous versus endogenous error i e originating outside versus inside the individual 8 situation assessment versus response planning 9 and related distinctions in error in problem detection also see signal detection theory error in problem diagnosis also see problem solving error in action planning and execution 10 for example slips or errors of execution versus mistakes or errors of intention 11 3 by level of analysis for example perceptual e g optical illusions versus cognitive versus communication versus organizational physical manipulation error 12 slips occurring when the physical action fails to achieve the immediate objective lapses involve a failure of one s memory or recall active error observable physical action that changes equipment system or facility state resulting in immediate undesired consequences latent human error resulting in hidden organization related weaknesses or equipment flaws that lie dormant such errors can go unnoticed at the time they occur having no immediate apparent outcome equipment dependency error lack of vigilance due to the assumption that hardware controls or physical safety devices will always work team error lack of vigilance created by the social interpersonal interaction between two or more people working together personal dependencies error unsafe attitudes and traps of human nature leading to complacency and overconfidenceSources editThe cognitive study of human error is a very active research field including work related to limits of memory and attention and also to decision making strategies such as the availability heuristic and other cognitive biases Such heuristics and biases are strategies that are useful and often correct but can lead to systematic patterns of error Misunderstandings as a topic in human communication have been studied in conversation analysis such as the examination of violations of the cooperative principle and Gricean maxims Organizational studies of error or dysfunction have included studies of safety culture One technique for analyzing complex systems failure that incorporates organizational analysis is management oversight risk tree analysis 13 14 15 Controversies editSome researchers have argued that the dichotomy of human actions as correct or incorrect is a harmful oversimplification of a complex phenomenon 16 17 A focus on the variability of human performance and how human operators and organizations can manage that variability may be a more fruitful approach Newer approaches such as resilience engineering mentioned above highlight the positive roles that humans can play in complex systems In resilience engineering successes things that go right and failures things that go wrong are seen as having the same basis namely human performance variability A specific account of that is the efficiency thoroughness trade off principle 18 which can be found on all levels of human activity in individual as well as collective See also editBehavior shaping constraint Error tolerant design Human reliability Poka yoke SHELL model User error Technique for human error rate prediction Fallacy To err is humanReferences edit a b c d Senders J W and Moray N P 1991 Human Error Cause Prediction and Reduction Lawrence Erlbaum Associates p 25 ISBN 0 89859 598 3 Hollnagel E 1993 Human Reliability Analysis Context and Control Academic Press Limited ISBN 0 12 352658 2 a b c Reason James 1990 Human Error Cambridge University Press ISBN 0 521 31419 4 Woods 1990 Hollnagel E Woods D D amp Leveson N G 2006 Resilience engineering Concepts and precepts Aldershot UK Ashgate Jones 1999 Wallace and Ross 2006 Senders and Moray 1991 Roth et al 1994 Sage 1992 Norman 1988 DOE HDBK 1028 2009 https www standards doe gov standards documents 1000 1028 BHdbk 2009 v1 images file Rasmussen Jens Pejtersen Annelise M Goodstein L P 1994 Cognitive Systems Engineering John Wiley amp Sons ISBN 0471011983 The Management Oversight and Risk Tree MORT International Crisis Management Association Archived from the original on 27 September 2014 Retrieved 1 October 2014 Entry for MORT on the FAA Human Factors Workbench Hollnagel E 1983 Human error Position Paper for NATO Conference on Human Error August 1983 Bellagio Italy Hollnagel E and Amalberti R 2001 The Emperor s New Clothes or whatever happened to human error Invited keynote presentation at 4th International Workshop on Human Error Safety and System Development Linkoping June 11 12 2001 Hollnagel Erik 2009 The ETTO principle efficiency thoroughness trade off why things that go right sometimes go wrong Farnham England Burlington VT Ashgate ISBN 978 0 7546 7678 2 OCLC 432428967 External links editAutrey T D 2015 6 Hour Safety Culture How to Sustainably Reduce Human Error and Risk and do what training alone can t possibly do Human Performance Association Archived from the original on 2021 04 11 Retrieved 2020 08 21 Retrieved from https en wikipedia org w index php title Human error amp oldid 1183172258, wikipedia, wiki, book, books, library,
