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‘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

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learning objectives of error and risk
‘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.
error
Error
  • Conceptual Issues
  • Generic models
  • Prevention
conceptual issues
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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, 1987. Also Chapter by Brehmer.
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