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Chapter 14: Safety, accidents, and human error. Factors contributing to accidents and human error Descriptions and models of human error Accident and incident investigation Hazard management (eliminate, reduce, control, mitigate) Safety analysis and product design

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Chapter 14: Safety, accidents, and human error


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    Presentation Transcript
    1. Chapter 14: Safety, accidents, and human error • Factors contributing to accidents and human error • Descriptions and models of human error • Accident and incident investigation • Hazard management (eliminate, reduce, control, mitigate) • Safety analysis and product design • Warning design, decision making, and risk taking

    2. Safety legislation and product liability • Moral and economic concerns of occupational safety • Failure to perform safely when used in • a reasonably foreseeable manner • or if the inherent risks outweighed the benefits • Juggling chainsaws, using a lawnmower as a hedge trimmer, removing guards

    3. Organizational Factors Active versus Latent Failures (Reason, 1990) • Latent Conditions • Excessive cost cutting • Inadequate promotion policies • Latent Conditions • Deficient training program • Improper crew pairing Unsafe Supervision • Latent Conditions • Poor CRM • Mental Fatigue Preconditions for Unsafe Acts Unsafe Acts • Active Conditions • Failed to Scan Instruments • Penetrated IMC when VMC only Failed or Absent Defenses “Robbing the pillar” • Accident & Injury • Crashed into side of • mountain

    4. Descriptions and models of of human error • No such thing as human error?? • Human error as starting point of investigation • Genotype and phenotype • Phenotype: external appearance of error • Genotype: underlying cognitive mechanisms • Errors of omission/commission • Slips and mistakes (SRK levels of cognitive control)

    5. Descriptions and models of of human error • Human reliability assessment • Identify potential errors • Quantify error likelihood • Combine to assess system-level effects: THERP, GEMS, SHERPA • No one method is the “best” • All depend on analyst skill • Eliminate through: selection, training and design • Design to be error proof and error tolerant

    6. Accident and incident investigation • Incidents= Near misses or near accidents • Why incidents rather than accidents? • How to code errors? • How to respond to errors? • Hazard analysis as proactive accident/incident investigation

    7. Factors contributing to errors and accidents Work System Employee Job Equipment and tools Physical environment Social environment Management or Design Error Accident/ Injury Hazard Operator error

    8. Hazards • Set of conditions that, together with other conditions, will inevitably lead to an accident • Electrical • Mechanical • Pressure • Toxic substances • Radiation (300 REM kills 50% in 50 days) • Fire • Fall and trip (11ft fall kills 50%, but flight attendant survived 33,000 ft fall)

    9. Managing hazards • Hazard elimination • Substitution (lambs rather than lions) • Decoupling • Elimination of specific human errors • Hazard reduction • Design for control • Lockouts • Hazard control • Reduce exposure • Isolation and containment • Damage minimization

    10. Hazard management • Focus on severe hazards • Criticality = Severity X Frequency • Reduce hazards by addressing: • Source (elimination, control, limit damage) • Path (guards, task redesign) • Person (warnings, training) • Administration (rules, regulations)

    11. Hazard management: Addressing the source • Hazard elimination • Substitution (lambs rather than lions) • Decoupling (separate grain production from consumption) • Hazard control • Reduce exposure (minimize additive effects) • Isolation and containment • Damage minimization • First aid stations • Emergency response plan • Safety programs for a systems approach

    12. Safety analysis and product design • Bottom-up (Failure modes and effects analysis) • Top-down (Fault tree analysis) • Analyze: • Task • Users • Environment • Identify and evaluate hazard controls • Effect on usefulness and safety of product • Effect on cost • Comparison to other products

    13. Warning design, decision making, and risk taking • Risk perception depends on perceived • Criticality (more influential than frequency) • Frequency/likelihood • Availability • Response depends on perceived risk and cost of compliance

    14. Warning design • Warnings should contain: • Signal word (Danger, Caution, Warning) • Description of hazard • Consequences • Behavior needed to avoid hazard • Challenges to warning design • Perceive warning • Comprehend severity, Language/cultural barriers • Proliferation can reduce salience and compliance

    15. Key concepts regarding safety, accidents, and error • Human error is the starting place for investigation • Types of error and the need to go beyond the surface description of single causes • Hazard management: address severe hazards at their source • Perceived risk and cost of compliance govern risky behavior