Human Error, Accidents, and Safety Human Error Human Error Human Error Classification Scheme o Discrete-Action Classification

n Errors of Omission Errors of Commission Sequence Errors Timing Errors Errors of Omission Involve failure to do something. An electrician was electrocuted while positioning himself on a steel framework of an electric substation. There were several points of disconnect in order to shut off power completely to the substation. He apparently forgot to disconnect one of them. Errors of Comission Involve performing an act incorrectly. A mechanic sitting on a conveyer belt called for his partner to lightly hit the start button to jog the belt a few inches forward. The helper lost his balance & hit the button hard enough to start the belt at full speed. The mechanic was pulled between the belt & a steel support 9 in. above the belt. Sequence Error (A subclass of errors of commission) occurs when a person performs some task, or step in a task, out of sequence. A crane operator lifting a 24-ton stone block has the crane over turn. Rather than lifting the boom and then rotating it 90 degrees, he rotates the near flat boom first, and before he can lift it, the crane overturned. Timing Error (A subclass of errors of commission) occurs when one fails to perform an action within an allotted time, either performing too fast or to slow. Taking too long to remove ones hand from a workpiece in a drill press, a timing error that can result in a nasty injury. Rasmussen (1982) He identifies 13 types of errors. The errors depend on the type or level of behavior. They are:

o Skill-based behavior - controlled by subconscious routines & stored patterns of behavior & is appropriate for skilledbased behavior. Primarily errors of execution. o Rule-based Behavior applies to familiar situations where stored rules for coordinating behavioral subroutines can be can be applied. Errors usually involve recognizing the salient features of the situation & remembering & applying the correct rule. o Knowledge-based Behavior occurs in unique, unfamiliar situations for which actions must be planned in relation to goals. Errors result from inadequate analysis or decision making. Dealing with Human Error Selection o Select people with capabilities & skills required to perform job. Limitations to approach are: Identifying skills needed Reliable, Valid Tests Supply of Workers Training Design o Exclusion designs: Design to make it impossible to commit the error. o Prevention designs: Design to make it difficult, but not impossible, to commit the error. o Fail-safe designs: design reduces the consequences or errors without necessarily reducing the likelihood of errors. Factors Contributing to Accidents Management Physical Environment Equipment Design Work Itself Social/Psychological Environment Worker/Co-worker Unsafe Behavior/Chance (Risk) Exposure to Hazardous Situation Perception of Hazard Cognition of Hazard Decision to Avoid Ability to Avoid

Safe Behavior

Evaluation of Risk Numerous studies on the perception and ability to estimate the risk or frequency of injury associated with technological risks (pollution, or nuclear power) Perception of common accidents & injuries has been less thoroughly studies. The Question is WHY? Availability Heuristic process Tversky & Kahneman (1973) Tend to give higher probabilities to event they can remember. New stories bias thinking. o Car accidents vs private air crash Risk Perception of Accidents Fail to perceive hazard Underestimated hazard Fail to respond to recognized hazard Respond to hazard, but ineffectively