"Managing human error is fundamental to maintaining the viability and profitability of any organization."


The need to manage human error comes as no great revelation to anyone involved in system safety. Truth be told, however, the "battle cry" that human error is associated with 60% to 80% of all accidents in complex, high-risk systems has become passe in many organizations. The reason behind this attitude is that human error statistics have not changed appreciably in more than a half century! So, while safety professionals can all agree that something must be done to reduce errors, a growing number of executives in the boardroom are becoming skeptical to the idea that something actually can be done. In fact this attitude is often reflected in statements by CEO's, such as "In high-risk industries, accidents are simply the cost of doing business."

Unfortunately, most of us don't have the luxury of embracing this laissez-faire approach to safety. Safety Professionals are paid to prevent accidents, or at a minimum, mitigate their consequences. And although some stakeholders express cynicism while discussing safety behind closed doors, when an accident does occur, attitudes quickly change. Unfortunately, it is at these moments that safety engineers and managers finds themselves at the center of the storm answering very pointed questions like, "How could this have happened," "Why didn't you do anything to prevent it," and "What are you going to do to prevent this from happening again?"

The Safety Management Process

Most safety professionals are very familiar with the traditional system safety approach illustrated in Figure 1. While there are many variants to the approach, most involve the following components: collecting data, identifying and assessing hazards, identifying/developing interventions, assessing intervention feasibility, intervention implementation, and system monitoring/program evaluation. Ideally, this is a dynamic process involving the real-time identification of hazards, deployment of interventions and hopefully, improvements in safety.

Historically, this approach to system safety has been highly successful at addressing mechanical and engineering problems within a variety of operational contexts. Albeit, it has been facilitated by the development of a comprehensive set of engineering tools and techniques for implementing each step. Not surprising, given the success of system safety in the engineering world, many safety professionals have been quick to adopt this same approach when attempting to manage human error and other complex human factors issues. But, why hasn't it been working?

Figure 1. The Safety Management Process (available in full paper).

Unfortunately, the requisite tools and techniques for employing a system safety approach to human error management have been largely ineffectual or nonexistent. As a result, it has been virtually impossible to get beyond the first step in the process - data collection. In fact, when an accident or incident does happen, the most common response is simply to collect more data. However, merely gathering more data about the occurrence of errors is not the solution.

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