 Students will be able to:  List items in a AI plan  List items to include in an AI kit  Explain why human error could be a cause or a symptom of a system problem.  Distinguish between active and latent errors  Convince management of the need for identifying symptom errors  Begin to identify personal biases  Avoid blame as an outcome of AI based on this theory

 The accident investigation process involves the following steps:  Report the accident occurrence to a designated person within the organization  Provide first aid and medical care to injured person(s) and prevent further injuries or damage  Investigate the accident  Identify the causes  Report the findings  Develop a plan for corrective action  Implement the plan  Evaluate the effectiveness of the corrective action  Make changes for continuous improvement

 This plan should address:  investigator training-Where?  investigation kits-What?  the investigation priorities-Which ones?  gathering of evidence-Who?  preservation of evidence-Who & How?

 Human Error and Accident Management offers means and ways to recognize and prevent these behaviors (error).  Provides for a means to control and recover from these behaviors when they do occur and to contain and escape from their adverse.  New approach (last 10 years)  Error Theory is not new (focused on moral decisions)  First focused on just unsafe acts (cause v. system)  Origin in major disasters: Three Mile Island, Aviation Accidents, Challenger Disaster  Caution: Avoid Blame Game

 Human error is the cause of accidents  To explain a failure, you look for a failure  You must find person’s inaccurate assessments, wrong decisions, and bad judgments  Human error is a symptom of trouble deeper inside a system  To explain failure, do not try to find where people went wrong  Instead, find how person’s assessments and actions made sense at the time, given the circumstances that surrounded them

 Concept Check: Are we all on the “same page?”  What is your concept of Human Error?  Give examples of Human Error

 forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness (J. Reason Western Journal of Medicine,, June 2000)  4 Categories according to James Reason:  slips,  lapses  violations  mistakes

 Random versus Systemic Errors  What’s the difference?  Is one type easier to control than the other?

 Based on aviation accidents (pilot error)  Active-Human Error  Cognitive error  Distraction  inattentive  Latent-Systematic  Inadequate supervision

 Active errors become very visible in the evolution of an event.  The active errors are also the most obvious occurrences and the most rapidly identified human contributors in an accident.

 The higher in the organization these latent errors are made, the more serious the consequences at the front line operation.  Latent errors of strategic nature, such as defining company policies affect safety attitudes and the safety culture in the organization.  The most serious and dangerous errors to be tackled.  Also see terms in the lit “covert failure” and “Operationally invisible"

 Technique for Human Error Rate Prediction (THERP)-quantitative method

 Accident Investigation Process  What are some ways you as an investigator can identify human errors as they contribute to the accident sequence?  Are human errors the root causes for accidents? Why or why not?  What role does your knowledge about human error play in your investigation process?

 W AS THE POSSIBILITY OF THE ERROR KNOWN ? *  W ERE THE POTENTIAL CONSEQUENCES OF THE ERROR KNOWN ? *  W HAT ABOUT THE ACTIVITY MADE IT PRONE TO THE OCCURRENCE OF THE ERROR ?  W HAT ABOUT THE SITUATION CONTRIBUTED TO THE CREATION OF THE ERROR ?  W AS THERE AN OPPORTUNITY TO PREVENT THE ERROR PRIOR TO IT ' S OCCURRENCE ? *  O NCE THE ERROR WAS COMMITTED, WAS THERE ANY WAY TO RECOVER FROM IT ? *  W HAT ABOUT THE SYSTEM SUSTAINED THE ERROR INSTEAD OF TERMINATING IT ?  W HAT FED THE ERROR, AND DROVE IT TO BECOME A BIGGER PROBLEM ?  W HAT MADE THE CONSEQUENCES AS BAD AS THEY WERE ?  W HAT ( IF ANYTHING ) KEPT THE CONSEQUENCES FROM BEING WORSE ?  * I F YES, WHY DID THE EVENT PROCEED BEYOND THIS POINT ? I F NO, WHY NOT ?

Based on tonight’s discussion you should be able to:  List items in a AI plan  List items to include in an AI kit  Explain why human error could be a cause or a symptom of a system problem.  Distinguish between active and latent errors  Convince management of the need for identifying symptom errors  Begin to identify personal biases  Avoid blame as an outcome of AI based on this theory

 PMC / PMC /  tent/public/document/eec/report/2006/017 _Swiss_Cheese_Model.pdf tent/public/document/eec/report/2006/017 _Swiss_Cheese_Model.pdf