Latest / Safe As Podcast / E62: Types of error - error as cause, event, or harm

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E62: Types of error - error as cause, event, or harm · Safe As Podcast

• 0:07
  Welcome to the next quickest way to safe as What is human error
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  and how's it used? It's kind of obvious, isn't it?
• 0:15
  I mean, we use it so regularly in normal conversations as much
• 0:19
  as in the scientific world. However, Holnag in his chapter
• 0:24
  Human Error, Trick or Treat, argues that despite its common
• 0:28
  use, it's really ambiguous and not so simple to define.
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  From Hohenagle and Wood's perspectives, human error is
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  best understood as a judgement made in hindsight, after the
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  outcome is clear. Any attribution of error is a
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  social and psychological judgement process, not a narrow,
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  purely technical or objective analysis.
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  In any case, that's a bit of a whole point.
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  Hohenagle argues that we probably don't need any more
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  error mechanisms. Or more specifically, in his
• 1:00
  words, there's no need of a theory of human error because
• 1:04
  the observed discrepancies in performance should be explained
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  by a theory of normal performance rather than specific
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  error mechanisms. Putting that aside, though,
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  error, as mentioned, is pretty ambiguous.
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  What do we mean by error? Again, Hornagel argues that
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  error includes at least three meanings.
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  There's error as cause the oil spill was caused by human error.
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  There's error as outcome which is really about the consequences
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  or observable failures. Like I left the key in the lock
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  and error as a action I forgot to check the water level.
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  Now, to briefly unpack these different meanings, I'm using
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  the descriptions from Read ET al 2021 titled State of Science,
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  Evolving Perspectives on Human Error, published in the Journal
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  of Ergonomics. 1. Human error is a 'cause when
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  human error is used as a cause or explanation for any sort of
• 2:01
  adverse event, it represents a stopping point for an
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  investigation. This is set to hinder learning,
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  with broader factors that played a contributing role in the
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  accident potentially being overlooked.
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  Human error is not an explanation of failure, but
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  rather it demands an explanation.
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  Framing error as a cause of failure generates several
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  negative outcomes, such as reinforcing blame,
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  recommendation of inappropriate countermeasures like retraining,
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  and a failure to act on the systemic issues that are really
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  the underpinning factors of failure. 2 Human error as a
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  process When error is discussed as a process or an event, the
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  focus is on the error itself rather than its outcomes.
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  One of the issues with this approach is that error is often
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  defined as a departure from some sort of good process or some
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  sort of ground truth in an objective reality where we can
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  necessarily identify what good looks like in advance and then
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  we can hold people to account. But this raises further
• 3:02
  questions on what standards applicable and how we account
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  for local rationality as in the local context, and how people
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  make sense of the information that they have at the time.
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  It also raises questions around what it means for other
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  deviations, given that these are relatively common and occur with
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  no adverse consequences. Indeed, most sort of errors, not
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  really errors, but it's more just regular performance
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  variability that typically leads to success and three,
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  confounding error with its outcome.
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  This is where error is defined in terms of its consequence, the
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  actual accident event. Human error in this sense is
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  really mixed up with the harm that's being produced.
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  In all, many of these authors argue that these different world
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  views on what error is and embedded in our language
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  typically carries negative connotations and ultimately this
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  mass recognition that in everyday life all people make
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  mistakes, but we're primed or even biassed to assume bad
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  things like errors happening to bad people.
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  The so called just world hypothesis and aligned with a
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  broader movement. It's said that we should reject
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  human error as a cause of accidents and adverse events.
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  Instead, we should focus on how the system failed and use
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  interventions that increase the system's capacity to manage
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  disturbances and ultimately, erformance variability.