Ever looked back at an incident or accident to find the reason it happened and realised that you were stressed, tired or distracted and that is what caused the event? These are three of the ‘Dirty Dozen’ which human factors experts have identified as key contributory factors or precursors to incidents and accidents.
The term ‘The Dirty Dozen’ refers to twelve of the most common human error pre-conditions or precursors which lead to accidents and incidents. These twelve have been shown to influence people to make mistakes, errors or violations. The concept was developed by Gordon Dupont in 1993 and is now a key element to Human Factors in Maintenance training.
Note that these twelve are not the only factors which lead to mistakes, errors and violations, but they certainly give you a focal point to identify conditions where errors and violations are more likely to occur. Different domains or even subsets within domains like pilots, ramp crews, air...
This blog was originally submitted as an article for the NAUI ICUE Journal following my presentation at the Long Beach show in 2017.
The aim of this manuscript is to enable the reader to recognise that often when we read accident and incident reports the cause of outcome is reported as ‘human error’ and yet this is such a simplistic and reductionist approach which adds very little when it comes to improving diving safety. As a consequence, the article will explain that we need to understand the context and sense-making which is present with any adverse event and determine why it made sense to those involved to make the decisions they made. Fundamentally, divers or instructors do not aim to injure or kill themselves on a dive. If, using hindsight, the risks are perceived to be so obvious, why didn’t those involve see them and prevent the accident from happening?
The paper will explain some of the theory behind human error and in the process describing a couple...
Ελλήνισε και απέδωσε: Κώστας Ανδρεάδης
Το ανθρώπινο λάθος είναι φυσιολογικό. Το ανθρώπινο λάθος είναι μέρος του τρόπου με τον οποίο μαθαίνουμε. Είναι σχεδόν αδύνατο να αφαιρέσετε το...
It is easy to ascribe ‘human error’ to diving incidents because we often lack details about what happened. It is also perversely satisfying to blame someone, an individual, rather than attribute it to a system issue. Part of this is because we can then start internalising this, distancing ourselves and say that “we wouldn’t have made that mistake”, a natural human reaction.
Unfortunately looking to blame individuals, calling them ‘Darwin Award winners’ or pointing out their stupidity, does nothing to help identify what the real issues were which led to the adverse event, nor do these actions help improve learning because those who have had near misses are scared of the social media backlash when posts are made about events which are so ‘obvious’ in their outcome.
This short piece will cover the Human Error framework from James Reason and look at ways in which we can use this to improve safety and human performance in diving.
Human error is normal. Human error is part of the way we learn. It is almost impossible to remove human error from any system. Therefore, 'Human error' should not be the conclusion of an investigation. If it is, then we are not likely to improve the situation for the future. Depending on the outcome of the error or errors, the impact can be minor or it can be fatal, the problem is we don't necessarily know the scale of the issue until after the event.
In the last blog I covered the basic concept of a Just Culture and why it is essential to have this if we are to improving safety. We need to be able to talk about the errors or violations (at risk behaviours) that occur, and the reasons why it made sense to us at the time if we are to improve performance and safety, and reduce the likelihood of the same adverse event happening again. In this blog I am going to talk about 'human error' and the differences that exist within this overly-simple classification. The next...
You may be wondering what the vandalism of a piece of art has to do with diving safety and improved personal/team performance, but read on. One of the best ways of getting a point across is by telling a story…and so this story begins.
"An elderly German woman was questioned by police after filling in blank spaces on a crossword puzzle that was being displayed as a work of art at a local museum. The BBC reports that the 91-year-old woman used a ballpoint pen to write on the work of art titled "Reading-work-piece" by avant garde artist Arthur Koepcke during a senior citizens tour to Nuremberg's Neues Museum.” - Link
How could someone be so daft as to write on a piece of art in a museum, surely it was obvious that the exhibit was an exhibit and not something to be interacted with? Maybe it was because she was old and had dementia? Indeed, one news report called it an error but she admitted that she did it on purpose. Using that rationale and your normal thought...
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