Please enable JavaScript.
Coggle requires JavaScript to display documents.
5.2 Compensating fro Human Error - Coggle Diagram
5.2
Compensating fro Human Error
Ergonomics
Ergonomics is the study of people’s efficiency in a working environment
It involves the application of science to the interaction of humans with machines, systems or environments
Ergonomic Design is also known as
Human Factor Engineering
seeks to optimise the role of people in hazard prone systems, for safety and efficiency.
The objective of ergonomics is to maximise human performance and minimise human error.
Three branches of ergonomics are:
Physical
: this is concerned with the response of the human body.
Cognitive
: this considers the response of the mind–body interface.
Organisational
: this focuses on the influence of structure, policy, etc., on human performance.
Approaches and responses to
human fallibility
James Reason Two approaches to human fallibility
Person Approach
focuses on errors by individuals, and on blaming them for the error.
This approach neglects system influences on error
Blame culture erodes trust and works directly against reporting systems
System Approach
accepts the existence of human fallibility and so focuses on the conditions within the organisation and workplace under which errors occur
this approach seeks to erect system-level defences that prevent and/or mitigate the effects of errors – a good example of this is the Swiss cheese model
Responses to Human Errors
Engineering responses
full or partial automation or task simplification
improving the human-machine interface
warning and alerting hardware.
Regulatory, administrative or procedural responses
regulatory structures that mandate and/or forbid actions, in order to reduce human error
management practices that promote working in a fashion that reduces human error
selection and training of crews (e.g. CRM) to reduce human error
work procedures or operational rules that restrict or modify behaviour.
Providing effective training
High quality training should give workers:
a correct perception of the problem
the ability to distinguish suitable ‘correct’ solutions from unsuitable, ‘incorrect’, solutions
knowledge and skills needed to think creatively in situations that they have not trained for, and/or where systems behave in an unexpected fashion (upset conditions).
Training needs to be a balance of do and think
Do:
effective training develops suitable automatic responses, allowing rapid reaction where needed.
Think
: effective training also builds the cognitive skills necessary to:
solve problems
address unusual events that people have not been specifically trained for
recognise cases where the normal instinctive responses are inappropriate.
DECIDE model of decision making
Detect
that a change has occurred.
Estimate
the need to counter or react to the change.
Choose
a desirable outcome, in terms of safety.
Identify
the action(s) needed, in response to the change.
Do
the necessary action(s).
Evaluate
the effects of the actions, in responding to the change.
Promoting situational awareness
There are two phases in attaining situational awareness:
Phase 1
: Situational assessment involves monitoring and recognition
(“I see a problem”).
Phase 2:
Situational awareness involves evaluation and challenging (“
What do the data mean, and have I interpreted inputs correctly?”)
.
Monitor and challenge
an approach to error detection and response
involves someone other than the decision maker monitoring the decision making process and challenging it, if they believe that the wrong decision has been made.
Monitor and challenge can be difficult when a junior employee has to challenge a senior one (authority gradient)
Work environment design
organisational design
needs to promote effective decision making.
is the hierarchy of the organisation made up of too many layers, that hinder effective safety communication or collaboration?
if the organisational design is such that responsibilities are very rigid and there are gaps between these, then this may prevent or impede establishing a culture where safety is everyone’s problem
physical layout
An organisation’s physical layout should be designed to make problems easy to identify and respond to
the human–machine interface.
Human–machine interfaces should support effective decision making
is the interface easy to use and aids situational awareness both in routine and upset conditions?
An effective human-machine interface should be designed to be:
hierarchical
, such that this brings priority information forward, rather than bombarding the user with extraneous data.
clearly displayed
to aid interpretation by people.
Regulatory, administrative and procedural responses
Regulatory responses
Regulation can be a key driver of safety improvement. Sadly, regulations are often only put in place after people have died
regulations can encompass:
regulations governing the conduct of organisations and activities
regulations governing the conduct of individuals
Approaches to rule-making have tended to change in recent years
Traditionally
, regulations specified process (i.e., that organisations had to carry out actions a, b and c).
More
modern approache
s to regulation specify outcomes, i.e that organisations need to achieve aims x, y and z.
Regulatory culture
Regulator culture is likely to reflect that of the wider country, for example attitudes to risk, levels of bureaucracy, etc. Some regulators are purely reactive.
Regulatory inertia and stability
Regulations need an appropriate degree of stability and need to be able to change in an evolutionary, or even a revolutionary way
Conversely, excessively frequent changes in regulation can make compliance burdensome, confusing, or even impractical
Management practices and procedures
organisations need to identify, prioritise and respond to the human factors aspects of their business model and operations, recognising the connection between the organisation, the workplace and unsafe acts.
Companies need clear procedures, including:
documentation and dissemination
training and employee development
employee engagement at all levels
rewards for employees who engage positively with safety and sanctions for those who won’t take this seriously
testing and ongoing refinement.
Do management practices make sense?
when running a fair reward scheme you might divide a site, such as a production line or an office, into zones, each pairing high risk and low risk areas.
In order to reduce human error through management practices, organisations need to:
employ individuals with a responsible attitude to safety, so initial selection and induction are important
promote a positive approach to health and safety, in every individual, through staff training and development
correct unsuitable attitudes to safety, and weed out those who won’t take safety seriously
Attitudes to safety
a lack of respect for safety rules/policies
a sense of invincibility or overconfidence
a lack of initiative
dictatorial leaders
weak people
defeatist people
distraction or sloppiness
panic, or failure to think decisions through.
Fatigue management
Regulation
: many safety critical industries have mandatory rest requirements.
Management
: some companies have bespoke fatigue risk management systems (
FRMS
), encompassing
revised work schedules
ongoing data collection
the staff fatigue reporting system/culture
investigating the role of fatigue in events.
Individuals
: people need to take a responsible attitude and use rest periods for their intended purpose
Automation
Automation
reduces the level of human input required to complete a task or process.
An alternative to full automation is
Task Simplification (Partial Automation)
An example of partial automation is adaptive cruise control
Task Support
aids humans in a task, without automating the task. An example of this is parking sensors.
Full Automation
of a task eliminates the need for human involvement (beyond perhaps supervision). An example would be fully autonomous cars
ways automation can be implemented
involves sufficient automation to minimise distraction and prevent likely errors, without seeking to automate all aspects of the task
aims at a balance, with not so much automation so as to prevent people using creative solutions, in an emergency, but enough automation to allow operators to focus on those tasks that benefit from human decision making
requires redundancy, including a (basic) emergency backup system, where critical systems are involved.
it is important to use automation with care, to avoid the erosion of the manual operation skills that may be needed if automation fails
Warning and alerting systems
‘confusion matrix’