Human Performance Tools: Engaging Workers as the Best Defense Against Errors & Error Precursors
- Jan K. Wachter (Indiana University) | Patrick L. Yorio (University of Pittsburgh)
- Document ID
- American Society of Safety Engineers
- Professional Safety
- Publication Date
- February 2013
- Document Type
- Journal Paper
- 54 - 64
- 2013. American Society of Safety Engineers
- 0 in the last 30 days
- 73 since 2007
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Consider these three related truisms: To err is human. Workers are fallible. Errors are inevitable (as well as predictable). These are some fundamentals of the human performance approach to understanding safety. Generally speaking, human performance encompasses the way workers, the organization, the environment and the management system (e.g., programs and processes) work synergistically as an entire sys-tem. Workers are the focal points of this system, since any flaws in the system can affect workers’ performance and, conversely, any worker flaws can affect the system. Errors are largely viewed as consequences of working in a flawed system.
Given this human performance perspective, it should not be surprising that work-place incidents are triggered by human actions and in many cases the human actions causing these events are errors (which are unintentional actions without malice or forethought). About 80%: of all incidents are attributed initially to human error (Perrow, 1984; Reason, 1990; U.S. DOE, 2009a). The remainder involves elements such as equipment and material failures. But, when the 80% human error is analyzed in detail, the analysis reveals that most errors are associated with events that stem from latent organizational weaknesses, whereas about 30%: are caused by individual workers interfacing "erroneously" with systems and equipment (U.S. DOE, 2009). Thus, incidents result from a combination of factors both within and beyond the control of workers.
Although error is universal, the traditional belief that human performance is a worker-controlled phenomenon and that failures are introduced to the system only through the inherent unreliability of workers is in itself an error of understanding. Since experience indicates that weaknesses in organizational processes and cultural values are involved in most incidents, reducing human errors that are often the result of organizational weaknesses will reduce the likelihood that such events will occur.
Susceptibility to error is heightened when workers operate within complex systems that contain concealed weaknesses. These latent conditions either provoke error or weaken controls against the consequences of error. From a human performance perspective, Figure 1 diagrams the framework for incidents involving these organizational and human elements. The two ways to prevent human error from affecting operations are to 1) keep workers from making errors (error prevention) or 2) stop the errors from having an effect (controls). Figure 1 provides clues regarding intervention mechanisms that workers can use to prevent human error arising from the provocation of error at the workplace or the weakening of controls. Breaking the component linkages as presented in this figure prevents events from occurring. Using this model, events can be avoided.
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