According to the Health and Safety Executive (HSE)… human errors can be active or latent.
Active failures are direct and immediate causes of an accident, and are usually made by front-line staff such as drivers or machine operators. There are 3 types of active human error:
- Slips and lapses – made inadvertently by experienced operators during routine tasks;
- Mistakes – decisions subsequently found to be wrong, though the maker believed them to be correct at the time; and
- Violations – deliberate deviations from rules for safe operation of equipment.
Familiar tasks carried out without much conscious attention are vulnerable to slips and lapses if the worker’s attention is diverted: for example, missing a step in a sequence because of an interruption. Mistakes occur where a worker is doing too many complex tasks at the same time, or is under time pressure; for example, misjudging the time and space needed to complete an overtaking manoeuvre. Violations, though deliberate, usually stem from a desire to perform work satisfactorily given particular constraints and expectations.
Latent failures are those aspects of an organisation which influence human behaviour and make active failures more likely. Factors which contribute to human error include:
- Job – distractions, lack of time, inadequate procedures, poor lighting or extremes of temperature;
- Human – physical ability, competency, fatigue, stress or drugs;
- Organisational – work pressure, long hours or insufficient supervision; and
- Plant and equipment – poor equipment design or workplace layout.
Whenever an error event occurs, corrective and preventive actions (CAPA) must be developed to make an organization’s systems stronger. A company will create systems to detect similar future errors or events, which will serve as the alarm that triggers corrective action and recovery.
CAPA procedures should describe what the data sources are, how data is collected, as well as by whom, when and how it is routed to the CAPA system. Procedures can be conducted manually or electronically; there can be separate procedures for collecting data and for evaluating the root cause. The sources of information will vary, but at some point all of the data with the results of the investigation must flow into CAPA. Then, recommended and approved actions can be taken and implementation and verification of those actions can be documented and tracked.
Three Boeing employees failed to follow the rules and created a dangerous fire hazard aboard the world’s most recognizable jet. To read the complete informative article please click here.
So yes, this happened, TO AIR FORCE ONE!. It was human error so we investigated.
Read below the root cause codes and recommendations from our end.
The concept of error that many are familiar with comes from tests taken. A wrong answer represents an error. In general, a wrong answer comes from not knowing the right answer… The concept of error in human error reduction in manufacturing is much broader.
There are many instances in which an error occurs, and everyone knows that it is an error. And, in fact, everyone knows the right answer. So why was the error made? Answering that question is at the heart of human error reduction techniques. And there are many possible answers. Listed below are a few:
- Poor lighting or other environmental impediments
- Communication failures
- Excessive workload
- Deliberate overriding of established procedure Continue reading