I’m sure others have posted this recently, but it’s an interesting video from James Reason talking about error and performance.
I particularly love the retro-ambience. It’s like something you’d see on VHS in science class.
Jim talks about some interesting properties of task errors. Like making tea, “these errors aren’t random or bizarre…we don’t find ourselves blowing raspberries down the teapot”
Instead, “The errors we make are all part of the normal repertoire of skilled behaviour and it is because the behaviour is so skilled that these particular kinds of errors occur”.
Further in the video they show a control panel with walls of identical buttons and switches. They highlight how people ‘finish the design’, – “In your million dollar control room, you tell [the identical switches apart] like this – with beer taps”
Dr Embrey appears later and talks about the many situations where the operators are set up to make errors by the poor information they’re presented with – error producing design.
Jim remarks:
“In the past, accident researchers spent most of their time looking at serious accidents, but one of the changes that has now come about is … becoming more interested in everyday inconsequential errors on the reasonable assumption that they are really no different from the errors with said consequences”.
Jim draws analogy between inadvertently switching on the toaster when intending the kettle, versus a pilot inadvertently activating a safety-critical system on the flight deck.
He argues that the difference between these two situations isn’t so much what gave rise to the errors but “whether or not the environment is forgiving”, that is, whether it is error tolerant.
SafetyInsights.org 