Everyone can make errors no matter how well trained and motivated they are. However in the workplace, the consequences of such human failure can be severe. Analysis of accidents and incidents shows that human failure contributes to almost all accidents and exposures to substances hazardous to health. Many major accidents e.g. Texas City, Piper Alpha, Chernobyl, were initiated by human failure. In order to avoid accidents and ill-health, companies need to manage human failure as robustly as the technical and engineering measures they use for that purpose.
The challenge is to develop error tolerant systems and to prevent errors from initiating; to manage human error proactively it should be addressed as part of the risk assessment process, where:
Significant potential human errors are identified,
Those factors that make errors more or less likely are identified (such as poor design, distraction, time pressure, workload, competence, morale, noise levels and communication systems) - Performance Influencing Factors (PIFs)
Control measures are devised and implemented, preferably by redesign of the task or equipment
This Key Topic is also very relevant when trying to learn lessons following an incident or near miss. This also involves identifying the human errors that led to the accident and those factors that made such errors more likely – PIFs.
It is important to be aware that human failure is not random; understanding why errors occur and the different factors which make them worse will help you develop more effective controls. The choice is very simple. Either you manage human error or human error manages you.
The Managing Human Error traning program aims to provide a comprehensive error management resource at a small fraction of the cost of achieving these ends by any other means. The package is designed for ready implementation by the non-specialist facilitator. 3 training DVDs cover:
Program 1: Why Things Go Wrong
Program 2: Building a Safe Culture
Program 3: HERO (Human Error Reduction Operation)
James Reason, world renowned expert in human performance in hazardous systems, is featured in the Managing Human Error training course.
He is well known as the originator of the Swiss cheese model of how defences, barriers, and safeguards may be penetrated by an accident trajectory
Also featured in MHE is Professor Patrick Hudson of Leiden University, well known to many safety professionals following various his visits to Australia.
His expertise includes safety management systems, cost-benefit analysis models for safety and change management. Look at James Reason's article "Managing Human Error - Knowledge Requirements".
This safety training package includes a number of case studies, including the Glenbrook Rail Disaster in New South Wales.
A User's Guide, which allows easy application from toolbox to boardroom.
- 3 x DVD Program
- 3 Sets of Materials that support the DVD programs, in PowerPoint format on CD-ROM, provide resources for: Management Briefings, Training Courses, Workshops and Awareness Groups
2 Further Sets of Materials, also in PowerPoint format on CD-ROM for management information and courses based on studies of international case histories. Resource manual to address human performance improvement issues.
Companies using this program include: Federal Aviation Information Bureau - Australia, Civil Aviation Safety Authority - Australia, Air Transportation Safety Board - Australia, BOC, Exxon Mobil, BP, Chevron Texaco, Shell Expro, Woodside Energy Australia, Minerals Industry Safety & Health Centre - University of Queensland, QNI Pty Ltd, Rio Tinto Australia, Air New Zealand, British Airways, Singapore Airlines.
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Engineering Solutions to Human Problems