Chapter 1: What is Human Error?
The first chapter of the book “The Field Guide to Understanding ‘Human Error’” by Sidney Dekker provides an in-depth understanding of human error and its effects. The chapter highlights that human error is a complex phenomenon that is often misunderstood and oversimplified. It defines human error as a natural and inevitable aspect of human behavior that can occur at any time and in any situation. The author emphasizes that human error is not a character flaw or a personal failing, but a consequence of the interaction between humans and their environment.
An example of human error in the workplace can be seen in the aviation industry. Airline pilots are highly trained and experienced professionals, yet errors can still occur. In 2009, the crash of Air France Flight 447 was attributed to human error. The pilots misinterpreted the aircraft's stall warning system, and as a result, the plane stalled and crashed into the Atlantic Ocean, killing all 228 people on board. This tragic incident highlights that even well-trained individuals can make errors due to the complexity of the environment and the tasks at hand.
Chapter 2: The Bias of Seeing Human Error
The second chapter of the book delves into the biases that people have when it comes to understanding human error. Author Sidney Dekker argues that humans tend to view errors retrospectively, which means they judge them based on the outcome rather than the actions and intentions of the person at the time. This bias can lead to a blame culture in organizations, where errors are seen as an individual's fault rather than a systemic issue.
A real-life example of this can be seen in the medical field. When a patient dies or suffers harm, it is common for healthcare professionals to be blamed for the error. However, studies have shown that most medical errors are the result of a flawed system, not individual negligence. By only focusing on the individual's failure, the underlying issues in the system are not addressed, and similar errors are likely to happen again.
Chapter 3: Exploring Performance Modes
In Chapter 3, the author explores different modes of human performance: skill-based, rule-based, and knowledge-based. These modes describe how humans perform tasks and how errors can occur at each level.
For example, let's consider a construction worker operating heavy machinery. In the skill-based mode, the worker has repeated the same task numerous times before and has fine-tuned their skills to operate the machinery effectively. However, a momentary lapse in concentration or unexpected changes in the environment can lead to an error. In the rule-based mode, the worker follows strict procedures and protocols for operating the machinery, but a rule may not apply to a particular situation, leading to an error. In the knowledge-based mode, the worker relies on their knowledge and experience to troubleshoot and solve problems. However, if they encounter a new or unusual situation, they may not have the necessary knowledge or experience, leading to an error.
Chapter 4: The Traps and Pitfalls of Human Error
The fourth chapter of the book discusses the traps and pitfalls that can lead to human error. The author emphasizes that humans are fallible and can make mistakes, even in highly automated and controlled environments. The chapter also highlights the impact of time pressure, workload, and shift work on human performance.
An example of this can be seen in the transportation industry. Train operators often work long shifts with tight schedules, which can lead to fatigue and decreased performance. In 2013, the Metro-North train derailment in New York City was blamed on the engineer's fatigue. The engineer had fallen asleep at the controls, leading to the train's speeding and ultimately derailing, causing four deaths and dozens of injuries.
Chapter 5: Understanding Human Error in Complex Systems
The final chapter of the book explores the role of complex systems in human error. The author argues that humans operate in a constantly changing and unpredictable environment, and errors are an inevitable consequence of this complexity.
An example of this can be seen in the oil and gas industry. In 2010, the Deepwater Horizon oil spill was caused by a series of complex errors and failures. The drilling operations were conducted in a complex and ever-changing environment, and multiple factors, such as communication breakdowns and cost-cutting, contributed to the disaster.
In conclusion, each chapter of “The Field Guide to Understanding ‘Human Error’” provides real-life examples of how human error can occur in various industries and contexts. The book challenges the traditional view of human error and offers a new perspective by focusing on the systemic and environmental factors that contribute to errors. It highlights the importance of understanding and managing human error to create a safer and more productive work environment.
