Human Error and Accident Causation Theories, Frameworks and Analytical Techniques: An Annotated Bibliography

Over the last several decades, humans have played a progressively more important causal role in aviation accidents as aircraft have become more [complex]. Consequently, a growing number of aviation organizations are tasking their safety personnel with developing safety programs to address the highly complex and often nebulous issue of human error. However, there is generally no “off-the-shelf” or standard approach for addressing human error in aviation. Indeed, recent years have seen a proliferation of human error frameworks and accident investigation schemes to the point where there now appears to be as many human error models as there are people interested in the topic. The purpose of the present document is to summarize research and technical articles that either directly present a specific human error or accident analysis system, or use error frameworks in analyzing human performance data within a specific context or task. The hope is that this review of the literature will provide practitioners with a starting point for identifying error analysis and accident investigation schemes that will best suit their individual or organizational needs

Development of Human Error Identification Tool for Processing Industries

Human error analysis method quantitatively is to be investigated by development of tool for analyzing human error in processing industries and oil and gas industries. The development of quantitative human error analysis is for the improvement of human performance focusing critical industrial location such as plant site and offshore. The development of the tools is based on traditional analyzing method that has been developed in the past such as Swiss Cheese and Human Reliability Assessment. This project aims to develop a tool that will assess and identified human error by quantification method for studies and enhancement of human performance in processing industries. The development of human error identification tools is still new in chemical industries and tool that works based on quantitative methods is still not much due to lack of data. In this project, there are two case studies used. First is frmn a report on Data Informed Model of Performance shaping Factors for use in Human Reliability Analysis, which is for calculation of error probabilities. Second is to calculate risk level which is from case study of method use for food processing industry in Japan. The result of this project is a simple, easy and practicable tool for workers in plant to assist them to evaluate human error probabilities and risk level due to standardized factor of error in plant

Central Florida Future, Vol. 23 No. 20, October 25, 1990

13 protest suspension of SG statutes; Russian poet travels to UCF to recite works; Kuwaiti woman vacationing in U.S. can\u27t go home, finds work at UCF; UCF works to drop human error in aviation accidents.https://stars.library.ucf.edu/centralfloridafuture/2025/thumbnail.jp

Human error management

The focus of this research is safety critical systems management set within the context of a series of Lean brown field manufacturing case studies. The thesis is founded upon a human factors perspective of quality/safety management and the perceptions of over 800 workers drawn from 4 corporately owned aero repair & overhaul UK sites. Traditionally, human factors and aviation research has focused upon aircraft operations, where pilots and to a lesser extent air traffic controllers, have increased their ability to make safety critical decisions based on improved levels of team situational awareness. No literature exists to demonstrate the same potential from a front line operations perspective of aircraft maintenance engine overhaul, especially, within the context of Lean operations. The research hypothesis is problem driven and theory building using a cross-case comparative method involving both qualitative and quantitative data collection. Data was analysed using a non-parametric design and seeks to extract differences in quality attitudes. Results show the most significant barrier to quality and safety effectiveness, originates from management planning and workplace control. This is a condition that was found to be perpetuated by a lack of understanding for how to transition from traditional craft based engineering, towards a more lean approach within the context of Total Quality Management (TQM) literatures. The study shows corner cutting is a precondition of leadership and its front line engineering resource namely; self-managed teams. Results also demonstrate that people do not intentionally make mistakes, but generally do, because of operations system pace/instability of material flow. The researcher therefore concluded with a challenge to design new ways of neutralising latent error conditions before the safety critical events breach the quality systems defence mechanisms at each case study concerned

Developing a Methodology for Assessing Safety Programs Targeting Human Error in Aviation

There is a need to develop an effective methodology for generating comprehensive intervention strategies that map current and proposed safety programs onto well-established types of human error. Two separate studies were conducted using recommendations from NTSB accident investigations and several joint FAA and industry working groups. The goal of the studies was to validate a proposed framework for developing and examining safety initiatives that target human error in aviation. The results suggest five approaches to reducing human factors associated with aviation accidents. When combined with the Human Factors Analysis and Classification System, the resulting Human Factors Intervention Matrix will provide a useful tool for evaluating current and proposed aviation safety programs

From theory to practice: itinerary of Reasons’ Swiss Cheese Model

International audienceSince the early 1990s, the Swiss Cheese Model (SCM) of the English psychologist James Reason has established itself as a reference model in the etiology, investigation or prevention of organizational accidents in many productive systems (transportation, energy, healthcare …). Based on the observation that it’s still today widely used, this article intends to revert to the history and the theoretical background of the SCM. By doing so, the article focuses on the collaboration between the psychologist (James Reason) and a nuclear engineer (John Wreathall) who happened to be at the origin of the creation and evolution of SCM. The methodology is based on an exhaustive literature review of Reason's work and the interviews of Reason and Wreathall carried out in 2014. The study suggests that the success of the model is not so much due to appropriation of the work of the psychologist by the industrial community but to a complex process of co-production of knowledge and theories. To conclude, we try to figure out whether the SCM still has a contemporary interest in accident prevention or explanatio

Developing a Lean Based Model for a Hospital Pharmacy Environment

Lean strategies have become necessary in healthcare due primarily to two factors: a demand for efficiency and a need to reduce medical error. The case for the necessity of a lean program is based on trends of increasing costs and decreasing revenues resulting from government intervention. Profit margin per patient has been reduced, and therefore more patients per time period must be seen in order to meet profitability goals. Preventable medical error is shown to be a leading cause of death. Current research in the area of hospital and healthcare efficiency proves that a parallel exists between healthcare efficiency today and the state of efficiency in manufacturing during the late 70’s and early 80’s. In the 70’s and 80’s, MRP technology came into vogue as a means for attacking complicated problems with expensive, complicated, technology-based solutions. Today, many hospitals hope to solve their efficiency and human error problems by implementing computer based delivery, order-filling, and data systems. Better manufacturers made a move away from complicated solutions, toward lean practices focused on instead of simplifying the problems; healthcare should then do the same. A generic lean methodology geared toward the differing nuances of healthcare is developed. Lean is offered as a solution to both efficiency and medical error (on the basis that visual systems reduce error and that lean reduces stress, a major contributor to human error). A connection between stress and lean has been found by prior research and is taken a step further and connected with human error. This is based on research showing that stress cases the potential for human error in skilled workers to increase by 2-5 times

Why Catastrophic Organizational Failures Happen

Excerpt from the introduction: The purpose of this chapter is to examine the major streams of research about catastrophic failures, describing what we have learned about why these failures occur as well as how they can be prevented. The chapter begins by describing the most prominent sociological school of thought with regard to catastrophic failures, namely normal accident theory. That body of thought examines the structure of organizational systems that are most susceptible to catastrophic failures. Then, we turn to several behavioral perspectives on catastrophic failures, assessing a stream of research that has attempted to understand the cognitive, group and organizational processes that develop and unfold over time, leading ultimately to a catastrophic failure. For an understanding of how to prevent such failures, we then assess the literature on high reliability organizations (HRO). These scholars have examined why some complex organizations operating in extremely hazardous conditions manage to remain nearly error free. The chapter closes by assessing how scholars are trying to extend the HRO literature to develop more extensive prescriptions for managers trying to avoid catastrophic failures