THE HUMAN ERROR
To Err is Human — But NOT With Aircraft
By Gordon Dupont, System Safety Services Here’s a simple error. Has anyone ever left their gas cap
off after fi lling up with gas — or worse, drove off with the hose still attached as in the picture? I recently went to the gas station to fi ll a gas can for my
including the person who made the error) would say they were either careless, stupid or just too lazy to do it right. Obviously they just didn’t use their common sense. All of the reasons we have listed are not causes of a human error. For centuries we have been blaming human error but human error does not cause accidents. We can all agree that human error is never done with the intent to cause an accident. If it is, the correct term would be sabotage. We have established that we don’t ever intend to cause an accident, so what is it that interfered with someone’s judgment or performance at that critical moment? The outcome of this is the error. Many people have bet their life (and lost) that the actions they were performing were the correct ones.
W What can interfere with a person’s judgment or
performance at a critical moment? Let’s take a look at the Dirty Dozen. They are lack of communication, lack of resources, complacency, pressure, lack of knowledge, lack of assertiveness, distraction, stress, lack of teamwork, lack of awareness, fatigue and norms. For some, the notion that human error does not cause accidents will require a paradigm shift. A few will feel that we are just making excuses for a careless person and that he or she must be held accountable for their actions. The good news is that we can do something about human error. We can learn how to avoid making errors or, at the very least, we can lessen the consequences when a mistake is made.
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e humans have been making errors for a very, very long time and sadly will continue to do so. In the past, when an error was made we (often
lawnmower. While there, I thought I might as well fi ll the truck’s tank, too. I fi lled the jerry can fi rst and then the truck. While I was replacing the truck gas cap, my mind was on the jerry can and that I must not forget it. I picked it up and put it in the back of the truck and somehow managed to drive off without shutting the truck’s gas door. There was no intent to not close that door. Common sense says to close it before driving off and I think I have common sense. Why did I do it? Putting the gas in the back of the pickup was a distraction that occurred at a critical moment. I was also under some stress knowing I was running a little late to pick up my wife at the store. There were at least two of the Dirty Dozen preconditions in the works; I managed to not complete the job at hand. I made a human error.
LESSENING ERROR RECURRENCE We often create new regulations to help prevent another from making the same error. An accident in a curve on a highway might result in the erection of a new sign indicat- ing a curve ahead with a lower speed limit. The second way we try to lessen errors is to “Murphy
proof” the aircraft so the errors cannot be repeated. The gear up warning horn is a classic example of this. Today gas caps are attached so we can’t forget them and some cars have a warning light when the gas door is not closed. Notice in the photo, the fuel hose has a breakaway at the end of it so that the gas pump can’t be ripped off of its base. This would cause fuel to go everywhere with a high risk of an explosion.
DOMmagazine
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