Human error

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Human error refers to something having been done that was "not intended by the actor; not desired by a set of rules or an external observer; or that led the task or system outside its acceptable limits". In short, it is a deviation from intention, expectation or desirability. Logically, human actions can fail to achieve their goal in two different ways: the actions can go as planned, but the plan can be inadequate (leading to mistakes); or, the plan can be satisfactory, but the performance can be deficient (leading to slips and lapses).Hollnagel, E. (1993) Human Reliability Analysis Context and Control. Academic Press Limited. {{ISBN|0-12-352658-2}}.Reason, James (1990) Human Error. Cambridge University Press. {{ISBN|0-521-31419-4}}. However, a mere failure is not an error if there had been no plan to accomplish something in particular.

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Human error and performance are two sides of the same coin: "human error" mechanisms are the same as "human performance" mechanisms; performance later categorized as 'error' is done so in hindsight:Woods, 1990 therefore actions later termed "human error" are actually part of the ordinary spectrum of human behaviour. The study of absent-mindedness in everyday life provides ample documentation and categorization of such aspects of behavior. While human error is firmly entrenched in the classical approaches to accident investigation and risk assessment, it has no role in newer approaches such as resilience engineering.Hollnagel, E., Woods, D. D. & Leveson, N. G. (2006). Resilience engineering: Concepts and precepts. Aldershot, UK: Ashgate.

There are many ways to categorize human error:Jones, 1999Wallace and Ross, 2006

• exogenous versus endogenous error (i.e., originating outside versus inside the individual)Senders and Moray, 1991
• situation assessment versus response planningRoth et al., 1994 and related distinctions in
• error in problem detection (also see signal detection theory)
• error in problem diagnosis (also see problem solving)
• error in action planning and executionSage, 1992 (for example: slips or errors of execution versus mistakes or errors of intentionNorman, 1988)
• by level of analysis; for example, perceptual (e.g., optical illusions) versus cognitive versus communication versus organizational
• physical manipulation error{{Cite web |date=June 2009 |title=Human Performance Improvement Handbook |volume=1: Concepts and Principles |url=https://www.standards.doe.gov/standards-documents/1000/1028-BHdbk-2009-v1/@@images/file |publisher=U.S. Department of Energy|id=DOE-HDBK-1028-2009}}
• 'slips' occurring when the physical action fails to achieve the immediate objective
• 'lapses' involve a failure of one's memory or recall
• active error - observable, physical action that changes equipment, system, or facility state, resulting in immediate undesired consequences
• latent human error resulting in hidden organization-related weaknesses or equipment flaws that lie dormant; such errors can go unnoticed at the time they occur, having no immediate apparent outcome
• equipment dependency error – lack of vigilance due to the assumption that hardware controls or physical safety devices will always work
• team error – lack of vigilance created by the social (interpersonal) interaction between two or more people working together
• personal dependencies error – unsafe attitudes and traps of human nature leading to complacency and overconfidence

The cognitive study of human error is a very active research field, including work related to limits of memory and attention and also to decision making strategies such as the availability heuristic and other cognitive biases. Such heuristics and biases are strategies that are useful and often correct, but can lead to systematic patterns of error.

Misunderstandings as a topic in human communication have been studied in conversation analysis, such as the examination of violations of the cooperative principle and Gricean maxims.

Organizational studies of error or dysfunction have included studies of safety culture. One technique for analyzing complex systems failure that incorporates organizational analysis is management oversight risk tree analysis.{{cite book|title=Cognitive Systems Engineering|url=https://books.google.com/books?id=i2xRAAAAMAAJ&q=10:+0471011983|author-link1=Jens Rasmussen (human factors expert)|first1=Jens |last1=Rasmussen|first2=Annelise M. |last2=Pejtersen|first3=L.P.|last3=Goodstein|year=1994|publisher=John Wiley & Sons|isbn=0471011983}}{{cite web|title=The Management Oversight and Risk Tree (MORT)|url=http://www.icma-web.org.uk/06-9_mort.html|publisher=International Crisis Management Association|access-date=1 October 2014|archive-url=https://web.archive.org/web/20140927003111/http://www.icma-web.org.uk/06-9_mort.html|archive-date=27 September 2014|url-status=dead}}Entry for MORT on the [https://web.archive.org/web/20150924025944/http://www.hf.faa.gov/Workbenchtools/default.aspx?rPage=Tooldetails&toolID=151 FAA Human Factors Workbench]

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Some researchers have argued that the dichotomy of human actions as "correct" or "incorrect" is a harmful oversimplification of a complex phenomenon.{{cite web|author=Hollnagel, E.|year=1983|title=Human error. (Position Paper for NATO Conference on Human Error, August 1983, Bellagio, Italy|url=https://www.researchgate.net/publication/327212150}}Hollnagel, E. and Amalberti, R. (2001). The Emperor's New Clothes, or whatever happened to "human error"? Invited keynote presentation at 4th International Workshop on Human Error, Safety and System Development.. Linköping, June 11–12, 2001. A focus on the variability of human performance and how human operators (and organizations) can manage that variability, may be a more fruitful approach. Newer approaches, such as resilience engineering mentioned above, highlight the positive roles that humans can play in complex systems. In resilience engineering, successes (things that go right) and failures (things that go wrong) are seen as having the same basis, namely human performance variability. A specific account of that is the efficiency–thoroughness trade-off principle,{{cite book | last=Hollnagel | first=Erik | title=The ETTO principle : efficiency-thoroughness trade-off : why things that go right sometimes go wrong | publisher=Ashgate | publication-place=Farnham, England Burlington, VT | year=2009 | isbn=978-0-7546-7678-2 | oclc=432428967}} which can be found on all levels of human activity, in individuals as well as in groups.

• Behavior-shaping constraint
• Error-tolerant design
• Human reliability
• Poka-yoke
• SHELL model
• User error
• Technique for human error-rate prediction
• Fallacy
• To err is human

{{reflist}}

• {{cite book|author=Autrey, T.D.|year=2015|title=6-Hour Safety Culture: How to Sustainably Reduce Human Error and Risk (and do what training alone can't possibly do)|url=https://6hoursafetyculture.com/|publisher=Human Performance Association|access-date=2020-08-21|archive-date=2021-04-11|archive-url=https://web.archive.org/web/20210411030535/https://www.6hoursafetyculture.com/|url-status=dead}}

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Category:Human reliability

Category:Error

Category:Management cybernetics

Category:Reliability engineering