Vulnerability in Complex Systems: Do We Approach the Problem of Human Error in an Appropriate Way? Stefân Einarsson dr.ing., Inst. of Production and Quality Engineering NTNU, Trondheim, Norway
Safety scientists have long recognised the central role of human error in system safety. Human error accounts for 80% of major accidents. The use of the term human error has been extended from the traditional meaning of "unsafe acts" of lower level operators to include management decisions on higher administrative level. Dr. James Reason has made this especially transparent by distinguishing between active and latent errors. Latent errors are generated by those "at the blunt" end of a system. They are harder to deal with, may remain dormant for a long time and may become real when they combine with other "resident pathogens" and local triggering events. Cognitive psychology has been used to predict the individual potential for error but has little to say about how individual tendencies interact within a complex grouping of people working in high risk systems. Safety culture, or a particular aspect of it, safety climate, has been considered the main indicator of group safety performance in high risk systems. This belief emerged after the Chernobyl accident. Other beliefs exist. Dr. Charles Perrow claims that complex systems cannot be analysed and considers accidents to be normal in high risk systems.
This may be true but the employees in a company will nevertheless have to maintain an efficient level of safety in the company. The level may change for better or worse during the company's life due to many factors. Today we use safety management systems to control safety and health in a high risk company. Some of the latent errors Dr. James Reason spoke about may be detected in inputs to systems or by evaluation of them. Inputs to safety management systems and evaluation of saf6ty management systems may usually e done by specialised consulting firms, or the company itself. But inputs may also come from different parties like insurance companies, governmental bodies and standardisation organizations. We would like to seek an answer to the question "What is the traditional approach to the control of human error within SMS? " and then discuss ways and means to respond to human error within SMS?
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