Human Error Essay Example

would be human error occurs when a person commits an error due to their shortcomings rather than external factors (Civil Aviation Authority, 2003). According to Reason (1990), errors hold different meanings. In terms of cognitive theory, errors give reason to routine human actions. For applied practitioners, errors are a threat for high-risk technologies to operate safely.

Errors by humans could also contribute to both human and economic damage. Factors such as depression, disappointment and stress could disable people in performing their duties, and negative emotions due to responsibility ineffectiveness may result in errors (Campbell & Bagshaw, 2002). Also, when large sums are spent on error mitigation, organizations are forced to reduce spending on other factors such as salary and bonuses for their employees. One of the many industries that human error can occur in is the aviation industry, which will be the focus of this essay.

As human error has caused more than 70 percent of aviation accidents, many of those were caused by communication breakdown, teamwork and decision-making rather than technical drawbacks (Helmreich, 1997). Many questions were raised on how well-trained personnel can crash an aircraft that is fit for flight (Helmreich, 1997). As such, programs and training are being provided to minimize the effects of human error in the industry (Helmreich, 1997).

Programs like crew resource management or CRM for short were developed to tackle these issues (Helmreich, 1997). One of the more well-known systems perspectives is the SHEL model, made popular by Edwards (1988) (cited in Wiegmann and Shappell, 2003). Its name is derived from the initial letters of its four components. The first letter “S” represents software, where

it reflects on regulations, manuals and standard operating procedure on how crews operate (Wiegmann and Shappell, 2003).

The letter “H” on other hand represents hardware, which comprises of the actual cockpit, like the flight controls, seat design and computer system (Wiegmann and Shappell, 2003). The letter “E” represents environment, which consist of elements such as, temperature, noise, vibration, weather, terrain, landing and approach (Wiegmann and Shappell, 2003). Lastly letter “L” refers to liveware, it represents the different individual that work in aviation industry, such as pilots, flight crew, air traffic control and maintenance crew (Wiegmann and Shappell, 2003).

The purpose of the SHEL model is to help to find any productive process, by examining the interaction and relationship of all the vital components (Wiegmann and Shappell, 2003). The SHEL model was one of the first coordinated efforts to explore the various relationships that work in the aviation process (Wiegmann and Shappell, 2003). As aviation has became more sophisticated, the SHEL model began to reflect on more complex process with layering method in aviation environment (Wiegmann and Shappell, 2003).

For example, as aircraft technology and software improve, checklist expanded, safety procedures required, more regulation were necessary and pilots became further immersed in multi-tasked efforts (Wiegmann and Shappell, 2003). As engineers test new aircraft designs to accommodate more passengers, the liveware component of the SHEL model became further embedded in safety critical processes (Wiegmann and Shappell, 2003). Another perspective is the “swiss cheese” model, which was introduced by Reason (cited in Wiegmann and Shappell, 2003).

He was able to categorize active and latent failures that could occur in any given situation, active failures

represents actions that cause the failures, whereas, a latent failure contributes indirectly to error in the chain of command. Even if there is several safe guards are emplaced to protect accidents from occurring, like the “swiss cheese”, there are holes in the best layer. However, if the holes becomes in line indicating a break down in safeguards, an accident is likely to occur.

Applying the concept of the “swiss cheese” model, the authors of “A human error approach to aviation accident analysis”, Douglas A. Wiegmann and Scott A. Shappell, designed a human factor analyst and perspective system known as HFACS. The HFACS system examines on how aviation problems are developed on, whether the issues are skilled base, perceptual or can be attributed to organizational factors (Wiegmann & Shappell, 2003). HFACS, helps examine on how and why human errors occur in aviation (Wiegmann & Shappell, 2003).

Using a four theory approach to demonstrate on how accidents occur this theory provides guidance on how to improve human performance (Wiegmann & Shappell, 2003). The top theory represents organizational factors, followed by unsafe supervision, preconditions for unsafe act and finally unsafe act, which eventually results in an accident (Wiegmann & Shappell, 2003). Being able to recognize active and latent conditions it helps in preventing an accident (Wiegmann & Shappell, 2003).

Therefore, crew resource management reinforces the importance of accident prevention through human error. The aviation industry consists of a complicated system that involves the designing and manufacturing of all equipment, the maintenance of the system, organization and management of all processes, the selection and training of the operational staff and government regulations (O’Hare,1999). As such, it

can be said that almost all crashes are the result of a human error of some sort (O’Hare,1999).

Having said that, successful results are also the end product of human performance, though rarely recognized (O’Hare, 1999). Human capability is to measure the assurance that sophisticated technology can be operated safely as well as to reduce human error and the affirmative of not mishandling the system that could cause a mishap (Whittingham, 2004). Even with the best training or an individual’s capability of performing the duty well, errors occur (Campbell and Bagshaw, 2002).

According to Campbell and Bagshaw(2002), 86% of aircrafts accidents are caused by, pilots who proceeded to fly despite of bad weather conditions, mishaps in mid-air, fuel burn out, pilots unable to perform due to influence of alcohol and drugs, fatigue, stress due to overload of work, financial or family problems among other factors (Campbell & Bagshaw, 2002). As mistakes are committed by human behavior, technology has built to minimize the error (Campbell & Bagshaw, 2002). Errors form from different type of factors, such as fatigue, decision-making and overload of work.

One of the reasons on why human performance capabilities are unlikely to reduce error is due to fatigue (Campbell & Bagshaw, 2002). Fatigue has both short-term and long-term physiological problems, where short-term physiological is resulted from insufficiency of sleep, manual labor or emotional and psychological stress (Campbell & Bagshaw, 2002). Where else, long-term physiological results from overload of work, financial difficulty, family or work stress (Campbell & Bagshaw, 2002).

The symptoms of fatigue is that it disables and reduces the level of awareness, slower in reactions, decrease motor skills

and visual acuity (Campbell & Bagshaw, 2002). However, preventative strategies are advised on how to reduce errors and increase human performance (Campbell & Bagshaw, 2002). Advises are given to cope wit jet lag, stop-over of less than 24hours is to maintain home time eating and sleeping pattern, stop-over of 24 hours, is advised to get a short period of sleep upon arrival and then a longer period of sleep before their next scheduled flight (Campbell & Bagshaw, 2002).

However, stopovers of more than 24 hours are advised to gain enough sleep prior to the next schedule, with possible delays to occur (Campbell & Bagshaw, 2002). Good sleeping habits should also be cultivated, where one should avoid going to bed hungry, avoiding alcohol or caffeine before sleep and proper sleeping procedure should be developed as well (Campbell & Bagshaw, 2002). Other strategies to prevent or slow down the fatigue is to have a regular exercising routine, abstaining from alcohol consumption and having proper balanced meals (Campbell & Bagshaw, 2002).

However, there is no simple or one solution to avoid fatigue from re-occurring, therefore one has to learn what is the best way to help them resolve from this issue (Campbell & Bagshaw, 2002). Decision-making is also another major factor that human performance will not dominate in error reduction (Campbell & Bagshaw, 2002). Decision- making, is the capability to make the right choice at the right circumstance (Campbell & Bagshaw, 2002).

Evidence shows that decision-making skills can be improved through structured training, where making alternative choices, gathering of information and making right decision with given information (Campbell & Bagshaw, 2002). However, risk is involved

in decision-making, if one is unable to analysis and tackle the issue prominently, errors will reoccur again (Campbell & Bagshaw, 2002). Still further reason on why human performance capabilities will not enhance in error reduction is because of overload of work.

According to Kantowitz and Casper (1988), extreme levels of workload contribute to human error when the human is not able deal with high levels of information from the environment. They further quoted that, as wide-bodied aircrafts are flown without flight engineers nowadays, the need of the third crew does not exist. Debates have arisen with regards to necessity of placing a third crew member on board (Kantowitz & Casper, 1988). Having a third crew member on board does not decrease the work load by a third, but would increase the interaction between the three(Campbell & Bagshaw, 2002).

This may lead to human error accidents due to distractions arising from an increased communication (Campbell & Bagshaw, 2002). In conclusion, the error mitigation techniques mentioned in this essay allow for a reduction in human error accidents within the aviation industry. The current safety systems in place are half a century old. With technology preceding this system, it is important review the system and keep abreast with current technology to reduce errors.