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".Senders, J.W. and Moray, N.P. (1991)
Human Error: Cause, Prediction, and Reduction
'. Lawrence Erlbaum Associates, p.25. . Human error has been cited as a primary cause contributing factor in disasters and accidents in industries as diverse as nuclear power (e.g., the

Three Mile Island accident The Three Mile Island accident was a partial meltdown of the Three Mile Island, Unit 2 (TMI-2) reactor in Pennsylvania, United States. It began at 4 a.m. on March 28, 1979. It is the most significant accident in U.S. commercial nuclea ...

), aviation (see

pilot error Pilot error generally refers to an Aviation accidents and incidents, accident in which an action or decision made by the Aircraft pilot#Airline, pilot was the cause or a contributing factor that led to the accident, but also includes the pi ...

), space exploration (e.g., the

Space Shuttle Challenger disaster On January 28, 1986, the broke apart 73 seconds into its flight, killing all seven crew members aboard. The spacecraft disintegrated above the Atlantic Ocean, off the coast of Cape Canaveral, Florida, at 11:39a.m. Eastern Time Zone, EST (1 ...

and

Space Shuttle Columbia disaster The Space Shuttle ''Columbia'' disaster was a fatal accident in the United States space program that occurred on February 1, 2003. During the STS-107 mission, Space Shuttle ''Columbia'' disintegrated as it reentered the atmosphere over Texa ...

), and medicine (see

medical error A medical error is a preventable adverse effect of care (" iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior ...

). Prevention of human error is generally seen as a major contributor to

reliability Reliability, reliable, or unreliable may refer to: Science, technology, and mathematics Computing * Data reliability (disambiguation), a property of some disk arrays in computer storage * High availability * Reliability (computer networking), a ...

and

safety Safety is the state of being "safe", the condition of being protected from harm or other danger. Safety can also refer to risk management, the control of recognized hazards in order to achieve an acceptable level of risk. Meanings There are ...

of (complex) systems. Human error is one of the many contributing causes of

risk In simple terms, risk is the possibility of something bad happening. Risk involves uncertainty about the effects/implications of an activity with respect to something that humans value (such as health, well-being, wealth, property or the environme ...

events.

Definition

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".Senders, J.W. and Moray, N.P. (1991)
Human Error: Cause, Prediction, and Reduction
'. Lawrence Erlbaum Associates, p.25. . 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 Slips (or SLIPS) may refer to: *Slips (oil drilling) *SLIPS (Slippery Liquid Infused Porous Surfaces) *SLIPS (company) *SLIPS (Sri Lanka Interbank Payment System) *Slip (cricket), often used in the plural form *The Slips, a UK electronic music duo ...

and lapses).Reason, James (1990) ''Human Error''. Cambridge University Press. . However, a mere failure is not an error if there had been no plan to accomplish something in particular.

Performance

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: therefore actions later termed "human error" are actually part of the ordinary spectrum of human behaviour. The study of

absent-mindedness Absent-mindedness is where a person shows inattentive or forgetful behavior. It can have three different causes: # a low level of attention ("blanking" or "zoning out") # intense attention to a single object of focus (hyperfocus) that makes a pers ...

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.

Categories

There are many ways to categorize human error: *

exogenous In a variety of contexts, exogeny or exogeneity () is the fact of an action or object originating externally. It contrasts with endogeneity or endogeny, the fact of being influenced within a system. Economics In an economic model, an exogeno ...

versus

endogenous Endogenous substances and processes are those that originate from within a living system such as an organism, tissue, or cell. In contrast, exogenous substances and processes are those that originate from outside of an organism. For example, es ...

error (i.e., originating outside versus inside the individual) * situation assessment versus response planning and related distinctions in ** error in problem detection (also see

signal detection theory Detection theory or signal detection theory is a means to measure the ability to differentiate between information-bearing patterns (called stimulus in living organisms, signal in machines) and random patterns that distract from the information (ca ...

) ** error in problem diagnosis (also see

problem solving Problem solving is the process of achieving a goal by overcoming obstacles, a frequent part of most activities. Problems in need of solutions range from simple personal tasks (e.g. how to turn on an appliance) to complex issues in business an ...

) ** error in action planning and execution (for example: slips or errors of execution versus mistakes or errors of intention) * by level of analysis; for example, perceptual (e.g.,

optical illusions Within visual perception, an optical illusion (also called a visual illusion) is an illusion caused by the visual system and characterized by a visual percept that arguably appears to differ from reality. Illusions come in a wide variety; the ...

) versus cognitive versus

communication Communication (from la, communicare, meaning "to share" or "to be in relation with") is usually defined as the transmission of information. The term may also refer to the message communicated through such transmissions or the field of inquir ...

versus

organizational An organization or organisation (Commonwealth English; see spelling differences), is an entity—such as a company, an institution, or an association—comprising one or more people and having a particular purpose. The word is derived fro ...

* physical manipulation error **'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 Latent human error is a term used in safety work and accident prevention, especially in aviation, to describe human errors which are likely to be made due to systems or routines that are formed in such a way that humans are disposed to making thes ...

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

Sources

The

cognitive Cognition refers to "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thought, ...

study of human error is a very active research field, including work related to limits of

memory Memory is the faculty of the mind by which data or information is encoded, stored, and retrieved when needed. It is the retention of information over time for the purpose of influencing future action. If past events could not be remembered, ...

and

attention Attention is the behavioral and cognitive process of selectively concentrating on a discrete aspect of information, whether considered subjective or objective, while ignoring other perceivable information. William James (1890) wrote that "Atte ...

and also to

decision making In psychology, decision-making (also spelled decision making and decisionmaking) is regarded as the cognitive process resulting in the selection of a belief or a course of action among several possible alternative options. It could be either rati ...

strategies such as the

availability heuristic The availability heuristic, also known as availability bias, is a mental shortcut that relies on immediate examples that come to a given person's mind when evaluating a specific topic, concept, method, or decision. This heuristic, operating on the ...

and other

cognitive biases A cognitive bias is a systematic pattern of deviation from norm or rationality in judgment. Individuals create their own "subjective reality" from their perception of the input. An individual's construction of reality, not the objective input, m ...

. 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 Conversation analysis (CA) is an approach to the study of social interaction, embracing both verbal and non-verbal conduct, in situations of everyday life. CA originated as a sociological method, but has since spread to other fields. CA began with ...

, such as the examination of violations of the cooperative principle and

Gricean maxims In social science generally and linguistics specifically, the cooperative principle describes how people achieve effective conversational communication in common social situations—that is, how listeners and speakers act cooperatively and mutual ...

Organizational An organization or organisation (Commonwealth English; see spelling differences), is an entity—such as a company, an institution, or an association—comprising one or more people and having a particular purpose. The word is derived fro ...

studies of error or dysfunction have included studies of

safety culture Safety culture is the collection of the beliefs, perceptions and values that employees share in relation to risks within an organization, such as a workplace or community. Safety culture is a part of organizational culture, and has been describe ...

. One technique for analyzing complex systems failure that incorporates organizational analysis is ''management oversight risk tree analysis'' (MORT).

Controversies

Some researchers have argued that the dichotomy of human actions as "correct" or "incorrect" is a harmful

oversimplification The fallacy of the single cause, also known as complex cause, causal oversimplification, causal reductionism, and reduction fallacy, is an informal fallacy of questionable cause that occurs when it is assumed that there is a single, simple cause of ...

of a

complex phenomenon Complex commonly refers to: * Complexity, the behaviour of a system whose components interact in multiple ways so possible interactions are difficult to describe ** Complex system, a system composed of many components which may interact with each ...

. 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 (ETTO principle), which can be found on all levels of human activity, in individual as well as collective.

References