22
Sensemaking in Safety Critical and Complex Situations
in safety occurrences, this is a sign that changes are needed, such as better documentation, better maintenance or improved training to support better s ense-making.
This kind of thinking leads us to consider the design of the system and its resilience
against certain types of error. In w ell-designed systems, there are barriers to stop
human error from ‘ leaking’ into the rest of the system:
• Fail-safe operation – human error causes the system to fail but nobody gets
hurt
• Fail-soft operation – the system fails slowly, gives cues that something is
wrong so operators have time to prevent a disaster
• Removal of ‘ latent’ hazards and design deficiencies that prompt mistakes
Figure 2.5 presents a flowchart for categorising human error.
Some questions to consider when using the flowchart include whether the action
was intentional, whether the person had the right training, the information operators
had, the instructions they had been given, whether the person had done the same
Error in Action
ERROR OR VIOLATION?
ERROR
The action was
unintentional
VIOLATION
The action was intentional
Error in Thinking
Slip
(Commission)
Lapse
(Omission)
Rule based
Knowledge
based
Routine
Exceptional
Situational
Recklessness
Sabotage
Violation for
Organisational Gain
Violation for Personal
Gain
Psychomotor
Did an error or
violation occur?
Was there a
system
failure?
No
Yes
Yes
No
Review
procurement &
maintenance
procedures
Unforeseeable
occurrence
True accident
FIGURE 2.5 Flowchart for classifying errors and violations in accident investigations.
( From Bridger et al., 2012, Crown Copyright, Contains public sector information licensed
under the Open Government Licence v2.0.)
Sensemaking in Safety Critical and Complex Situations
in safety occurrences, this is a sign that changes are needed, such as better documentation, better maintenance or improved training to support better s ense-making.
This kind of thinking leads us to consider the design of the system and its resilience
against certain types of error. In w ell-designed systems, there are barriers to stop
human error from ‘ leaking’ into the rest of the system:
• Fail-safe operation – human error causes the system to fail but nobody gets
hurt
• Fail-soft operation – the system fails slowly, gives cues that something is
wrong so operators have time to prevent a disaster
• Removal of ‘ latent’ hazards and design deficiencies that prompt mistakes
Figure 2.5 presents a flowchart for categorising human error.
Some questions to consider when using the flowchart include whether the action
was intentional, whether the person had the right training, the information operators
had, the instructions they had been given, whether the person had done the same
Error in Action
ERROR OR VIOLATION?
ERROR
The action was
unintentional
VIOLATION
The action was intentional
Error in Thinking
Slip
(Commission)
Lapse
(Omission)
Rule based
Knowledge
based
Routine
Exceptional
Situational
Recklessness
Sabotage
Violation for
Organisational Gain
Violation for Personal
Gain
Psychomotor
Did an error or
violation occur?
Was there a
system
failure?
No
Yes
Yes
No
Review
procurement &
maintenance
procedures
Unforeseeable
occurrence
True accident
FIGURE 2.5 Flowchart for classifying errors and violations in accident investigations.
( From Bridger et al., 2012, Crown Copyright, Contains public sector information licensed
under the Open Government Licence v2.0.)