Error Prevention

Some key challenges

  • Error, or to be more accurate, organisational systems failure is inevitable in any organisation.
  • Some failures are easy to recover from and can be educational. Others can be catastrophic.
  • Systems need to be designed to degrade gracefully not fail catastrophically
  • Its about people and systems not about the kit

Solutions

  • Hierarchical Task analysis, Failure Mode Effects Analysis and other related techniques
  • Analysis of both proximal and distal contexts paying attention to organisational culture ad socio-psychological context of the organisation
  • Bespoke, targeted interventions such as training, systems design, feedback and recovery procedures
  • Enhanced Cognitive Task Analysis (ECTA) to safely and effectively maximise the benefits of AI and Autonomous Systems

Thinking about the issue

  • The use of the term ‘error’ precipitates a mantle of causality around those proximate to an event.
  • Errors are usually system failures where several disparate occurrences combine in an unexpected way. Unforeseen contingencies come to the fore.
  • Blame does not help prevent reoccurence
  • Context is all. Generic models of human error explain everything after the event and give no clues as to how to prevent future system failures

Examples of past work

  • Prevention and mitigation of operator failures in power plants
  • Upgrading existing information systems with ‘break in service’ provision in public service organisations
  • Replacement of an risk assessment methodology that focused only on potential loss with on that also accounts for opportunity cost.