A systems approach to human error identification

The involvement of human error is high which is surprising because almost all technological systems not only run by a man, but it is also design, construct, organize, manage, maintain and govern by men.

The series of accidents start with the impact of the decision in the Organization (decision related to planning, scheduling, divination, communication, design, specifications, procedures, maintenance, and so on).

This decision is a product that is affect by the financial and political constraints under which the company is run, and is determine by the factors that can be control by the Manager Individuals cannot be blame for all the mistakes, just as we know that making a mistake at a particular time is seen by many as something that cannot be avoid.

Introduction

Describes the system approach to organizational errors. There is no doubt that the failure of humans is not limit to the ' sharp end ', i.e. on the driver, pilot, ship's officers, control room operators and others in the direct control of a system. Have found indications that human factors are widely distribute, covering all that is in the system as a whole and usually new years later led to the actual event.

This model is showing people at the sharp end as a result of the insurer and not as a cause of defects of construction. Sharp end no longer blame, but had been divert to the managerial system in the organization.

Modern thought is also now recognizing that because the cause of the failure is more complex. Than the simple linkage to the workers or to the manager. Action of human error is something not intentional from decisions base on physical or psychological factors. Cognitive and psychological factors must be take into account at the time of assessing the ' power of control '.

Operation setup

The behavior of the operator set up by conscious awareness create by the work planner/Manager. They are more ' in control ' rather than the power of the operator. Analysis for the improvement of the system stating that the people in the system. It can create/design a different decision in the days to come. But one cannot assume a predictable specific lines of human behavior.

The controls are on a higher level on the system need more than the level of activity of the workers. The behavior of individuals, orient to the requirements. That have been set up, to be complete on the working environment, as accept by the individual. Individual performance is acceptable is form by the restrictions that exist.

The subjective criteria of the individuals affect by the social and cultural norms of the Organization. System failure is a reflection of the lack of control of the environment job. Control system base on risk analysis do not have any influence on the Organization. Should be the most important thing is to consider the development of operational management method. To create the initial conditions explicitly and communicate. It effectively in operations management.