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Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 1 Copyright Error Management Solutions, LLC 2004 The need to manage human error comes as no great revelation to anyone involved in system safety. Truth be told, however, the “battle cry” that human error is associated with 60% to 80% of all accidents in complex, high-risk systems has become passé in many organizations. The reason behind this attitude is that human error statistics have not changed appreciably in more than a half century! So, while safety professionals can all agree that something must be done to reduce errors, a growing number of executives in the boardroom are becoming skeptical to the idea that something actually can be done. Unfortunately, most of us don’t have the luxury of embracing this liaise faire approach to safety. We are paid to prevent accidents, or at a minimum, mitigate their consequences. And although some stakeholders express cynicism while discussing safety behind closed doors, when an accident does occur, attitudes quickly change. Unfortunately, it is at these moments that safety engineers and managers finds themselves at the center of the storm answering very pointed questions like, “How could this have happened,” “Why didn’t you do anything to prevent it,” and “What are you going to do to prevent this from happening again?” As former safety officers and accident investigators ourselves, we too have felt the painful sting of the boss’ stare when an accident occurs. Perhaps that is why we have relentlessly pursued better ways to manage human error. Most safety professionals are very familiar with the traditional system safety approach illustrated in Figure 1. While there are many variants to the approach, most involve the following components: collecting data, identifying and assessing hazards, identifying/developing interventions, assessing intervention feasibility, intervention implementation, and system monitoring/program evaluation. Ideally, this is a dynamic process involving the real-time identification of hazards, deployment of interventions and hopefully, improvements in safety. Hazard Identification Hazard Assessment Identify Interventions Intervention Assessment Intervention Implementation Data Monitor Figure 1. The Safety Management Process “Managing human error is fundamental to maintaining the viability and profitability of any organization.” Wiegmann & Shappell “In high-risk industries, accidents are simply the cost of doing business.” Anonymous CEO “When the only tool you have is a hammer, every problem becomes a nail.” Anonymous HUMAN FACTORS IN SAFETY MANAGEMENT SYSTEMS Douglas A. Wiegmann, Ph.D. and Scott A. Shappell, Ph.D. Error Management Solutions, LLC Error Management Quarterly, vol. 1 (1), 2004 Human Factors in Safety Management Systems 2 Copyright Error Management Solutions, LLC 2004 Historically, this traditional approach to system safety has been highly successful at addressing mechanical and engineering problems within a variety of operational contexts. Albeit, it has been facilitated by the development of a comprehensive set of engineering tools and techniques for implementing each step. Not surprising, given the success of system safety in the engineering world, many safety professionals have been quick to adopt this same approach when attempting to manage human error and other complex human factors issues. But, it hasn’t been working. Why? Unfortunately, the requisite tools and techniques for employing a system safety approach to human error management have been largely ineffectual or nonexistent. As a result, it has been virtually impossible to get beyond the first step in the process - data collection. In fact, when an accident or incident does happen, the most common response is simply to collect more data. However, merely gathering more data about the occurrence of errors is not the ultimate solution. Organizations have been busy collecting data for decades. In fact, most safety engineers and managers are swimming (or perhaps drowning) in data, particularly given recent advances in technology that have increased the amount of information available exponentially. Most safety professionals have become frustrated with just watching the human error “data bucket” fill up and are eager to get beyond this seemingly perpetual data collection www.aero.cn 航空翻译 www.aviation.cn 本文链接地址：HFSMS-article
