β Scribed by Willem A. Wagenaar; Jop Groeneweg
No coin nor oath required. For personal study only.
Accidents are the consequences of highly complex coincidences. Among the multitude of contributing factors human errors play a dominant role. Prevention of human error is therefore a promising target in accident prevention. The present analysis of 100 accidents at sea shows that human errors were not as such recognizable before the accident occurred. Therefore general increase of motivation or of safety awareness will not remedy the problem. The major types of human error that contribute to the occurrence of accidents are wrong habits, wrong diagnoses, lack of attention, lack of training and unsuitable personality. These problems require specific preventive measures, directed at the change of undesired behaviors. Such changes should be achieved without the requirement that people comprehend the relation between their actions and subsequent accidents.
Accidents in complex man-machine systems are usually caused by a multitude of events which occur in a coincidental manner that was never foreseen. These events, or causes, may vary from uncontrollable 'acts of God', unforeseeable technical mishap, to human negligence or failure. It is the thesis of this study that among these causes human error is the category which is most simply controlled. However, such a control can be exerted only by change of the work environment, consisting of hardware systems, machinery, tools, procedures and schedules. A change of human behavior through selection of better personnel, through safety training programs or increase of motivation will be of little avail. Such measures assume that the chains of events leading to accidents can be overseen by the people who are a part of them, and that not preventing the chain is the result of stupidity. However, making the mistakes people tend to make is only stupid in hindsight. Psychologists are talking moonshine if they claim that accident-prone people can be removed through psychological testing. There is no well-controlled study that has convincingly shown that a decrease of accident rate can be obtained through general safety-training or motivation programs (cf. Kletz, 1985, p. 68).
Nevertheless, in this paper prevention of human error is proposed as the option that will be the most successful remedy of accidents because human error is involved in the large majority of accidents, because human error is basically quite invariant, and because many forms of human error are invited by the design of hardware and software.
In this study we will supply some results of an analysis of 100 accidents at sea, which support the theses presented above. The chains of causes leading to the
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