To Err is Human

We are all familiar with the adage ‘To Err is Human.’ We have come to understand that even the most careful, conscientious, by-the-book employee can, and will, commit errors. And some people are under the erroneous impression that human error can be eliminated by using such tools as human factors training, CRM/TEM training, and automation. While safety training programs and automation do certainly mitigate some of the factors that can lead to error causation, they are not, in and of themselves, silver bullets.

Human factors training is mostly an awareness-building exercise that helps aircraft engineers understand the error-provoking conditions that may cause them to make mistakes. As far as automation, since there will always be a requirement for human interaction with automated systems, errors will continue to occur.

With that being said, when it comes to human error, let’s focus on two basic error management principles:

Avoidance-

We need to try to prevent the error from happening in the first place (avoidance). Certain conditions such as pressure, fatigue, poor communication, and distractions/interruptions (among myriad others) are common precipitating factors for error commission. Thus, addressing these precipitating factors can help to significantly reduce the likelihood of error occurrence. But if an error does occur, prompt resolution is required to trap the error to prevent further issues. ?????

Resolution-

Since we cannot eliminate human error, even with the most effective avoidance practices in place, we need to quickly identify and address the errors that do inevitably occur. Most errors are non-intentional (the pilot did not purposely commit the error, and subsequently there may be a lack of awareness that the error was even committed). A common example of this would be a pilot inadvertently entering an incorrect waypoint in the FMS. Without prompt identification and?resolution of this error, there can be additional errors (i.e., an error chain), possibly leading to a serious, consequential event. On the other hand, with prompt recognition, the error can be trapped, resulting in an inconsequential outcome (i.e., no additional errors or undesired aircraft state). So how do we resolve this error quickly and effectively? By strictly adhering to your company SOPs; and by this we are talking specifically about cross-verification by the other crewmember. This is a simple, prescriptive, and very effective error management tool. And yet, out of the thousands of Line Operations Safety Audits (LOSA) observations we have conducted over the last 15 years, we have identified cross-verification errors as one of the most persistent SOP violations. Throw in a lack or absence of CRM, and you can see how things can get pretty ugly, pretty quickly. This is just one example of poor error management, and unfortunately a number of these cross-verification errors have led to more serious outcomes.

Summary

Remember, to err is human! Mistakes will be made. Error avoidance is ideal, but when errors do occur, rapid identification and resolution are critical in order to prevent the error from becoming more consequential. This includes prescriptive measures (such as following your SOPs, checklists, etc.) as well as soft skills measures such as good CRM!

You may also be interested in this presentation about human error as a learning tool.

Dr. Bob Baron conducts aviation safety training, consulting, and program implementation for aviation operators on a global basis. Sensitive and knowledgeable about various cultures, Dr. Baron uses his 36+ years of academic and practical experience to assist aviation organizations in their pursuit of safety and quality excellence. He has extensive experience working with developing nations and island countries. He also provides training and consulting to some of the largest airlines and aircraft manufacturers in the world, as well as civil aviation authorities and accident investigation bureaus.

Dr. Baron is also available as a paid speaker at your company's safety events or conferences. Not just limited to aviation, Dr. Baron can also present to any high-risk industry that has a genuine interest in improving its safety culture and/or safety management processes. To request a speaking engagement, you can contact Dr. Baron by clicking here.

Dr. Baron’s company, The Aviation Consulting Group LLC, provides numerous training, consulting, and auditing services. For more information, click here.