Over the past decade, anaesthetists and human factors specialists have worked together to find wa... more Over the past decade, anaesthetists and human factors specialists have worked together to find ways of minimising the human contribution to anaesthetic mishaps. As in the functionally similar fields of aviation, process control and military operations, it is found that errors are not confined to those at the "sharp end". In common with other complex and well defended technologies, anaesthetic accidents usually result from the often unforeseeable combination of human and organisational failures in the presence of some weakness or gap in the system's many barriers and safeguards. Psychological factors such as inattention, distraction and forgetfulness are the last and often the least manageable aspects of the accident sequence. Whereas individual unsafe acts are hard to predict and control, the organisational and contextual factors that give rise to them are present before the occurrence of an incident or accident. As such, they are prime candidates for treatment. Errors...
... 822 Journal ofthe Royal Society ofMedicine Volume 71 November 1978 ... initial exposure phase... more ... 822 Journal ofthe Royal Society ofMedicine Volume 71 November 1978 ... initial exposure phase in which illusions of motion, various psychomotor disturbances and motion sickness reactions make ... by all outward signs at least, they are restored to their pre-exposure state of well ...
Complex, well defended, high technology systems are subject to rare but usually catastrophic orga... more Complex, well defended, high technology systems are subject to rare but usually catastrophic organisational accidents in which a variety of contributing factors combine to breach the many barriers and safeguards. To the extent that healthcare institutions share these properties, they too are subject to organisational accidents. A detailed case study of such an accident is described. However, it is important to recognise that health care possesses a number of characteristics that set it apart from other hazardous domains. These include the diversity of activity and equipment, a high degree of uncertainty, the vulnerability of patients, and a one to one or few to one mode of delivery. Those in direct contact with patients, particularly nurses and junior doctors, often have little opportunity to reform the system's defences. It is argued that some organisational accident sequences could be thwarted at the last minute if those on the frontline had acquired some degree of error wisdom. Some mental skills are outlined that could alert junior doctors and nurses to situations likely to promote damaging errors.
Philosophical Transactions of the Royal Society B: Biological Sciences, 1990
Several recent accidents in complex high-risk technologies had their primary origins in a variety... more Several recent accidents in complex high-risk technologies had their primary origins in a variety of delayed-action human failures committed long before an emergency state could be recognized. These disasters were due to the adverse conjunction of a large number of causal factors, each one necessary but singly insufficient to achieve the catastrophic outcome. Although the errors and violations of those at the immediate human-system interface often feature large in the post-accident investigations, it is evident that these 'front-line' operators are rarely the principal instigators of system breakdown. Their part is often to provide just those local triggering conditions necessary to manifest systemic weaknesses created by fallible decisions made earlier in the organizational and managerial spheres. The challenge facing the human reliability community is to find ways of identifying and neutralizing these latent failures before they combine with local triggering events to breach the system's defences. New methods of risk assessment and risk management are needed if we are to achieve any significant improvements in the safety of complex, well-defended, socio-technical systems. This paper distinguishes between active and latent human failures and proposes a general framework for understanding the dynamics of accident causation. It also suggests ways in which current methods of protection may be enhanced, and concludes by discussing the unusual structural features of 'high-reliability' organizations.
International Journal of Man-Machine Studies, 1987
... The same exponential growth in computer technology that made centralized, supervisory control... more ... The same exponential growth in computer technology that made centralized, supervisory control possible in the first place can also provide the ... Fitts sought to provide a rational basis for allocating functions between them in the increasingly complex man-machine systems of the ...
... the necessary skills and resources to collect, analyse and disseminate safety-related informa... more ... the necessary skills and resources to collect, analyse and disseminate safety-related information and, cru ... Safety Reporting System developed by NASA and the British Airways Safety Informa-tion ... collaborated to produce a blueprint for en-gineering a reporting culture.30 The ...
... Broadening the cognitive engineering horizons: more engineering, less cognition and nophiloso... more ... Broadening the cognitive engineering horizons: more engineering, less cognition and nophilosophy of science, please ... While this is important, there is a strong case for arguing that other types of human performance, most especially maintenance, calibration and testing, are ...
... accident period. Pre-accident errors are prior latent failures discovered during the course o... more ... accident period. Pre-accident errors are prior latent failures discovered during the course of the event. Of ... associated events. As a result, the operating crews tended to be lacking inboth state-specific training or relevant procedures. In ...
This paper reviews some of the more important theoretical and practical considerations relating t... more This paper reviews some of the more important theoretical and practical considerations relating to the widespread problem of motion sickness. A brief outline is given of the sensory rearrangement theory which seeks to define the essential nature of the nauseogenic stimulus. A wide range of provocative situations is classified as involving either a visual-inertial conflict, or a canal-otolith conflict or both. A number of behavioural measures by which the passenger can minimise the risk of motion sickness are described. Also considered are quantitative studies of vertical oscillatory motion, factors influencing motion sickness susceptibility (sex, age, exposure-history, receptivity and adpatability and personality characteristics), and the paper concludes with recommendations regarding the most effective use of anti-motion sickness drugs.
Over the past decade, anaesthetists and human factors specialists have worked together to find wa... more Over the past decade, anaesthetists and human factors specialists have worked together to find ways of minimising the human contribution to anaesthetic mishaps. As in the functionally similar fields of aviation, process control and military operations, it is found that errors are not confined to those at the "sharp end". In common with other complex and well defended technologies, anaesthetic accidents usually result from the often unforeseeable combination of human and organisational failures in the presence of some weakness or gap in the system's many barriers and safeguards. Psychological factors such as inattention, distraction and forgetfulness are the last and often the least manageable aspects of the accident sequence. Whereas individual unsafe acts are hard to predict and control, the organisational and contextual factors that give rise to them are present before the occurrence of an incident or accident. As such, they are prime candidates for treatment. Errors at the sharp end are symptomatic of both human fallibility and underlying organisational failings. Fallibility is here to stay. Organisational and local problems, in contrast, are both diagnosable and manageable.
... Captain Dan Maurino, ICAO Human Factors Digest No.7 (1993) introduced the Mark I model to the... more ... Captain Dan Maurino, ICAO Human Factors Digest No.7 (1993) introduced the Mark I model to the aviation world. He and Rob Lee were also influential in getting a form of the model adopted by ICAO Annexe 13 (8th edition). ...
Over the past decade, anaesthetists and human factors specialists have worked together to find wa... more Over the past decade, anaesthetists and human factors specialists have worked together to find ways of minimising the human contribution to anaesthetic mishaps. As in the functionally similar fields of aviation, process control and military operations, it is found that errors are not confined to those at the "sharp end". In common with other complex and well defended technologies, anaesthetic accidents usually result from the often unforeseeable combination of human and organisational failures in the presence of some weakness or gap in the system's many barriers and safeguards. Psychological factors such as inattention, distraction and forgetfulness are the last and often the least manageable aspects of the accident sequence. Whereas individual unsafe acts are hard to predict and control, the organisational and contextual factors that give rise to them are present before the occurrence of an incident or accident. As such, they are prime candidates for treatment. Errors...
... 822 Journal ofthe Royal Society ofMedicine Volume 71 November 1978 ... initial exposure phase... more ... 822 Journal ofthe Royal Society ofMedicine Volume 71 November 1978 ... initial exposure phase in which illusions of motion, various psychomotor disturbances and motion sickness reactions make ... by all outward signs at least, they are restored to their pre-exposure state of well ...
Complex, well defended, high technology systems are subject to rare but usually catastrophic orga... more Complex, well defended, high technology systems are subject to rare but usually catastrophic organisational accidents in which a variety of contributing factors combine to breach the many barriers and safeguards. To the extent that healthcare institutions share these properties, they too are subject to organisational accidents. A detailed case study of such an accident is described. However, it is important to recognise that health care possesses a number of characteristics that set it apart from other hazardous domains. These include the diversity of activity and equipment, a high degree of uncertainty, the vulnerability of patients, and a one to one or few to one mode of delivery. Those in direct contact with patients, particularly nurses and junior doctors, often have little opportunity to reform the system's defences. It is argued that some organisational accident sequences could be thwarted at the last minute if those on the frontline had acquired some degree of error wisdom. Some mental skills are outlined that could alert junior doctors and nurses to situations likely to promote damaging errors.
Philosophical Transactions of the Royal Society B: Biological Sciences, 1990
Several recent accidents in complex high-risk technologies had their primary origins in a variety... more Several recent accidents in complex high-risk technologies had their primary origins in a variety of delayed-action human failures committed long before an emergency state could be recognized. These disasters were due to the adverse conjunction of a large number of causal factors, each one necessary but singly insufficient to achieve the catastrophic outcome. Although the errors and violations of those at the immediate human-system interface often feature large in the post-accident investigations, it is evident that these 'front-line' operators are rarely the principal instigators of system breakdown. Their part is often to provide just those local triggering conditions necessary to manifest systemic weaknesses created by fallible decisions made earlier in the organizational and managerial spheres. The challenge facing the human reliability community is to find ways of identifying and neutralizing these latent failures before they combine with local triggering events to breach the system's defences. New methods of risk assessment and risk management are needed if we are to achieve any significant improvements in the safety of complex, well-defended, socio-technical systems. This paper distinguishes between active and latent human failures and proposes a general framework for understanding the dynamics of accident causation. It also suggests ways in which current methods of protection may be enhanced, and concludes by discussing the unusual structural features of 'high-reliability' organizations.
International Journal of Man-Machine Studies, 1987
... The same exponential growth in computer technology that made centralized, supervisory control... more ... The same exponential growth in computer technology that made centralized, supervisory control possible in the first place can also provide the ... Fitts sought to provide a rational basis for allocating functions between them in the increasingly complex man-machine systems of the ...
... the necessary skills and resources to collect, analyse and disseminate safety-related informa... more ... the necessary skills and resources to collect, analyse and disseminate safety-related information and, cru ... Safety Reporting System developed by NASA and the British Airways Safety Informa-tion ... collaborated to produce a blueprint for en-gineering a reporting culture.30 The ...
... Broadening the cognitive engineering horizons: more engineering, less cognition and nophiloso... more ... Broadening the cognitive engineering horizons: more engineering, less cognition and nophilosophy of science, please ... While this is important, there is a strong case for arguing that other types of human performance, most especially maintenance, calibration and testing, are ...
... accident period. Pre-accident errors are prior latent failures discovered during the course o... more ... accident period. Pre-accident errors are prior latent failures discovered during the course of the event. Of ... associated events. As a result, the operating crews tended to be lacking inboth state-specific training or relevant procedures. In ...
This paper reviews some of the more important theoretical and practical considerations relating t... more This paper reviews some of the more important theoretical and practical considerations relating to the widespread problem of motion sickness. A brief outline is given of the sensory rearrangement theory which seeks to define the essential nature of the nauseogenic stimulus. A wide range of provocative situations is classified as involving either a visual-inertial conflict, or a canal-otolith conflict or both. A number of behavioural measures by which the passenger can minimise the risk of motion sickness are described. Also considered are quantitative studies of vertical oscillatory motion, factors influencing motion sickness susceptibility (sex, age, exposure-history, receptivity and adpatability and personality characteristics), and the paper concludes with recommendations regarding the most effective use of anti-motion sickness drugs.
Over the past decade, anaesthetists and human factors specialists have worked together to find wa... more Over the past decade, anaesthetists and human factors specialists have worked together to find ways of minimising the human contribution to anaesthetic mishaps. As in the functionally similar fields of aviation, process control and military operations, it is found that errors are not confined to those at the "sharp end". In common with other complex and well defended technologies, anaesthetic accidents usually result from the often unforeseeable combination of human and organisational failures in the presence of some weakness or gap in the system's many barriers and safeguards. Psychological factors such as inattention, distraction and forgetfulness are the last and often the least manageable aspects of the accident sequence. Whereas individual unsafe acts are hard to predict and control, the organisational and contextual factors that give rise to them are present before the occurrence of an incident or accident. As such, they are prime candidates for treatment. Errors at the sharp end are symptomatic of both human fallibility and underlying organisational failings. Fallibility is here to stay. Organisational and local problems, in contrast, are both diagnosable and manageable.
... Captain Dan Maurino, ICAO Human Factors Digest No.7 (1993) introduced the Mark I model to the... more ... Captain Dan Maurino, ICAO Human Factors Digest No.7 (1993) introduced the Mark I model to the aviation world. He and Rob Lee were also influential in getting a form of the model adopted by ICAO Annexe 13 (8th edition). ...
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