By Tim Sandle

Published in: IVT Blog

Published on: January 13, 2022

INTRODUCTION In terms of how human error can be defined, then one potentially useful definition of human errors is as “any member of a set of human actions that exceed some limit of acceptability, i.e., an out-of-tolerance action, where the limits of tolerable performance are defined by the system”. In other words, an outcome that was not intended or desired. At first glance the cause of a human error may seem straightforward, all too often followed by the hasty conclusion that training or retraining can fix the issue. However, ‘human error’ is very rarely the root cause and instead a more detailed and iterative human error root cause analysis investigation will more often reveals a deeper issue at the heart of the matter and allows for an appropriate preventative action to be set.

This article looks at a process of defining human error and provides some guidance on constructing a checklist for getting to the root of the error. In following this method, there are very few cases of actual human error; instead, there is typically a fault with a system, procedure, knowledge, or with the environment within which the error occurred.

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