Wednesday, November 28, 2012

Error


Error: An action or inaction by an operational person that leads to deviations from organizational or the operational persones intentions or expectations.
                   In the context of an SMS, both the State and the product or service provider must understand and expect that humans will commit errors regardless of the level of technology used, the level of training, or the existence of regulations, processes and procedures. An important goal then is to set and maintain defences to reduce the likelihood of errors and, just as importantly, reduce the consequences of errors when they do occur. To effectively accomplish this task errors must be identified and reported and analyzed so that appropriate remedial action can be taken. Errors can be divided into the two following categories:
            a) Slips and lapses are failures in the execution of the intended action. Slips are actions that do not go as planned, while lapses are memory failures. For example, operating the flap lever instead of the (intended) gear lever is a slip. Forgetting a checklist item is a lapse.
            b) Mistakes are failures in the plan of action. Even if execution of the plan was correct, it would not be possible to achieve the intended outcome.
Safety strategies must be put into place to control or eliminate errors.
The strategies to control errors leverage the basic defences within the aviation system. These include:
     Reduction strategies provide direct intervention to reduce or eliminate the factors contributing to the error. Examples of reduction strategies include improvement of ergonomic factors and reducing environmental distractions.
    Capturing strategies assume the error will be made. The intent is to \capture. the error before any adverse consequences of the error are felt. Capturing strategies are different from reduction strategies in that they utilize checklists and other procedural interventions rather than directly eliminating the error.
    Tolerance strategies refer to the ability of a system to accept that an error will be made but without experiencing serious consequences. The incorporation of redundant systems or multiple inspection processes are examples of measures that increase system tolerance to errors.
Since the performance of personnel is generally influenced by organizational, regulatory and environmental factors, safety risk management must include consideration of organizational policies, processes and procedures related to communication, procedures, scheduling of personnel, allocation of resources and budgeting constraints that may contribute to the incidence of errors

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