For anybody approaching the book with an open mind, Human Error should provide an insightful and entertaining reading experience. Human Error makes for an inspiring and entertaining read. Insightful, passionate, theoretically sophisticated, but also provocatively playful.
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I predict that readers will find their own customized hooks in Human Error , and find themselves inspired to write from one of the many starting points this fascinating book presents. Acknowledgments Introduction: The Human Element 1.
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Zooicide: Animal Love and Human Justice 3. Frames Cinema Journal reviews Human Error.
The Holographic Human. Human Error: Species-Being and Media Machines by Dominic Pettman "marries knotty theoretical concepts with accessible cultural touchstones, in order to help guide the reader through some difficult territory. University of Minnesota Press Coming soon.
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Home Current Catalogs Blog. View Cart Checkout. Search Site only in current section. Advanced Search…. Author: Dominic Pettman. Argues that humanity can be seen as a case of mistaken identity. Dominic Pettman is associate professor of culture and media at New School University. A wildly engaging exploration of what it means to be human.
If a plan is adequate, but an unintentional action does not follow the plan, then the desired outcome will not be achieved. Similarly, if a plan is inadequate, and an intentional action follows the plan, the desired outcome will again not be achieved.
These error points are demonstrated in the figure below and explained in the example that follows. Sam has finished his last task for the day and his desired outcome is to get to the accommodation module. He knows that his usual path to the accommodation module has been barricaded off, so he plans a different route to get there.
From a human error perspective, there are three potential alternative scenarios that he may experience when executing his plan:. Outcome 1 - Success: The accommodation module is easily reached via his planned route adequate plan , and he follows that route intentional action , arriving at the accommodation module.
Outcome 2 - Error: The accommodation module is easily reached via his planned route adequate plan , but as he starts walking, his brain switches to autopilot. He follows his usual path unintentional action until he reaches the barricade, and has to retrace his steps. Outcome 3 - Error: His planned route does not lead to the accommodation module inadequate plan , and he follows the planned route intentional action , until he arrives at a workshop and has to find a different route to get to the accommodation module. Each of the failure types can be further broken down into categories and subcategories, as detailed in the following section.
Failures of action, or unintentional actions, are classified as skill-based errors. This error type is categorised into slips of action and lapses of memory. Failures in planning are referred to as mistakes , which are categorised as rule-based mistakes and knowledge-based mistakes. Skill-based errors tend to occur during highly routine activities, when attention is diverted from a task, either by thoughts or external factors. Generally when these errors occur, the individual has the right knowledge, skills, and experience to do the task properly.
The task has probably been performed correctly many times before. Even the most skilled and experienced people are susceptible to this type of error. As tasks become more routine and less novel, they can be performed with less conscious attention — the more familiar a task, the easier it is for the mind to wander.
This means that highly experienced people may be more likely to encounter this type of error than those with less experience.
This also means that re-training and disciplinary action are not appropriate responses to this type of error. A memory lapse occurs after the formation of the plan and before execution, while the plan is stored in the brain. This type of error refers to instances of forgetting to do something, losing place in a sequence, or even forgetting the overall plan.
A slip of action is an unintentional action. This type of error occurs at the point of task execution, and includes actions performed on autopilot, skipping or reordering a step in a procedure, performing the right action on the wrong object, or performing the wrong action on the right object. Typical examples include:. Slips and lapses can be minimised and mitigated through workplace design, effective fatigue management, use of checklists, independent checking of completed work, discouraging interruptions, reducing external distractions, and active supervision.
The Top 7: How To Reduce Manufacturing Human Error
Mistakes are failures of planning, where a plan is expected to achieve the desired outcome, however due to inexperience or poor information the plan is not appropriate. People with less knowledge and experience may be more likely to experience mistakes. Mistakes can be minimised and mitigated through robust competency assurance processes, good quality training, proactive supervision, and a team climate in which co-workers are comfortable observing and challenging each other.
Mistakes can be rule-based or knowledge-based. The different types of mistakes are explained below through the use of an example from NOPSA Safety Alert 28, where a construction vessel failed to avoid a cyclone. This example demonstrates how multiple errors at various levels of an organisation can interact to lead to a hazardous event. In these cases, insufficient knowledge about how to perform a task results in the development of a solution that is incorrectly expected to work. A construction vessel was unable to avoid a cyclone because the operator failed to initiate preparations to evacuate in a timely manner.
The risk of tropical lows rapidly developing into cyclones within the Timor Sea location was not well understood, with insufficient time allocated for evacuation tasks.
follow site Rule-based mistakes refer to situations where the use or disregard of a particular rule or set of rules results in an undesired outcome. Some rules that are appropriate for use in one situation will be inappropriate in another.
Incorrect application of a good rule occurs when a rule has worked well on previous occasions, so it is applied to a similar situation with the incorrect expectation that it will work. Example - Incorrect application of a good rule. The operator of the construction vessel planned for cyclone response times based on typical North West Shelf cyclone development patterns.
These time frames were then applied to a Timor Sea location. In this case, a good rule regarding evacuation time frames was incorrectly applied to a different location. Sometimes rules are inappropriate or incorrect, and adherence leads to negative outcomes.
In these cases, application of a bad rule does not deliver the desired outcome. Bad rules may be created based on incorrect knowledge i. The two mistakes described above were incorporated into the Cyclone Response Procedure. When applied, this bad rule allowed insufficient time for evacuation and associated preparation times before the tropical low developed into a cyclone.
It is fortunate that no injuries were experienced during this situation. Failure to apply a good rule is also known as a violation.