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4.6.3 Even if not altogether avoidable, human errors are manageable through the application of
improved technology, relevant training, and appropriate regulations and procedures. Most measures aimed
at error management involve front-line personnel. However, the performance of pilots, ATCOs, AMEs, etc.
can be strongly influenced by organizational, regulatory, cultural and environmental factors affecting the
workplace. For example, organizational processes constitute the breeding grounds for many predictable
human errors, including inadequate communication facilities, ambiguous procedures, unsatisfactory
scheduling, insufficient resources, and unrealistic budgeting — in fact, all processes that the organization
can control. Figure 4-5 summarizes some of the factors contributing to human errors — and to accidents.
Error types
4.6.4 Errors may occur at the planning stage or during the execution of the plan. Planning errors lead
to mistakes; either the person follows an inappropriate procedure for dealing with a routine problem or
builds a plan for an inappropriate course of action to cope with a new situation. Even when the planned
action is appropriate, errors may occur in the execution of the plan. The Human Factors literature on such
errors in execution generally draws a distinction between slips and lapses. A slip is an action which is not
carried out as planned and will therefore always be observable. A lapse is a failure of memory and may not
necessarily be evident to anyone other than the person who experienced the lapse.
4-18 Safety Management Manual (SMM)
Figure 4-5. Contributing factors to human error
Planning errors (mistakes)
4.6.5 In problem solving, we intuitively look for a set of rules (SOPs, rules of thumb, etc.) that are
known and have been used before and that will be appropriate to the problem in hand. Mistakes can occur
in two ways: the application of a rule that is not appropriate to the situation, or the correct application of a
rule that is flawed.
4.6.6 Misapplication of good rules. This usually happens when an operator is faced with a situation
that exhibits many features common to the circumstances for which the rule was intended, but with some
significant differences. If the significance of the differences is not recognized, an inappropriate rule may be
applied.
4.6.7 Application of bad rules. This involves the use of a procedure that past experience has shown to
work but that contains unrecognized flaws. If such a solution works in the circumstances under which it was
first tried, it may become part of the individual’s regular approach to solving that type of problem.
4.6.8 When a person does not have a ready-made solution based on previous experience and/or
training, that person draws on personal knowledge and experience. Developing a solution to a problem
using this method will inevitably take longer than applying a rule-based solution, as it requires reasoning
based on knowledge of basic principles. Mistakes can occur because of a lack of knowledge or because of
faulty reasoning. The application of knowledge-based reasoning to a problem will be particularly difficult in
Culture
Training
Personal
factors
Other
factors
Procedures
Equipment
design Organizational
factors
HUMAN ERRORS
Incidents
Accidents
Chapter 4. Understanding Safety 4-19
circumstances where the individuals are busy, as their attention is likely to be diverted from the reasoning
process to deal with other issues. The probability of a mistake occurring becomes greater in such
circumstances.
Execution errors (slips and lapses)
4.6.9 The actions of experienced and competent personnel tend to be routine and highly practiced;
they are carried out in a largely automatic fashion, except for occasional checks on progress. Slips and
lapses can occur as the result of:
a) Attentional slips. These occur as the result of a failure to monitor the progress of a routine action at
some critical point. They are particularly likely when the planned course of action is similar, but not
identical, to a routinely used procedure. If attention is allowed to wander or a distraction occurs at
the critical point where the action differs from the usual procedure, the result can be that the
operator will follow the usual procedure rather than the one intended in this instance.
b) Memory lapses. These occur when we either forget what we had planned to do, or omit an item in a
planned sequence of actions.
c) Perceptual errors. These are errors in recognition. They occur when we believe we saw or heard
something which is different from the information actually presented.
Errors versus violations
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Safety Management Manual (SMM) 安全管理手册(34)
