Since most accidents and losses inevitably involve the results (consequences) of human actions, it is reasonable to assume that human error is a factor in every accident and loss. A great deal of time and energy is invested in communicating to people that they do well, and yet this human error tends to be thought of in terms of "guilt" (and not responsibility), as if implying that if were "good accidents" would never occur.
Today attention is given to the analysis of "human error" to try to establish why humans make mistakes. It has been found, perhaps not surprisingly to the reader, that some mistakes are very easy to make, while others are very difficult.
Air pilot error was considered the biggest cause of plane crashes. This was very convenient since, in many cases, while the pilot was dead, there was no arguing with him.
A few years ago, the Strategic Air Command of the United States Air Force abolished the "pilot error" claim as an acceptable reason for an accident and suggested that some alternatives be sought instead.
Alternatives that replace the “human error” argument would include the following considerations:
- The sub-optimal design. Sub-optimal systems. Sub-optimal training. Sub-optimal recruitment of staff.
Sub-optimal design is unfortunately everywhere. Two identical switches should not cause a problem if they operate on two different lamps in a room, except (perhaps) that each of the lamps is close to the other next to an aircraft crew cabin and that their use, in In this way, it implies different circumstances that definitely compromise human life.
In the oil industry, there was a key piece of specialized equipment that could be used in more than one specific situation.
This situation is known as Ekofisk's “Bravo Explosion”. As an example and in addition, we still read in the press about the “wounded” and “deceased” in certain hospitals and clinics, where the staff confuses the different “gas tubes” to be administered to the patient.
Risk Management involves asking the persistent question of "Why?" Often times to find out the real cause of the accidents so that you can manufacture reliable equipment that is proof of “foolish human errors”.
However, there are many industrial situations that impose impossible demands on us from operators in terms of the “constant alert expectation” in an extremely tedious occupation, or that require professional skills greater than those available or that create a conflict between the production and security people.
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