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The Secret of Human Mistakes: Why Can This Seemingly Ordinary Behavior Lead to Disaster?
In many high-risk industries, whether nuclear power, aviation, space exploration or medicine, "human error" is considered one of the main causes of disasters and accidents. This seemingly ordinary behavior often leads to catastrophic outcomes, and the reasons behind it are thought-provoking.
Human error refers to the occurrence of an action that is not intended by the actor and does not conform to the rules or expectations of external observers, often causing a task or system to exceed its acceptable limits.
Human error can be summarized as a behavior that deviates from intent, expectation, or desirability. This type of error can be caused by two situations: one is that although the action is carried out as expected, the plan itself is insufficient, leading to errors; the other is that the plan is appropriate, but the performance during execution is poor, leading to errors and omissions.
In short, a single failure without a specific plan is not a mistake.
Human error and performance are two sides of the same coin. The mechanism of "human error" is the same as that of "human performance", where wrong behaviors are labeled as errors after the fact, but in fact they are part of normal human behavior. In daily life, there are indeed a large number of mindfulness or wrong behaviors, and the research on these behaviors shows their diversity and classification methods.
Human Misclassification
There are many types of human errors, and classifying them according to different criteria can help us better understand and prevent them. Here are some common classification methods:
Exogenous errorsvsEndogenous errors: refer to causes that occur outside the individual and causes that occur within the individual, respectively.Situation AssessmentvsResponse Planning: Error Types from Problem Detection to Action Planning.Activity ErrorsandExecution Errors: Such as mistakes or execution errors, as opposed to intention errors.Active ErrorsvsLatent Errors: Errors that are obvious and hidden within an organization.
For example, active errors are behaviors that can be directly observed, while latent errors arise from underlying weaknesses in the organization.
Among these categories, individual-level error mechanisms and social-level team errors both affect the final results to a certain extent. Some mistakes can be traced back to moments of carelessness or distraction, while some stem from overconfidence and carelessness.
The Sources and Effects of Human Errors
Research on human cognition shows that many everyday behaviors are susceptible to lack of attention, memory limitations, and decision-making biases. These biases can lead to quantitatively incorrect patterns when presenting global system activity. Among them, research on the availability heuristic and other cognitive biases reveals humans’ vulnerabilities when faced with complex situations.
For example, misunderstandings in certain social interactions may lead to confusion in thought and, in turn, behavioral errors.
There is also debate about human fallibility. Some experts have suggested that simplifying human behavior into categories of "right" or "wrong" is an unhelpful simplification of a complex phenomenon. Current research is more inclined towards understanding the variability in human performance and exploring how to effectively manage this variability.
ConclusionHuman behavior and errors are predictable, and variations in human behavior can be managed effectively. Relative to the failure and success of events, resilience engineering provides a new perspective to understand the positive role of humans in complex systems. Can we improve overall safety and reliability by improving the management of human performance in the face of errors and disasters?
