Designing Safety Systems to Make Error Impossible

March 17, 2003
The day it was reported that the criminal inquiry into the January 2000 Alaska Airlines crash was reopened to probe the airline's alleged practice of falsifying maintenance records, and that workplace fatalities for Hispanics has increased, Dr. Donald A. Norman told the hundreds of occupational safety, health and environmental professionals, "We know it's not human error, it's system error, so then design the system to make error impossible, build safety into design."

The EHS professionals were attending the American Society of Safety Engineers' (ASSE) two-day Human Error and System Design Symposium held March 14 and 15 near Atlanta. The ASSE symposium, which featured 23 speakers and drew a diverse audience of close to 400 people from as far away as Australia and Puerto Rico, aimed to provide a different perspective into the causes of human error with a focus on the workplace and about managing occupational safety more effectively through a better understanding of human error.

"When it comes to mistakes, we want to find the cause of the problem and place blame, that's one of the problems," Norman, an expert on the human side of technology and a professor of computer science at Northwestern Technology, told the audience during the opening session. "One of our major problems is that the legal system is designed to find cause and then to punish. It should not be that way. People should not be afraid to report errors. Errors give us data and that is a good thing. It's a tool we use to prevent future accidents. In Japan they reward people that find errors."

As for the recent report that workplace fatalities had increased for Hispanic workers, Norman noted that many are ill paid, poorly trained and trained to work too fast. "To reduce fatalities and injuries you need to change the conditions that surround workers," Norman added. "The workers are asked to perform in non-human ways."

From hearing about "forced function" to "conceptual models" to the influence of culture in human error, attendees said they found the presentations, the sharing of practical solutions to be helpful and plan to incorporate much of the information learned at their workplace.

"I'm here because I want to take back and apply the principles of human factors that Dr. Norman and the others have discussed to our healthcare industry to improve quality," said Michelle Geis, of Healthinsight, a healthcare company that operates in Utah and Nevada.

"We have over 8,000 employees alone in Georgia. We're here to learn new ways to improve safety, the new techniques and new ways to measure safety performance other than just looking at the numbers," said Joe B. Mobley of Southern GEM Group, an energy corporation. "I then take the safety information and applications to our customers as part of our ongoing efforts to prevent injuries."

Before, during and after an accident occurs, companies and industries and professionals such as doctors and pilots need to look deep into any possible causes. "Don't fix the problem, fix the source of the problem," said Norman. "Don't jump to a solution, ask not just once, but many times what caused the problem. That's the philosophy behind the '5 whys' system in Japan. You can't just initiate the solution if you don't know what the cause is."

He used as an example the act of locking a car. The automotive industry designed a system whereby you have to lock your car with your keys when you are on the outside of the vehicle, thereby reducing the chance of locking your keys ever again in your car, Norman pointed out. "Now that's one example of forced function. Make the system so errors can't happen," he added.

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