435 / 975
Functional Safety 2014
4
th
– 5
th
November 2014
Copyright © 2014 by Cenbee Bullock PFS Consulting Ltd
Page 5 of 14
Fig. 2 Percentage of primary causes attributable to each phase of lifecycle (by UK HSE)
Why human errors?
Professor Reason
2
, in a paper on clinical mistakes, states
“Human error problems can be viewed in two ways: the person approach and the system
approach.…… Each has its model of error causation and each model gives rise to quite
different philosophies of error management. Understanding these differences has important
practical implications for coping with the ever present risk of mishaps in Clinical practice.”
This concept is also applicable to other fields, not just clinical, and in order to minimise the systematic
failures caused by human errors, it is essential to understand how a human’s mind works. A proverb
from Sun Tzu
3
says: “If you know the enemy and know yourself, you will not be imperilled in a hundred
battles.”
Plato
4
developed a cave allegory that describes three synopsis of the human mind:
i.
Imprisonment in the Cave
Perception – a human’s mind does not always see reality correctly;
ii.
Departure from the Cave
Adaptation – a human’s mind needs time to absorb new information or changes;
iii.
Return to the Cave
Ignorance – a human’s mind has a tendency to omit detail.
2
Professor J Reason, “Human error: model and management” 18 March 2000
3
Sun Tzu, “Art of War” 6
th
Century BC
4
Plato, “Allegory of the Cave”