Re:The Error Chain
Sakuma_at_BDZ.crane.jal.co.jp
Tue, 27 Jan 98 11:50:41 +0900
Dear Barry :
I am Hidetake Sakuma, working in Corporate Safety Dept., Japan Airlines
mainly for implementing human factors and CRM concepts into all areas
of airline safety business.
I have a slightly different idea from conventional notion of "Error
Chain" or "Chain of Events" and even from latest "James Reasons
Model( so-called Swiss Cheese Model). I hope this could be of any help
to your project.
The process in which any human error leads to catastrophic results like
accidents is very similar to water drops running down on the windows
glass. Once a water drop is produced( human error occured) then it
would never fail to find any other way to go in spite of any single and
naturally existing hindrance. This is because water drop itself has a
tendency to go downwards by gravity and significant human error has a
tendency to lead to unwanted events since it is a part of humans
intention. Only way to prevent both things from further proceeding may
be positive, powerful and intentional defences which are intellectually
constructed by other personnel like human factors specialists. This is
why vigorous human factors knowledge and skills are being disired in
this very area.