Re:The Error Chain
Sakuma_at_BDZ.crane.jal.co.jp
Wed, 28 Jan 98 11:39:18 +0900
> Dear Hidetake,
> I like the theory.
> You should develop this some more.
> Guess you can say that the occasional drop in a dry climate (like Duba
> i
> usually is) may dry up on the window pane, just as an isolated error i
> n a
> safe operation passes without incident.
> I wait to hear more with great interest.
> At 11:50 AM 1/27/98 +0900, you wrote:
> >
> >Dear Barry :
> >I am Hidetake Sakuma, working in Corporate Safety Dept., Japan Airlin
> es
> >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 hel
> p
> >to your project.
> >The process in which any human error leads to catastrophic results li
> ke
> >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 a
> nd
> >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 ma
> y
> >be positive, powerful and intentional defences which are intellectual
> ly
> >constructed by other personnel like human factors specialists. This i
> s
> >why vigorous human factors knowledge and skills are being disired in
> >this very area.
> >
> >
> Surendra Ratwatte
> Captain B-777
> Emirates Airlines
> PO Box 92
> Dubai
> U.A.E.
Dear Capt.Ratratte :
Thank you for your sympathy. I think you are right in saying that the
occasional drop( isolated error ) may dry up on the heated window
glass. According to my idea, the first thing to do for preventing the
accident/incident is to identify the sort of human errors which are
actually occuring in aviation environment, just like identifying the
sort of rain drop in view of its size, mass, composition, temperature,
etc. To identify the significancy of human errors, the in-depth
knowledge of not only human behavoural sciences but aircraft technology
and operation is needed. Same human errors exhibit quite different
characteristics in different environments. I think Human Factors must
cover both disciplines. I myself come from technical world and learned
a lot about human errors from Dr. James Reason's speech and
publications.