Re: Error Chains
Joan Kuenzi (joan.kuenzi_at_nwa.com)
Tue, 17 Jun 1997 13:39:23 -0700
CharlieRU_at_aol.com wrote:
>
> Neil,
> Paul Russell, Boeing Safety Office, did a nice piece of work on "error
> chains" a couple of years ago. As I remember his presentation, he addresses
> errors as variables being present or not present, kind of like holes in swiss
> cheese, the pieces of cheese being each individual's performance. What I
> liked about it is that events(performance) are directly linked to an
> individuals Situational Awareness. Crews like the concept in that if you make
> and error the variables can be altered by correcting the error made.
> Recovery. It reminds crews that mistakes made are not unalterable events or
> links in an error chain. The error chain is really what the accident
> investigation board witnesses. The mishap crew is unaware of such a chain
> but aware of their own performance, or lack of performance. CRM enhances
> this mode of check and balances, let's think this out together with all
> involved feeding the captain information.
> Have Fun Fly Safe
> CharlieI haven't been on for awhile, and I am sorting through myriad messages,
but the "error chains" discussed here is a product of Professor Jim
Reason out of the University of Manchester.