There is a common phrase in Human Factors Engineering… “Error Trap.” This is the image we will put next to this phrase in my new book… (i.e., an actual real-life “error trap” door).
Scenario: Your singing your favorite song in the shower. The spouse needs to go down to the basement and start a load of clothes in the washer. They open the door BUT DO NOT CLOSE IT, and you finish your shower… you can imagine that the first step is a real doozy.
Questions:
Root cause?
Who’s going to be the one to shoulder the blame? (just play along, as we know this is not a blame game for real pro’s)
Spouse for opening the Door?
You for not watching where you’re walking (a very popular root cause – albeit a fool’s root cause)?
Can you list the “Active Failures” and the “Latent Failures” that led to this fall?
Which ones would be causal factors in your causal analysis?
For me, this is a clear example of a bad design that was allowed to be put in place and was not captured as a hazard opportunity in the hazard evaluation exercises within the SMS. Even though two (2) humans committed acts in this event, their acts were NOT unsafe acts; the part that made their acts unsafe was this insane design that was allowed to be put in place and never identified after its installation. A complete failure (latent failure) of the organization.
Photo Credit: unknow