Northwest Airlines Flight 255, a McDonnell Douglas MD-82, crashed in Romulus, Michigan, shortly after takeoff from Detroit Metropolitan Wayne County Airport on August 16, 1987, at about 8:46 p.m. It killed all six crew members and 148 passengers, and two people on the ground. There was only one survivor, it was a 4-year-old girl who sustained…...
Human Factors – Failed Checklists Read More »
Human Factors means HUMANS making decisions- OUR roles as safety professionals is to chart a path to SUCESS IN SAFETY, rather than hoping they avoid failure. Safety is NOT about luck. Safety is the confidence that there is a path to safety success – CULTURE is convincing the workers that the best path is the…...
Human Factors is Humans making decisions Read More »
Human Factors mean HUMANS making decisions- OUR role as safety professionals is to chart a path to SUCESS IN SAFETY, rather than hoping they avoid failure. Safety is NOT about luck, safety is having the confidence that there is a path to success – CULTURE is convincing the workers that the best path is the…...
Human Factors 101… chartering a path for safe decisions Read More »
As the trial involving the fatal crash of Air France Flight 447 begins today, prosecutors will argue that Air France (the airline flying the plane) and Airbus (the manufacturer of the plane) are liable for their role in the fatal 2009 crash. Both companies face charges of manslaughter and negligence in the incident that killed…...
Air France flight 447 Crash – Technical Failures led to Human Errors Read More »
A traditional view of events and accidents is that they are caused by human competence, attention, or attitude shortcomings. It may be under the label of “loss of situation awareness,” “procedural violation,” or “poor management”. A new and different view is that human error is NOT the cause of failure but a SYMPTOM OF FAILURE…...
Investigating events triggered by Human Error Read More »
I want to share a perfect failure scenario that happened to me and has been happening to me since April 2021. And yes, I see the world through the lens of a safety engineer – hate me for it if you must. The failure is 99% my fault for trusting a simple financial tool via…...
Personal Human Factors Failure experience Read More »
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Human Error Decision Matrix Read More »
As my year comes to a close on the railroad, I recently has a discussion with a senior manager about ALARP, a new acronym for the RR. The manager wanted to know more about using the Hierarchy of Controls to reduce risks; more specifically, how we would reduce the SEVERITY of the consequence of an…...
ALARP and Railroading Read More »
In his 2018 book, Risk-Based Thinking – Managing the Uncertainty of Human Error in Operations, Muschara has a passage that hits a home run in how human error is viewed in American society and why this view of human error is so difficult to break through… (p.39)… Membership Required You must be a member to...
The notion of human error (Muschara) Read More »
I am betting most everyone has heard the old phrase, “that’s an accident waiting to happen.” My brother (also a safety engineer) and I have pondered whether our father, who used that phrase often, influenced our career choices more than we had ever imagined. But how many safety professionals understand what this phrase is saying?…...
Ever heard someone say “That’s an accident waiting to happen” Read More »
Although it may be possible to accept that errors are neither as numerous nor as varied as they might first appear, the idea of a predictable error is a much harder one to swallow. If errors were indeed predictable, we would surely take steps to avoid them. Yet they still occur. So what is a…...
Variable and Constant Errors (Dr. James Reason) Read More »
Assigning probability values to errors is still very much an art form. Nonetheless, there is sufficient general agreement about the likelihood of errors occurring in various generic tasks to put them into sensible rank order. Their main use is to provide benchmarks for the range of error probabilities over different jobs.Here is a list of…...
Error Probabilities (Reason Model) Read More »
