Part 1:
Is the act shown in the video an:
Mistake?
Or
Violation?
Keep in mind that we all make errors, mistakes, and commit violations.
Part 2:
Which class of error, mistake, or violation?
Tips to help:
Some errors are slips or lapses, often “actions that were not as planned” or unintended actions. They occur during a familiar task and include slips (eg, pressing the wrong button or reading the wrong gauge) and lapses (eg, forgetting to carry out a step in a procedure). These types of errors occur commonly in highly trained procedures where the person carrying them out does not need to concentrate on what they are doing. These cannot be eliminated by training, but improved design can reduce their likelihood and provide a more error-tolerant system.
Other errors are Mistakes or errors of judgment or decision-making, where the “intended actions are wrong,” ie, where we do the wrong thing believing it to be right. These tend to occur in situations where the person does not know the correct way of carrying out a task either because it is new and unexpected, or because they have not be properly trained (or both). Often in such circumstances, people fall back on remembered rules from similar situations, which may not be correct. Training based on good procedures is the key to avoiding mistakes.
Violations (non-compliances, circumventions, shortcuts, and work-arounds) differ from the above in that they are intentional but usually well-meaning failures where the person deliberately does not carry out the procedure correctly. They are rarely malicious (sabotage) and usually result from an intention to get the job done as efficiently as possible. They often occur where the equipment or task has been poorly designed and/or maintained. Mistakes resulting from poor training (ie people have not been properly trained in the safe working procedure) are often mistaken for violations. Understanding that violations are occurring and the reason for them is necessary if effective means for avoiding them are to be introduced. Peer pressure, unworkable rules, and incomplete understanding can give rise to violations. HSG48 provides further information.