Okay, something happened in which somebody seemed to make an error.
The important thing here is to look really closely at what type of error it really is, and where it comes from.
They can be subdivided into several different types of errors:
Slip (oops): Slips are often not so disastrous because they are noticed quickly and usually do not lead to damage or injury. However, every system that by design encourages slips is unacceptable
Lapse (omissions - something not done): These are more dangerous because they often go unnoticed (example: forgetting to replace an o-ring). The problem can get worse because people often think they did do it, so extra checks are necessary. They are especially dangerous during maintenance, where the problem can stay unnoticed for some time.
Mistake: Mistakes are more dangerous than omissions because people that make a mistake think they are doing the right thing. They can be so sure of themselves that they will not see the facts that say otherwise. Example: Somebody is behind in his operational training, whilst the system has already been changed. His trained reaction, based on the old system parameters, can lead to a mistake.
Tip: Refer to the "Managing Rulebreaking" section of the Hearts and Minds materials for more information about this category.
This is a general purpose navigator that has been inspired on a combination of theoretical models. Our purpose is to give you a quick method to get to a broad interpretation of observed behaviour. From there, you can go into more detail by delving into established safety culture models for further analysis and for appropriate remedies.
This "navigator" module will take you through a set of structured questions.
Select the most appropriate answer. You will get a chance to compare your outcome with examples from your own and possibly other industries, allowing you to 'calibrate' your thinking and opinion about the action during the safety event.
You can use the up arrow to go back to the previous step in the decision tree.
You can use the next arrow to see what follow-up and consequences for the person in question could apply.
The following diagram explains the complete structure of the decision flow chart (click on picture for full image in new window). Handy if you want to have the complete overview.
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