MIDTERM: HUMAN ERROR DETECTION AND PREVENTION METHODS

AUTHOR: JONEY KARAWA

CLASS CODE: IE673-TOTAL QUALITY MANAGEMENT (DL)

Due Date: MARCH 30, 2014

ELEARNING PACK ID: IE673-SPRING-2014-63-32

AUTHER’S STATEMENT: THIS MIDTERM IS COMPLETED BY JONEY KARAWA

CONTENTS:

12 HUMAN ERRORS DETECTION AND PREVENTION

INTRODUCTION:

STRAMLER 1993, defines human error as an inappropriate response by a system, whether of commission, omission, timing or inadequacy; any discrepancy between an observed or calculated value and the expected value or a value known to be correct. Errors that results to accidents are mostly attributed to negative character traits of a person which is either inherited or acquired as a result of the social environment.

Nevertheless, the very first step in reducing the occurrence of human mishaps should be to understand the causes of mishaps in order to reduce its occurrence. In my eight of active service in US Navy, I have witnessed the following human errors that cost billions of dollars and sometimes lives are lost.

1) Fig 1. An E-2C swerved off the runway in Norfolk, VA

DETECTION:

As we can see on Fig 1, the aircraft swerved off the runway in Norfolk VA; no lives were lost but it cost the Navy over $10 million. Apparently the main cause of this mishap was detected as bad brakes as well as pilot errors; this could be attributed the pilot’s lack of effective training. The problem started when the pilot was approaching rollout landing on the run way and immediately realized that the cockpit lights (beta lights) were not illuminated; which meant the aircraft will have issues decelerating. The pilot had to take control of the situation rather he made a wrong decision; decided to drop the tail hook in a last minute attempt to catch the airfields arresting wire but the aircraft veered off the runway and parts of the landing gear broke and the plane slid on its belly for about 250 feet.

PREVENTION:

If the pilot was experienced and well trained, he should have known that when the beta lights don’t illuminate he has to conduct an arresting landing. Secondly, it was recommended that the Naval Air Systems Command modify its landing systems control, add a secondary signal system and invest in a more robust braking system for its aircrafts. Moreover, funding is being requested from the Department of the department of the Navy to improve operational ground controllability on the aircraft. This program would address those system components which affect aircraft ground controllability, and the braking system would be included in the budget.

2) Fig 2. Electric burn.

PROBLEM:

We see in Fig 2 fingers burns resulting from electrical burns and this shows how electrical accidents in many cases can be tragic and fatal. For safety purposes, electrical work should be done by licensed electricians. What happened here is that the victim came in contact with a defective power cord as a result, he became part of the live electric circuit; meaning that the current entered his body. Since the

victim has no knowledge of electrical safety, he failed to realize that the power cord was energized. This power use AC current and had exposed internal components making it a hazard. His injuries were severe because of the length the electric shock acted on his body; no one was on the scene to provide first aid so the long lasting electric shock inflicted the burns.

DETECTION:

The electricity could have been detected by the use of a compact voltage detector which allows for a quick and efficient inspection by a technician. This detector is designed to make direct contact with the metallic tip to equipment to be tested and it will indicate the voltage on the power cord with visual and tactile alarm. The hand of the user forms a virtual ground around the handle of the device and collapses the electric field into the small distance between this hand and an inner electrode. Collapsing the very weak electric field in this manner increases the field strength and allows for a high degree of sensitivity and the detection of very small voltages including those resulting from power cord that is intact and working properly but simply ungrounded.

PREVENTION:

Electrical hazards can easily eliminate or reduced in the work place if employees and employers inspect the insulation on power cords, patch cords, and cables for deterioration. If a conductor is exposed, remove it from use or repair it immediately. The victim had use power cords rated for the device with which they are to be used instead he chooses to use a defective one. In addition, the situation could have been prevented if he had ensured that connecting cords and cables are also rated for the magnitude of the current to be found in an activity. Persons working with electrical instruments should have the technical know-how to understand that DC power sources are far less hazardous than activities in which AC is used. Regardless, personnel should remain cautious about working on electrical devices and apply all aspects of ORM ( Operational Risk management) in all procedures or processes.

3) Fig 3 Car crash

PROBLEM:

In figure 3 above, this is a crash caused by human error because the driver apparently was driving under the influence of alcohol according to the arresting officer’s report. Some of the statistics above by states

may be misleading but it is revealing as well. Thus, this crash is considered an ‘alcohol related’ crash even if the crash was a result of transmission malfunction. The is that the driver’s judgment is impaired and his driving skills are not effective.

DETECTION: Fig 4 Detection using alcohol odor sensors

At present drunken drivers have increased enormously and so is the deaths due to drunken drivers. The main reason for driving drunk is that the police are not able to check each and every car. So there is a need for an effective system to check drunken drivers. Drunk drivers can be monitored and detected by using a hi-sensitive alcohol sensor built into the transmission shift knob, which is able to detect the presence of alcohol in the perspiration of the driver’s balm or as he or she attempts to start driving. As shown above, if the alcohol level detected is above the predetermined threshold, the system automatically locks the transmission making the car inoperable. The drunken driving voice alert is issued through the car navigation system. In addition, alcohol odor sensors are incorporated into the drivers and passengers seats to detect the presence of alcohol in the air inside the vehicle cabin. When alcohol is detected, the system issues both a voice alert and a message alert on the navigation system.

PREVENTION:

Car manufacturers have implemented the auto safety from seatbelts and airbags that cradle and cushion the body in an accident to telemetric systems that provide automatic crash notification and send help send it right away. More car manufacturers now offer safety technology that intervenes before a crash to help minimize occupant injury and damage to a vehicle or even avoid an accident. Sensors, cameras and onboard computers these crash prevention systems warn the driver of a potential accident, so he can prepare the car and passengers for a collision. Sometimes, these cars automatically apply the brakes if the driver doesn’t act in time to avoid the crash. Although these systems are not a substitute for attentive and careful driving, they make substantial differences in the degree of injury to everyone and every vehicle in a car accident.

4) Motorcycle Crash

http://www.youtube.com/watch?v=tnuHL2JYmX4es

PROBLEM: More than 80% of all reported motorcycle crashes result in injury or death to the motorcyclist. Head injury is usually the leading cause of death in these crashes, which is why helmets that meet federal safety standards are required to be worn.

DETECTION:

Most of these motorcycles crashes result from hydroplaning as tires moving fast across a wet surface - so fast that they do not have sufficient time to channel that moisture away from the center of the tire. The result is that the tire is lifted by the water away from the road and all traction is lost. This is mostly when it’s snowing. Factors that determine at speed the tire will begin to hydroplane are; tire pressure, water depth, tread design and the weight of the motorcycle. The most dangerous control on the motorcycle is the rear brakes.

PREVENTION: Preventing crashes before they occur is a key component of a motorcycle safety program. Education programs to teach riders the basic knowledge and skills needed to safely operate a motorcycle on streets and highways. In addition, properly licensed motorcycle operators that can demonstrate basic knowledge of riding and can safely perform basic handling skills.

5) Fig 5: Oilfield Accident

PROBLEM:

Human error in manufacturing is becoming more and more visible every day. Human error is responsible for more that 80% of process deviations in drilling companies. This often results in occurrence deviation and if the resaons for such errors are unidentified, the corrective and preventive actions will fail to address the underlying conditions for that failure and will results in repaeted events.

DETECTION:

The photo above indicates a mistake that was made on a drilling rig iron and it was unforgiving. This was fatal and a lot of drilling workers were injured and two lives were lost; as a result of oilfield workplace malpractice and failure to follow all safety protocols that are in place to protect all drilling rig workers. In the oilfield drilling workplace, the external and internal variables that influence human behaviour include; procedures , human factor, training , supervision, communication and the worker.

PREVENTION:

In the oilfield drilling work place human errors can be prevented through training on how to use the drilling rig iron. Training is an effective corrective action however, this my only be effective for new employees and processes. Another effective control measure for human error in the oilfield company is to implement good systems; by providingclear, accurate procedures, instructions and job aids.If we provide supevision and good communication up and down the chain of command; that will be reduce the occurrence of these mishaps.

6) Fig 6: Computer human mistakes

Fig 6 shows a an employee of a law firm in livingtons, NJ who fell asleep on his keyboard during working hours and accidentally send send an wrong email to a client that ended with a lawsuit worth $100.000 for damages. The sleeping employing took a nap with his fingers on the keyboard and unintentionally hit multiple keys that resulted to the mistake; as a result the clerk’s supervisor was fired eventhough the court later ruled it was unfair and ordered the law firm to reinstate the supervisor.

DETECTION:

No matter how careful we may, errors and uncertainties are part of computation but some human errors can be prevented. The case above is a real error that the sleeping employee inevitably made and not introduced by the computer system. This typographical error was entered having a fault in reasoning.

PREVENTION:

We can minimize or prevent these by being more careful and thoughful especially in a working enviroment. However, as humans these things do not come easily.

To prevent this keyboards with tactile error detection shoukd be installed on computers: This type right is a new tactile input device.

Employees should get adequate night time sleep; most adults need seven to nine hours of sleep at night to be productive properly at work.

7) Human error' causes Brazil stadium roof to collapse

DETECTION:

Brazil preparations for the world cup 2014 tournament has been hit by human error and heavy rain that caused the roof of its stadium in the Arena Fonte Nova to collapse. The stadium administrators now faces major repairs as the tournament draws closer. According to investigation reports, the breakup of a part of the 36 panels of the roof membrane was caused by human error. During the findings it was realised that a portion of the membrane covering the metal deck was bent, which eventually became a barrier causing an accumulation of rain water which prevented the correct outlets for drainage. The probable cause of this damage includes; some basic structural engineering problems and mechanics of materials knwoledge of the engineers.

PREVENTION:

A lot of lessens learned from this incident and in order to prevent this from reoccurring; the design phase should comply with all the requirements of certain specified code of practices. The outpput from the structural design processes should be translated into drawings and specifications. During the construction phase, system must be established to ensure the construction will be done in accordance with the drawings and specifications. The process in such a system should include; materials acceptance, quality control, verification, validation and records management. Finally, thorough inpections should conducted by the engineering experts

8)Fig 8, Advice every parent needs to hear about firearm safety.

DETECTION:

The picture above shows a 10-year-old son of a New York police officer died after shooting himself in the face with his father's loaded revolver. The boy found the weapon on a shelf in the basement while looking for a ball his mom had hidden from him. The biggest mistake parents make is assuming their child doesn't know where the gun in the house. Ignorance and carelessness are the major causes of Handgun accidents. Other examples of handgun accidents that could have been avoided if basic gun safety rules had been practiced by parents include; two young children were playing in their home found a loaded handgun with the magazine removed on a bedside table. One child was injured when the handgun was fired. A 3-year-old Norfolk, VA boy shot himself in the foot and grazed his hand while playing with his father's gun which he found lying on the floor.

PREVENTION:

To prevent injury or death caused by improper storage of guns in a home where children are likely to be present, you should store all guns unloaded, lock them with a firearms safety device and store them in a locked container. Ammunition should be stored in a location separate from the gun. Secondly, Since children are both naturally curious and innocently unaware of many dangers around them, the government should imposes civil liability on the parent or guardian of a minor for damages resulting from the minor’s discharge of a firearm, where the parent or guardian permitted the minor to have the firearm or left it accessible to the minor.

9) Fig 9, US Navy sailor injured during a fire incident on the ship.

DETECTION:

During my long career at sea I saw fire fighters gasping for air and rushing out to open air during mock drills. Some of the many fire incidents were connected to failure to follow basic fire safety rules. In every space on the ship, there is a check off list for our guidance and support in case of observed deficiencies. We still falter; make mistakes because we felt we were too confident with shipboard damage control. Life at sea can be challenging and tough and checklist means more paperwork, filing, record keeping and inspections. Thus, because of these additional responsibilities sailors sometimes take short cuts and fail to follow the right procedures as required by the Naval Sea Systems command. Therefore safety has a new dimension altogether in today’s navy ships. If sailors diligently follow the safety management system, life would be less stressful on the ship, causing less accident.

PREVENTION:

To prevent these shipboard mishaps and safeguard life and property, an effective risk management has to be implemented with a high level of supervision. Every navy ship has its own risk management system in place and various checklists form part of the risk management system. Preventive maintenance system covers every aspect of the ship and each leading petty officer has a definite role to play under this system. Firefighting should be the responsibility should be a team effort involving every sailor assigned to that ship. They should attend basic fire fighting schools in order to learn basic fire fighting techniques.

10) Fig 10 Burns on hand

DETECTION:

This picture indicates a lady who suffered serious burns to her whole hand after fumes from petrol she was transferring between jerry can containers in her kitchen was ignited by the cooker. The lady was decanting fuel at her home in New York City when it ignited and set fire to her clothing resulting in the burns. She was treated on the scene by paramedics before taken to the hospital. Her daughter asked her for petrol because she had run out and she didn’t think about the fact that the gas cooker was on. There was shortage of petrol in the city because of a storm that led to power failure in New Jersey and New York. The petrol then went up and she got burnt on her left hand and thanks for her neighbors who were first responders and provided first aid. A few minutes’ later four firefighters wearing breathing apparatus arrived on scene and used a hose reel jet to extinguish the blaze in the kitchen and then removed the remaining petrol.

PREVENTION:

The government should draw up contingency plans for the city of NY residents to deal with petrol shortages instead of allowing them to store jerry cans filled with petrol at their homes. Keeping these cans filled with petrol at homes will massively increase the chances of having fires and explosions in the future.

The state of NY should enforce laws that will prohibit anyone from storing quantities of petrol in living accommodation such as kitchens, living rooms and bedrooms or under staircases. Any storage place should be well away from living areas and be secured to protect against the possibility of fires. In addition, warning labels about the danger of petrol and the appropriate use of petrol could be printed on

the containers such an awareness program would focus on the appropriate and safe use of petrol as well as its potential hazards.

11) Human errors in the healthcare sector.

DETECTION:

In the medical field, mistakes can cost lives. A couple of individual and environmental factors results in these mishaps. The individual factors include; fatigue, emotional stress and multitasking and environmental are things like noise, skeleton screws and culture. Fatigue is the prime factor that causes caregivers to become error-prone. Emotional stress can precipitate human error for instance, it’s imperative that caregiver’s minds focus on the patient care rather than on a dispute with a colleague. Multitasking is an effort to maximize task completion and caregivers may try to do several things at once. To save time, nurses sometimes carry medications for two patients rather than deliver the medications individually. A noisy environment not only hinders patient’s recovery but it is true that it affects the brain’s ability to focus on tasks. Many hospitals rely on reduced staff during weekends and holidays, or are short-staffed when someone calls in sick. This is a dangerous condition; when the ratio of nurse-to-patient care is greater than 1:6, the ability to properly fulfill patient needs decreases, increasing the likelihood of multitasking and fatigue

Finally, one of the most dangerous hospital cultures is one that encourages the hiding or ignoring of errors and a perfectionist may feel ashamed when he makes a mistake and try to cover it up leading to inconsistencies.

PREVENTION:

Employers should emphasize and make each caregiver feel obligated by his/her patient responsibilities to always come to work adequately rested. Hospitals should continuously conduct training and recommend that all providers learn how to control their emotions and interact with fellow caregivers in calm and constructive manners. Caregiver should be reminded of their core values and consistently serve one patient at a time. Hospitals should emulate the quietness of a library to create an environment conducive to healing. By understanding the nature of human errors and working together as teams in open and cooperative environments, we can all reduce the likelihood of human errors.

12) Fig 12, 2007 crash in Cameroon of a Kenya Airways flight

DETECTION

Fig 12 above shows rescue workers; it took over 36 hours for them to find the plane wreckage. It was reported that this crash was due to liot error which led to the death of 114 people. The Boeing 737 took off during a storm without clearance from the air traffic control in Douala Cameroon. The pilot was given misleading instrctions on how to stabilise the aircraft which led to the crash into the swamp. Flight recorders reveal that just 90 seconds after take-off the plane had rolled almost 90 degrees to the right. When the captain noticed the problem he said, "We are crashing." The first officer then mistakenly told the pilot to turn right, before correcting himself and saying, "Captain, left, left, left."Nine seconds later the plane crashed into the swamp, disintegrating on impact. The report identified the age difference between the 52-year-old pilot and the 23-year-old first officer as a contributing factor.

PREVENTION

Safety was a key issue for this flight. Pilots and staffs of other airlines should have similar data-monitoring initiatives approved by the cameroon/Kenyan Aviation Administration that are known as flight operations quality assurance programs. The aviation safety administration should also institute better cockpit communication. The cameroon Aviation administration and the kenyan counterpart should improve aviation safety systems and improving services; there should be an effective and efficient communication between both air traffic control. The pilot and co-pilot should be at least within same age group with same degree of experience and training otherwise we’ll have this discrepancy again.

References:

The Dictionary for Human Factors! Ergonomics by James H. Stramler 1993

http://www.navytimes.com

http://www.eppingelectrical.com/

http://www.nissan-global.com/EN/TECHNOLOGY/OVERVIEW

http://www.safetyrisk.net

http://www.edition.cnn.com/2013/05/28/sport/football

http://www.momlogic.com/2008/08/protect_your_kids_from_guns.php#ixzz2xSMra1yz http://www.dailymail.co.uk/news/article-452839/Cameroon-recovers-bodies-Kenya-plane-crash.html

http://www.ladycarehealth.com/7-effective-home-remedies-for-burns-on-hands/

http://www.msc.navy.mil

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