Human Error in the news

In Patient Safety on November 6, 2010 at 1:23 pm

Read the following from Google News this week. These are all being called “human error” although many seem like they are predictable human factor issues that should be built into safety systems. These involve police, pilots and NASA.

A woman reported calling 911 three times after being punched in the face by her brother. The call was sent to two different country police offers who were dealing with another violent situation nearby and an Alzheimer’s woman who was missing. The call center logged the complaint by woman who was punched, but the officers did not follow through with procedures. click read more below
The woman says she feels devalued, demoralized and re-traumatized by the delayed police response. Of course everyone wants immediate help when they call 911 but research has repeatedly shown that frontline workers have trouble with multitasking no matter how “good” they seem to be about it. I hope this issue gets reviewed as a process problem or a triage problem and not really a personal error.

A small plane crashed in Islamabad on November 6th. The cause of the crash is being called human error because one of the engines failed and when this happens that engine is supposed to be put into a condition called FEATHER It seems the pilot put both of the engines on FEATHER by mistake which zeroed both engines and therefore causes the plane to lose balance and thrust. A pilot back in 2006 made the same error which also caused a fatal crash. Human error by the pilot or by the manufacturer? How come a pilot is still allowed to put both engines on FEATHER??? Why isn’t this forced function that portrays a warning message such as “Confirm that you are FEATHERING the FAILED engine before proceeding”


An issues at NASA is also ebing called human error. During a test drill a NASA employee did not hear the prefaced warning and thought there was a real gunman on the campus. HE initiated an emergency response that brought SWAT team members, panicking workers and their loved ones who were receiving text messages about the situation. This is also being called a human error but once again… it seems to be a system error. When a communication is imperative shouldn’t we have more than one method of announcing it? This worker didn’t hear the warning but the warning was given. He wither had an equipment failure or a process failure.

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