Tuesday, May 08, 2012

Human Error in Complex Systems

Former Royal Australian Air Force test pilot, Robyn Clay-Williams, from the UNSW Centre for Clinical Governance Research in Health, will speak on "Human Error in Complex Systems" at the Australian National University in Canberra, 3pm 15 May 2012. This is a free talk with no need to book:

Human Error in Complex Systems

Robyn Clay-Williams (Centre for Clinical Governance Research in Health, UNSW)


DATE: 2012-05-15
TIME: 15:00:00 - 16:00:00
LOCATION: Seminar Room (N101), CSIT Building (Building 108, North Road)
CONTACT: Malcolm.Newey@anu.edu.au

One of the by-products of conducting normal human operations in complex systems is error. Colloquially, error has been acknowledged as an inherent part of the human condition since Cicero (106-43BC) declared "to err is human". It was not until the Second World War, when accidents occurred on a large enough scale to impact on performance, however, that error became linked to safety. With the introduction of computer-based information technology in the 1960s, systems became larger, increasingly centralised and more complex. As human ability to manage these systems started to become a limitation, accidents became a more common occurrence. Interdependency of system elements and fast system response may cause a seemingly innocuous error to develop into a catastrophic accident before a solution can be found. Well known examples include nuclear accidents at Three Mille Island, USA (1979) and Chernobyl, USSR (1986), and the space shuttle Challenger (1986) and Columbia (2003) accidents.

Despite a large body of literature on error modelling and categorisation, little progress has been made on elimination of errors. Research has found that errors can be statistically predicted, but not with sufficient precision for prevention. The best we can do is to explore ways to minimise or mitigate the undesirable consequences of error. Current research efforts concentrate on engineering and design, psychology and human factors, or a combination of both.

Through discussion of accidents in aviation and health care, the presentation will explore how the ways that humans behave, both as individuals and in groups, can contribute to error. Some of the methods currently used by industry to prevent human error will also be introduced, with examples from aviation and health care.

Robyn Clay-Williams has a 24 year background in the Royal Australian Air Force, where she worked as an engineer, test pilot, flight instructor and aviation team skills instructor. She was the operational advisory member on the Australian Defence Force board that introduced contemporary 5th Generation Crew Resource Management teamwork training into military aviation. Her PhD investigated the efficacy of aviation-style Crew Resource Management (CRM) training in improving public health safety, by evaluating attitude and behavioural changes in multi-disciplinary teams resulting from implementation of a CRM intervention in the Australian health care field.

Robyn's postdoctoral fellowship is in the field of human factors in health care. Specific areas of interest include teams and teamwork, decision making, and usability test and evaluation of medical devices and IT systems.

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