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Old 14th Mar 2010, 20:27
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turbocharged
 
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alf

"Limiting the unsafe act is akin to avoidance of error (the act) or error promoting situations (awareness) which might be strategic activities such as in improved planning, decision making.
Another aspect is the elimination of error promoting situations through the use of good design, procedures, etc.
The more forward thinking aspects include acceptance that humans suffer error and thus it is important to detect and recover from the result, and then learn from the experience".

Problem is that by making 'error' the object and making the goal 'to avoid error' we miss the point that an error is actually a symptom of flawed action. The failure has already occurred by the time the error is noticed. So, the real goal is to make performance more reliable such that action remains within acceptable bounds. In a similar vein, the idea is not to 'recover' but to continue action towards a goal but now from a different starting point. TEM places 'error' outside of the human: it is something to be avoided, trapped and managed. But in reality, 'error' is an organic part of action and what we really need to do is shape the process of work to accommodate error while remaining within safe bounds.
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