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At the beginning of this course, we will discuss about Human Failure especially on Air Traffic
Services. In this video we are going to explore how human failure occurs. Please feel free to pause
this video at any point to take notes. Human failure can be divided into two main types - human error
and violations. Human error tends to be caused by an unintentional decision or action. although the
intention was to carry out the task correctly. Violations, conversely, are intentional failures. This is
where a system or set of rules are in place but they have been ignored or disregarded for some reason.
Violations can be routine, for example where bad practice or not applying rules has become the norm
within a given environment.

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They can be situational, where rules are not adhered to due to other factors, such as time constraints or
not having the proper tools for the job. Or, they can be exceptional, where someone attempts to solve
a problem in unusual circumstances, leading to them taking a calculated risk but knowing they are
deliberately not sticking to the rules to do so. For the purpose of this module we are going to primarily
focus on human error and strategies to avoid this, rather than deliberate violations. However, non-
adherence to rules, policies and procedures should always be considered as a potential causative factor
when failure occurs. With regard to human error, this can be further divided into action-based errors
and thinking-based errors.

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The first type of action error is known as an action-based slip. Slips can be thought of as inadvertently
doing something you’re not supposed to do. Think of it like a kind of a whoops moment. Examples of
this could be accidentally activating your windscreen wipers instead of your indicators when driving a
car, or by putting a box of cereal into the fridge, instead of a carton of milk, when you’re half asleep
in the morning. They are unintentional errors but a mistake has been made nonetheless. We can also
have memory-based lapses. This is where you may be undertaking a task and you lose your train of
thought or forget to do a step in the process.

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These can occur in overly familiar tasks that require little thought but can also occur when the task
itself is very complicated and leads to poor decision-making. An example of a memory based lapse
could be misplacing your house keys and forgetting where you put them, particularly if you’re in a
hurry or you’ve been distracted. Conversely, thinking errors tend to be decision-making failures.
Thinking errors can be, rule-based mistakes, when someone makes a mistake during a task even if
they are aware of the rules, or knowledge-based mistakes, where someone may not have the
prerequisite information needed to undertake a task correctly.

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This often manifests itself in the person undertaking the task doing something incorrectly even though
they think they’re doing the right thing at the time. Mistakes frequently occur if a person is
undertaking too many tasks simultaneously, if the task is very complicated, or if there are time
pressures involved in the task. By understanding how human failure can occur and better still having
an awareness of what could have caused that failure, we can anticipate if human failure is probable in
a given situation and look at putting barriers and strategies in place to prevent that failure from
occurring.

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In our previous example of losing a set of house keys due to the person in question being rushed, we
could suggest several strategies to improve the situation, such as allowing more time to prevent
rushing or to have a permanent place to store the house keys such as a hook near the front door.