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In recent years, there has been a realization that total elimination of human error may be difficult to achieve. A further reduction of accidents will require a better understanding of how practitioners manage their errors in ways that consequences are contained or mitigated. With this goal in mind, the present study has set out to propose a framew...
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Context 1
... put into perspective the various cognitive strategies involved in detecting errors at the conceptual and execution stages, Figure 1 presents a simple model of human performance that encompasses four stages: (1) assessment of the situation, (2) formulation of a plan of action, (3) rehearsal, execution and adaptation of the plan and (4) evaluation of the outcome of performance based upon system feedback. The four stages are performed in a circular fashion, so that feedback of performance can be used to alter an existing goal or modify a previous assessment of the situation. ...
Context 2
... Figure 1 here This is a nonlinear model of performance since there is no need for practitioners to complete situation assessment before decision making. Practitioners may live up with some uncertainty about the situation and make a decision how to tackle the problem at an early stage; as more evidence becomes available, the situation can be revised. ...
Context 3
... main argument, put forward in this paper, is that human error should not be seen as a failure of cognitive resources to make a correct assessment or develop a correct plan in the first place. Figure 1 presents an incremental view of performance where an assessment can tolerate certain sources of uncertainty and proceed with a plan of action while remaining vigilant to new evidence. Detecting errors in situation assessment amounts to handling data uncertainty so that the assessment becomes more accurate and reliable. ...
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... sources of uncertainty faced by operators at different stages of performance (as shown in Figure 1) include: incomplete and conflicting data, goal tradeoffs, need to modify plans quickly, acting and monitoring simultaneously, masking effects and automation effects. Table 1 Antonogiannakis, 2003;Mitsotakis, 2006). ...
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Citations
... • Cognition: this issue discusses the importance of the mental process of acquiring knowledge and understanding information. This is related to the human factor field of research (Chen et al. 2021;Kontogiannis et al., 2009). • Error tolerant system: this issue discusses the benefits of error tolerant systems considering that human errors are inevitable (Kontogiannis et al., 2009;Reason et al., 2006). ...
... This is related to the human factor field of research (Chen et al. 2021;Kontogiannis et al., 2009). • Error tolerant system: this issue discusses the benefits of error tolerant systems considering that human errors are inevitable (Kontogiannis et al., 2009;Reason et al., 2006). • Commitment: this issue discusses the importance of commitment, in particular management, to the process or methods implemented by the organization (Lofquist, 2010;Rankin et al., 2000). ...
... Additionally, different authors agree that it is imperative to design a system that is error tolerant as human errors are hard to prevent (Rashid et al., 2014, Kontogiannis et al., 2009, Latorella et al., 2000. The timing of when the error is captured and identified could make all the difference. ...
This paper provides a systematic literature review (SLR) regarding risk management technological advances, including methods combined with proactive, interactive, and predictive measures that are currently being used to mitigate risks in the aviation sector. Predictive and interactive methods can create error tolerant systems, prevent accidents, and improve quality and safety systems by providing feedback to the system. This study began with a preliminary review of the human error and risk management fields of study. An initial string was created using the keywords of these initial references. This study developed an iterative protocol, searching and selecting articles in an iterative process refining the research scope. Once the scope was clearly defined, the articles were chosen using three selection criteria. The findings of the systematic literature review indicate that current risk tools and models are reactive, but there has been a significant recent effort to study proactive, interactive, and predictive analysis methods. There is an opportunity to use and develop advanced data analysis tools or artificial intelligence (AI) to mitigate risk in a more predictive way for the aviation sector.
... Air traffic controller errors are believed to play a significant role in 24% of air crashes. However, if we take into account aviation incidents, the share of air traffic controllers' errors is significantly higher and can be even 82% [48,49]. ...
(1) Background: Working in a high-risk profession is associated with taking on a large responsibility and risking loss of health or life. These professions include, among others, air traffic controllers, firefighters, and ECDs. People working in these professions are particularly vulnerable to experiencing high levels of stress and developing professional burnout syndrome. The aim of the conducted research was to assess the external and internal differences in the intensity of occupational burnout dimensions among representatives of high-risk occupations and to distinguish burnout profiles among them. (2) Methods: The total number of participants working in high–risk occupations who took part in the study was N = 1239, including the following job positions: air traffic controllers (n = 107), firefighters (n = 580), and ECDs (n = 558). The respondents completed the following self-report questionnaires: a structured survey and the Link Burnout Questionnaire. The following statistical tests were performed: cluster analysis, analysis of variance, and chi-square test of independence. (3) Results: The highest intensity of burnout dimensions was presented by representatives of ECDs. Profiles reflecting the types of occupational burnout were distinguished. The representatives of air traffic controllers demonstrated the following profiles: 1—low risk of burnout with a component of psychophysical exhaustion; 2—exhausted with a moderate tendency to disappointment; 3—burned out, ineffective, and uninvolved. The profiles of the ECDs were: 4—engaged, with a reduced sense of effectiveness; 5—with a reduced sense of effectiveness; 6—burned out with a low sense of effectiveness. However, the profiles of the firefighters were: 7—not burned out; 8—at risk of burnout; 9—exhausted with a tendency towards disappointment. Individuals representing the various burnout profiles differed in terms of the severity of the dimensions of occupational burnout as well as sociodemographic and work-related characteristics. (4) Conclusions: The process of occupational burnout varies among people in various high-risk occupations and due to sociodemographic characteristics. The internal differentiation of people representing high-risk professions requires different psychological interventions and preventive measures.
... First, by investigating the receptive quality of mindfulness that individuals can draw on to reduce error hiding, we extend current theorization on the link between mindfulness and error-related phenomena in particular. There is currently a relatively narrow focus on how enhanced attention to the present might relate to error prevention, for example, by reducing error occurrence Dane, 2011;van den Hurk et al., 2010) and unsafe behaviors (e.g., Feldman et al., 2011;Zhang & Wu, 2014); or increasing error detection (e.g., Kao et al., 2021;Kiken & Shook, 2011;Kontogiannis & Malakis, 2009;Tepper & Inzlicht, 2013). Yet, errors will inevitably occur, even by highly skilled/trained, expert performers (Nguyen & Williamson, 2015). ...
Hiding errors can undermine safety by amplifying the risks of undetected errors. This article extends research on occupational safety by investigating error hiding in hospitals and applies self-determination theory to examine how mindfulness decreases error hiding through authentic functioning. We examined this research model in a randomized control trial (mindfulness training vs. active control group vs. waitlist control group) within a hospital setting. First, we used latent growth modeling to confirm that our variables were related as hypothesized, both statically or cross-sectionally as well as dynamically as they evolved over time. Next, we analyzed whether changes in these variables were a function of the intervention and confirmed the effects of the mindfulness intervention on authentic functioning and indirectly on error hiding. To elaborate on the role of authentic functioning, in a third step, we qualitatively explored the phenomenological experience of change experienced by participants in mindfulness and Pilates training. Our findings reveal that error hiding is attenuated because mindfulness encourages a receptive view of one's whole self, and authentic functioning enables an open and nondefensive way of relating to positive and negative information about oneself. These results add to research on mindfulness in organizations, error hiding, and occupational safety. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Recently, mindfulness, as a personal characteristic of being attentive to and aware of what is taking place in the present (Brown and Ryan, 2003), has been identified as one potentially effective intervention for reducing workers' unsafe behaviors (Kao et al., 2021;Koppel et al., 2019). Mindful workers are considered to be more likely to notice potential risks, make unbiased judgments and control their unsafe or risky behaviors (Feldman et al., 2011;Kiken and Shook, 2011;Kontogiannis and Malakis, 2009;Zhang and Wu, 2014). The unique contributions of mindfulness towards safety performance have been well-recognized in safety-oriented contexts such as nuclear power (Solomon and Esmaeili, 2021;Zhang et al., 2013;Zhang and Wu, 2014), airline (Ji et al., 2018) and petroleum distribution (Kao et al., 2021). ...
This research developed and tested an integrative model regarding the effects of mindfulness on construction workers’ safety performance. Both psychological contract of safety and coping behaviors were examined as mediators. Empirical data were collected from 498 construction workers in China using a detailed questionnaire. Structural equation modeling was performed to analyze the data using AMOS and Mplus. The results showed that mindful workers were likely to have higher safety performance. Psychological contract of safety had stronger mediating effects on the relationship between mindfulness and safety performance than the coping behaviors. Furthermore, this research found that mindfulness was more related to errors and violations than safety participation. Problem-focused coping primarily mediated the effect of mindfulness on safety participation, while emotion-focused coping primarily mediated the effects on errors and violations. In addition, married workers reported more operational errors; older workers were more reluctant to follow safety rules; and workers with low education level were less likely to engage in voluntary safety activities. Theoretical and practical implications and associated research limitations are also discussed in this paper.
... Factor Event Analysis: Human errors are recognized as among the main causes of serious accidents/incidents across a wide range of industries. Systematic addressing to human errors in the design, operation, and maintenance of highly complex systems can lead to increased safety and more efficient operation 21,31,32 . Fault tree analysis: It is a deductive technique focusing on a specific accident and determining the causes of that event. ...
Background: The decision matrix risk assessment (DMRA) is a systematic approach widely adopted in risk management in occupational health and safety to make a risk analysis and assessment and assist in decision-making for risk tolerability. Risk is a substantial part of sports organizations as well as other organizations and daily life; therefore, it is inevitable in any activity. One may encounter various risks of injury since sports fields and equipment are not ergonomic for performing sports activities healthily Aim: Ultimately, to help improve the conditions of sports activities, the present strummed to determine the activities to be maintained as a result of a risk assessment using the decision matrix risk assessment technique where accidents are classified by their severity and probabilities. Methods: The present study adopted DMRA (L-shaped matrix); it is among the systematic methods widely used in occupational health and safety (OHS) risk assessment. In general, it is an assessment technique where one may obtain a risk assessment value by considering two factors. Results: Likewise, we identified those requiring control measures and a cease at the last resort. Conclusion: Overall, we proposed some corrective actions that may help prevent the occurrence of the presented accidents through the implementation of occupational health and safety regulations published by the correspondent institutions. Keywords: Risk assessment, sports activity, health and safety, decision matrix, risk analysis
... Just as many mistakes are made in situations of underload, which raises the role of the optimal stress level for cognitive function efficiency (Rodrigues et al., 2018). The so-called complacency syndrome-a sense of self-satisfaction accompanied by unawareness of actual dangers-may explain the causes of air accidents occurring during routine flights (Kontogiannis, Malakis, 2009). The errors in the subjective assessment of the stress level and assessment of the drop in the efficiency of cognitive processes were revealed. ...
... In addition, a high level of acute stress may lead to overconfidence and more risky behaviors. The next generation of crew resource management (CRM) includes new error management systems applied in high-risk environments of air traffic control (Kontogiannis, Malakis, 2009;Bove, 2004). Their role includes implementing strategies for self-detection of errors, explaining their sources and correcting them, and identifying personal factors contributing to errors. ...
How can one protect oneself against stress and burnout syndrome? What is the role of human cognitive processes? This study explores the moderated mediation effects of the trait of self-efficacy in a mode of perceived stress and burnout syndrome in a group of Polish air traffic controllers. The first aim of this study was to develop a better understanding of the construct of perceived stress. We proposed a latent variable, called psychological comfort, to clarify the role of self-efficacy in relation: stress and burnout. The second aim was to test the assumptions about the mediating role of self-efficacy in the relationship between stress and burnout via the level of psychological comfort. The most important aim was to investigate whether the direct and indirect associations between stress and burnout were moderated by the level of psychological comfort. For the study, self-report questionnaires were distributed to 609 active air traffic controllers from 18 air traffic control centers of the Polish Air Navigation Services Agency (PANSA). Three hundred forty sets of questionnaires were returned (55.88%) of which 110 were correctly completed (return rate - 18.1%). We formulated 5 hypotheses. Two of them were confirmed: the indirect effect of perceived stress on occupational burnout via general self-efficacy was significant and the indirect relationship between perceived stress and occupational burnout would be different for air traffic controllers characterized by various levels of psychological comfort. The study emphasizes the role of certain human cognitive resources which may play a role in the relationship between stress and burnout: self-efficacy, perceived stress, and psychological comfort. There are important practical conclusions from the research. Knowing about the level of psychological comfort helps to plan better actions to protect against the negative impact of chronic stress on cognitive functions and against the development of clinical symptoms of burnout syndrome.
... (2) use of redundancy for error detection. A four-stage human error detection strategy was proposed by Kontogiannis and Malakis (2009). The four stages are awareness-based detection, planning-based detection, actionbased detection, and outcome-based detection. ...
... This stage involves checking activities to detect errors before and after a specific task. Outcome-based detection includes strategies such as checking time-dependent changes, checking mismatches between reality results and expected outcomes, and the consideration of the effects from the interventions of other agents (Kontogiannis & Malakis, 2009). ...
... The former (forcing function) usually represents some forced measures to avoid some potential mismatches. For instance, in the context of aviation, a computer algorithm can serve as a forcing function that gives commands to a pilot as a response to his/her erroneous action which could put an aircraft in a dangerous situation (Kontogiannis & Malakis, 2009). For the latter (other person's detection), cross-checking is one of the effective ways for human error detection, and it can easily be understood that the people involved in cross-checking should better be from a third-party group and outside the operational situation (Sharit, 2012). ...
Human error has contributed considerably to accidents in various working environments. In the field of human error and reliability, environmental factors are termed performance-shaping factors, error-forcing conditions, common performance conditions. This chapter focuses on the cognitive mechanisms related to the occurrence of human errors. This theory foundation can serve as the technical basis for further research, such as error detection, error prediction, error analysis, error correction, etc. Human error classification is fundamental to human error research, investigation, prediction, detection, analysis, and control. For human reliability analysis (HRA) practitioners, its most important function is to quantify human error probabilities in a task or scenario of interest in risk assessments. In other domains in which human errors could be a great source of vulnerability, HRA also has many considerations and adoptions, such as oil and gas, aviation, spaceflight, health care and surgery, railways, cybersecurity, and human-autonomy interaction.
... In the disruption stage, prohibitive voice can be instrumental in preventing performance losses in teams by facilitating error management, a team process through which members reduce the amount, scope, and impact of errors in their teams (Rizzo, Ferrante, & Bagnara, 1994;Kontogiannis & Malakis, 2009). Errors are the discrepancy between expected and observed outcomes (Zapf & Reason, 1994). ...
Teams often confront exogenous events that induce discontinuous change and unsettle existing routines. In the immediate aftermath of such events (the disruption stage), teams experience a dip in their performance and only over time regain their previous performance levels (in the recovery stage). We argue that prohibitive voice that allows teams to manage errors better is instrumental for preventing performance losses in the disruption stage. Whereas, promotive voice that helps teams innovate or improve team processes, can facilitate steeper and more positive performance trajectories in the recovery stage. We also propose that voice is especially functional when teams confront higher change intensity and, thereby, highlight that voice is particularly important when change events cause greater discontinuity in the task environment. We found general support for our theory in a correlational field study involving 172 production teams in which we examined over time trajectories in objective team performance, and a field experiment involving 88 teams in a different production setting, where team members were trained, incentivized, and provided opportunities to engage in voice. We discuss the implications of our findings for literatures on voice, team adaptation and resilience.
... It is colloquially estimated that between 70% and 80% of all aviation accidents can be attributed to human error (O'Hare, Wiggins Batt & Morrison, 1994;Shappell & Wiegmann, 1997, Wiegmann & Shapell, 2003. It is becoming increasingly apparent that the human factor and consideration of human performance variability are crucial to maintaining and improving safety standards (Danaher, 1980;Shappell & Wiegmann, 1997;Reason, 2000a;Shorrock & Kirwan 2002;Bushnell, 2007;Kontogiannis & Malakis, 2009;Berry, 2010;Munene, 2016). ...
... Safety is the most important driver of operations at ATNS and ANSPs world-wide, and the control of performance variability is crucial to maintaining and improving safety standards (Danaher, 1980;Shappell & Wiegmann, 1997;Reason, 2000a;Shorrock & Kirwan 2002;Bushnell, 2007;Kontogiannis & Malakis, 2009;Berry, 2010;Munene, 2016). As a latent condition for human error, the definition and measurement of morale will enable its elevation, assisting in the control of performance variability as part of a systems approach to safety in safety-critical environments. ...
Background: Low morale is classified as a latent condition for performance variability in safety-critical environments. Morale management may assist in the control of performance variability as part of a systems approach to safety. A context-specific model for measuring and managing morale with reference to followership in a safety-critical air traffic control (ATC) environment could not be found.
Purpose/Aim: The purpose of this study was to develop a model that enables the measurement and management of air traffic controller (ATCO) team morale.
Research Design: An exploratory sequential mixed method design was adopted. A census approach to sampling was used to conduct 21 focus group sessions as the qualitative phase, providing the definition and drivers of morale. The Measure of Morale and its Drivers (MoMaD) survey instrument was created from qualitative data, then administered to 256 ATCOs in the quantitative phase. Statistical methods included exploratory factor analysis, correlation and regression analysis to construct the final MoMaD model.
Results: A context-specific definition of morale is provided and communication management, team cohesion, leadership interaction, staff incentive, staffing level, workplace health and safety and mutual trust were found to be the drivers of morale in a safety-critical ATC environment. A single-item measure of perceived morale reflected the state of context-specific ATCO team morale more accurately than an existing generalisable multi-item measure.
Conclusion: This study contributes to the body of knowledge by integrating applicable aspects of morale, followership, performance variability and organisational culture and climate in safety-critical ATC environments into a new theoretical framework. The MoMaD instrument is presented as a context-specific model for measuring and managing ATCO team morale in an ATC environment.
Recommendations: Future research opportunities include the possible influence of morale as a predictor of morale in safety-critical environments and the development of a context-specific multi-item measure of morale for integration into the MoMaD model.
Key terms: morale; followership; human error; human performance variability; air traffic control; aviation; corporate culture; safety culture; esprit de corps; motivation
... A good organizational culture relies heavily upon the attitudes and interpersonal skills engendered in the workforce. Working in the fields of aviation and air traffic control, Kontogiannis and Malakis (2009) identified multiple attitudinal factors which play a part in error detection. These include: vigilance and alertness (including being able to 'make the familiar strange'); suspicion and curiosity; awareness of vulnerability to errors, and awareness of degradation and disengagement, for example through distraction, fatigue or illness. ...
Errors in examination papers and other assessment instruments can compromise fairness. For example, a history question containing an incorrect historical date could be impossible for students to answer. Incorrect instructions at the start of an examination could lead students to answer the wrong number of questions. As there is little research on this issue within the educational assessment community, we reviewed the literature on minimizing errors in other industries and domains, including aviation, energy, and medicine. We identified generalizable principles and applied them to our context of educational assessment. We argue that since assessment instrument construction is a complex system comprising numerous interacting components, a holistic approach to system improvement is required. Assessment instrument errors stem primarily from human failure. When human failure occurs, it is not good enough to suggest that ‘to err is simply human’. Instead it is necessary to look deeper, evaluating the latent working conditions that underpin the efficacy of procedures, making the human failure more or less likely. Drawing from the aviation industry’s ergonomic SHELLO model, we articulate and explore three of the most critical working conditions that relate to our context: (i) time pressure, (ii) workload and stress, and (iii) wider organizational culture, including good error data collection. We conclude with recommendations for best practice in minimizing errors in assessment instruments. A ‘good’ error culture should be promoted, which avoids blaming individuals. Errors should be acknowledged readily by all, and system owners should take a scientific approach to understanding and learning from them.
