Human error and risk management

  • Published
  • By Lt. Col. Miguel Rosales Jr.
  • 21st Space Wing Safety Office
Everyone has at one time or another heard someone say, "I'm only human" or is familiar with the ancient Latin proverb, "Errare humanum est" - to err is human. As the 21st Space Wing chief of safety, I quickly learned what it really means to be human from a mishap standpoint.

Specifically, human error is identified as a causal factor in 80 percent to 90 percent of mishaps (civilian and military), and is present but not causal in another 50 to 60 percent of all mishaps, making it the single greatest mishap hazard. To counter this well-documented statistic, the Department of Defense safety community has implemented a human factors-based taxonomy for use in the mishap investigation process which classifies human error into 147 categories describing the involved human factor including fatigue, complacency, overconfidence, misperception, get-home-itis, negative transfer and procedural error.

The complex nuances of human error in the mishap investigation process are beyond the scope of this commentary. My team of trained safety investigators, with assistance from human factors experts in the base physiology lab, does an amazing job of capturing the causal and non-causal human factor errors that, once identified, ultimately lead to future mishap prevention strategies. Here in the 21st Space Wing, the prevailing human factor identified in on and off duty mishap investigations continues to be "Risk Assessment - During Operation." Risk Assessment - During Operation is a factor when the individual fails to adequately evaluate the risks associated with a particular course of action and this faulty evaluation leads to inappropriate decision and subsequent unsafe situation. This failure occurs in real-time when formal risk-assessment procedures are not possible.

Fortunately, the DOD and the U.S. Air Force have gone to great lengths to develop risk management processes for both on and off duty applications that address deliberate (The 5-Step Process) and real-time risk management needs (ABCD Model). Although both processes accomplish the same goal, the real-time risk management pneumonic of ABCD will be your best bet for mitigating risk in day-to-day job hazards or off duty activities.

ABCD Model
Assess the Situation: Identify and assess the hazards associated with a particular mission or activity.

Balance Controls: Consider all available controls (resources) available to ensure success or mitigate identified hazards.

Communicate: Communicate with leadership or others to discuss problems, intentions and possible alternatives. In individual situations this refers to carefully considering personal actions before deciding upon and implementing an action.

Decide and Debrief: Make the decision to continue, modify or abandon the mission or activity based upon real-time circumstances and conditions. To ensure lessons learned are passed on, provide feedback on what worked and what did not.

Remember, you are the decision maker in your personal life. I cannot emphasize enough the importance of making sound decisions based on the ABCD model which, realistically, can be accomplished in just seconds or minutes before acting on something that may change your life forever. Every mishap has a causal chain that often times can be broken by intervention - this is where the wingman concept comes into play and is critical to the risk management process. When on the job, regulatory guidance, technical orders and job guides have already accomplished the necessary risk management decisions for you to ensure your task is done safely. It is your responsibility to follow the published guidance or elevate decisions that may require any deviation from the standards.

The Air Force is at a critical juncture of balancing limited resources with available manpower to accomplish the mission. As our most valuable resource and vital asset to the 21st Space Wing mission, I ask that you employ risk management in your daily decision making process. For more information on the 21st Space Wing Risk Management program, see the safety Sharepoint page under wing staff agencies.