Abstract
Research cores are complex environments of highly skilled humans interacting with sophisticated instrumentation through multistep workflows. Cores often operate with significant constraints in staffing and resources and yet must consistently and efficiently deliver high-quality results to a wide range of customers. Mistakes and errors can be costly for both cores and researchers, and management of error risk is a critical component of core operation. A traditional view of error attributes adverse events primarily to individual misbehavior or frailty: forgetfulness, poor motivation, inattention, or noncompliance with established protocols. A response to error in the old model typically includes developing additional rules, adding automation, or administering disciplinary actions or training. These old-view solutions do not effect systematic improvement and are unlikely to reduce risk of future errors. A new view of error analysis accepts error as inevitable and systematically connected to the tools, tasks, and operational environment of the human actors. In a systems approach to error, complex systems are understood to force trade-offs between multiple conflicting goals. Safety improvements are developed at the systems or organizational and operational level from an understanding of mismatch between procedures and expected outcomes, and practice and actual results.
Cores can create a climate of embracing error by establishing a reporting culture in which mishaps, near-misses, and small incidents are openly discussed without reprobation and blame. Using examples from other high-reliability organizations like nuclear power plants, air-traffic control centers, and hospital trauma units, cores can develop an approach to error analysis that avoids bad apple explanations, hindsight bias, cherry-picking, and mistake micromanagement. Cores can apply different accident models, collect human factors data, and develop real safety and reliability intelligence that leverages the creativity and intelligence of humans for a robust and resilient high-reliability organization.