Why I'm typing with one hand and a thumb.
It is only fitting that just as I started assembling the human-error issue, I commited a slightly bloody, somewhat painful and powerfully inconvenient human error of my very own. I didn't exactly need material--you can't consume oxygen for as long as I have without logging some blunders and accruing a few scars--but it does explain why I am typing with my right hand and left thumb. Also why my long-suffering wife has to tie my running shoes for me, and why I'm going to miss a race that I've spent three months training for.
Riding to the base gym one week ago, my attention lapsed and I let the front wheel of my hybrid bicycle go off the sidewalk and drop two inches onto the grass. Instead of continuing down onto the grass and slowing down, I tried to horse the front tire back onto the sidewalk. I instantly lost control as the bike slid out. I simultaneously collided with my friend, who was riding just behind me to the left, and planted my left hand on the concrete. I was glad my buddy continued on over me and onto the grass, otherwise he would have had the three-point road rash and the fractured metacarpal.
The pertinent question is, why did I self-inflict this damage? I've been riding this same route to the gym a couple days a week for five years. There might have been a breeze, but that's nothing new. I was listening to my friend telling me a story, so distraction was a factor. Other than that, it was a minor slip and erroneous reflexes. You'll find a batch of similar blunders described in the articles in this issue, many of them more serious and costly than mine.
By focusing this issue on human error, we aren't exactly narrowing things down, since at least four out of five mishaps involve some type of miscue or gaffe. And we don't propose to launch a full-blown, Human Factors Analysis and Classification System extravaganza, complete with diagrams and charts and polysyllabic codes.
However, there are a few basic lessons worth noting. First, one of the variables with human error is that you can't tell in advance where the results are going to fall on the scale from first-aid to fatality. If you're going to err, err on the side of caution.
Second, error doesn't exist in a vacuum--it is part of a larger pattern, which offers manifold opportunities for intervention. It is preventable. It can be recognized and predicted. Walking down the hall here at the Naval Safety Center the other day, I heard one of our flight surgeons tell someone, "Everybody is stupid when they aren't trained."
You've all heard the adage, "To err is human, to forgive divine." I know one thing--that sidewalk wasn't very forgiving.
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|Date:||Sep 22, 2010|
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