Team errors: definition and taxonomy

doi:10.1016/S0951-8320(98)00074-X

Reliability Engineering & System Safety

Volume 65, Issue 1, June 1999, Pages 1-9

https://doi.org/10.1016/S0951-8320(98)00074-X Get rights and content

Abstract

In error analysis or error management, the focus is usually upon individuals who have made errors. In large complex systems, however, most people work in teams or groups. Considering this working environment, insufficient emphasis has been given to “team errors”. This paper discusses the definition of team errors and its taxonomy. These notions are also applied to events that have occurred in the nuclear power industry, aviation industry and shipping industry. The paper also discusses the relations between team errors and Performance Shaping Factors (PSFs). As a result, the proposed definition and taxonomy are found to be useful in categorizing team errors. The analysis also reveals that deficiencies in communication, resource/task management, excessive authority gradient, excessive professional courtesy will cause team errors. Handling human errors as team errors provides an opportunity to reduce human errors.

Introduction

Most human work is performed by teams rather than individuals. This is particularly true of complex technologies such as nuclear power generation, commercial aviation, chemical process plants and the like. There are many advantages in teamwork, perhaps the most important is the provision of mutual aid. One member can help another when he/she is busy, or about to mishandle an operation, or when a bad decision has been, or is about to be, made. Team members can divide their work among themselves to promote efficiency and economy of effort.

However, while teamwork can detect and recover errors, it can also create errors. A famous example is the foreign-policy decisions by the US [1]. This example is well known as “groupthink”. Janis's [1] analysis shows that the interest of the group members shifted to maintain their good human relations rather than to find the best decision to a given problem, so that they fell into a wrong decision. It is thought that the larger the group cohesiveness is, the more pronounced this tendency becomes. This example makes it clear that when considering errors in group processes, the focus should be put on not only how they made errors, whether they noticed their errors and why they failed to correct them, but also on how human relations caused errors.

Persuaded by this and other case studies involving teamwork, the paper studies human errors as team errors and proposes both a definition and a taxonomy of team errors. We also consider the relationships between the varieties of team errors and performance shaping factors (PSFs).

Section snippets

Definition and taxonomy

The authors think that “team error” is one form of “human error” as defined by Reason [2]. The difference is that “team error” considers how a group of people made human errors when they worked in a team or a group. Then we can define team error as human error made in group processes. Reason [2] also categorized human errors into three types: mistakes, lapses and slips. Mistakes and lapses arise in the planning and thinking process, whereas action slips emerge primarily out of the execution

Event analysis

The definition and taxonomy of team errors, set out above, were applied to the events that happened in the nuclear, aviation and shipping industries. The survey included 21 events in the nuclear industry, 21 in the aviation industry and 25 in the shipping industry. The data sources were human factors investigation reports issued by INEL (Idaho National Engineering Laboratory), an EPRI (Electric Power Research Institute) report, an aircraft accidents report issued by Department of Transportation

PSFs and their estimation

1.
Performance shaping factors (PSFs)
- The next question is why team errors are made. An error is usually the result of some influencing factors which are called Performance Shaping Factors. In what follows, we will use the concept of PSFs to elucidate the situations in which team errors occur.
- Generally, there are two kinds of PSFs: external PSFs and internal PSFs [8]. These two kinds of PSFs are probably enough to discuss why individuals made human errors. However, as described before, most human

Conclusion

First, this paper discussed the definition and taxonomy of team errors. Team errors are human errors that are made by individuals or groups of people in a team context. Two axes make up the taxonomy of team errors. One is how an error occurs (the error-making process) and the other is how the error is not recovered (the error-recovery process). There are also four types of error in the error-making process: independent individual errors, dependent individual errors, independent shared errors

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