Representing causal mechanism of defective designs: a system approach considering human errors

Reducing design defects by proactive actions requires comprehensive understanding of how and why they happen. To achieve this, it is necessary to know the causal relationships of inherent factors, by which design defects arise. This paper represents a causal mechanism of defective design occurrence by considering interactions of underlying factors in designing process. The mechanism draws on the system approach to human errors to describe defects in design caused by designers' active failuresand failures of design reviews as defences to catch defects. It portrays the causal process of the failures with workplace factors and organizational factors as influencing factors. Workplace factors arise from designers' working conditions and include internal and external factors to the actors. Organizational factors comprise elements due to client and designer company's conditions. Then, two failure pathways are discussed to show how the factors lead to design defects. Two case studies are presented in this paper to clarify and explain the mechanism.

[1]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[2]  T. Kletz An Engineer’s View of Human Error , 1991 .

[3]  James T. Reason,et al.  Achieving a safe culture : theory and practice , 1998 .

[4]  J Rasmussen,et al.  Human error and the problem of causality in analysis of accidents. , 1990, Philosophical transactions of the Royal Society of London. Series B, Biological sciences.

[5]  C. William Ibbs Quantitative Impacts of Project Change: Size Issues , 1997 .

[6]  Raymond S. Rollings,et al.  Pavement Failures: Oversights, Omissions and Wishful Thinking , 1991 .

[7]  J. Reason Human error: models and management , 2000, BMJ : British Medical Journal.

[8]  Andi,et al.  Design documents quality in the Japanese construction industry: factors influencing and impacts on construction process , 2003 .

[9]  STANLEY HYMAN,et al.  Research into Management , 1962, Nature.

[10]  A. Roy Duff,et al.  Development of Causal Model of Construction Accident Causation , 2001 .

[11]  E. William East,et al.  Abstracting Lessons Learned from Design Reviews , 1996 .

[12]  Takayuki Minato,et al.  Representing causal mechanism of defective designs: exploration through case studies , 2004 .

[13]  J Reason,et al.  The contribution of latent human failures to the breakdown of complex systems. , 1990, Philosophical transactions of the Royal Society of London. Series B, Biological sciences.

[14]  John F. McGeorge DESIGN PRODUCTIVITY: A QUALITY PROBLEM , 1988 .

[15]  Gregory P. Luth Chronology and Context of the Hyatt Regency Collapse , 2000 .

[16]  George F. Sowers Closure of "Human Factors in Civil and Geotechnical Engineering Failures" , 1994 .

[17]  Donald K. Hicks,et al.  Improvements in design review management , 1988 .

[18]  Andrew R. Atkinson Human error in the management of building projects , 1998 .

[19]  Colin B. Brown,et al.  Errors in Structural Engineering , 1988 .

[20]  Kunihide Sasou,et al.  Team errors: definition and taxonomy , 1999 .

[21]  J. Shaoul Human Error , 1973, Nature.

[22]  Shigeomi Nishigaki,et al.  Humanware, Human Error, and Hiyari‐Hat: A Template of Unsafe Symptoms , 1994 .

[23]  Andrzej S. Nowak Modeling human error in structural design and construction : proceedings of a workshop sponsored by the National Science Foundation, Ann Arbor, Michigan, June 4-6, 1986 , 1986 .

[24]  John W. Senders,et al.  Human Error: Cause, Prediction, and Reduction , 1991 .

[25]  Andrew R. Atkinson,et al.  The pathology of building defects; a human error approach , 2002 .

[26]  B. K. N. Rao,et al.  An Engineer’s View of Human Error , 1993 .

[27]  Dov Kaminetzky [沅뚰븯?붿콉] Design and Construction Failures , 1997 .

[28]  James T. Reason,et al.  A systems approach to organizational error , 1995 .

[29]  E. Salas,et al.  Team decision making in complex environments. , 1993 .

[30]  Robert I. Carr,et al.  Modeling Human Errors , 1984 .

[31]  LorRaine Duffy Team decision-making biases: An information-processing perspective. , 1993 .