Virtually every adverse event in medicine is part of an error chain
This investigation uncovers no single point of failure; instead, there were numerous links in the error chain
leading up to the grounding-had any one of which been appropriately addressed, the grounding would have been prevented," Haney said.
There was a screw up getting it re-registered and an error chain
in the forms has dragged on with the FAA, work gets in the way, there was winter, of course, and the appeal of local hops has dried up.
* The bridge team didn't allow an error chain
Determining the factors that contributed to the error, and removing one of these factors from the error chain
, is far more beneficial.
This helps to identify likely mishap causes early, allowing command personnel to break the error chain
before a major mishap occurs.
Automation also introduces a potential error chain
starting with a simple database bug.
In each case, an error chain developed, which, if left unchecked, could have led to a disaster.
In the past, these small acts of leadership would have been recognized at the watchstation, but the rest of the team would have been unaware of the total error chain, how it was developing, and how it was stopped.