An evaluation of error management in transmission

Abstract

There have been a number of interventions internationally in managing error but they are generally piecemeal (Reason and Hobbs, 2003). Transmission, a division of Eskom Holding Ltd have experience a large number of human errors similar to that of the aviation and medical organisations. The purpose of this research study is to provide a holistic error management model that could be applicable to the Transmission Division that incorporates all the facets of error management and not be piecemeal. The objectives were to get the perception of the experts on human error, identify the causes of human error and investigate if learning from human errors is taking place. The research methodology was based on a mixed qualitative analysis. Through a series of expert interviews, review of current literature and case studies, a number of themes, findings and recommendations emerged. Some of the primary themes that resulted from the study included leadership and commitment. learning's, investigations, reporting, risk assessments, and error management systems. The researcher found that even though there were pockets of excellence, no plans existed to systematically reduce human error risks in Transmission and that no individual or group seemed to have the accountability for driving human error reduction across the business units. There is no safety or error management system that embodies continuous risk reduction criteria and methodologies. The lack of a holistic system to promote continuous error reduction as lead to buzz words with no action plans.