ABSTRACT
Chapanis (1999) wrote that back in the 1940s he noted that “pilot error” was really “designer error.” This was a challenge to contemporary thinking, and shows that design is very important in human error reduction. He became interested in why pilots often retracted the landing gear instead of the landing flaps after landing the aircraft. He identified the problems as designer error rather than pilot error, as the designer had put two identical toggle switches side-by-side, one for the landing gear and the other for the flaps. Chapanis proposed that the controls were separated and coded. The separation and coding of controls is now standard human factors practice. Half a century after Chapanis’s original observations, the idea that one can design error-tolerant devices is beginning to gain credence (Baber and Stanton 1994). One can argue that human error is not a simple matter of one individual making one mistake, as much as the product of a design which has permitted the existence and continuation of specific activities which could lead to errors (Reason 1990). A systems analysis of human error requires that all of the system elements be considered. The analysis of errors can be used to inform design activity. Ideally, any new system should be designed to be as error-tolerant as is practicable.
