Dirty Dozen in human Errors
The "Dirty Dozen" in human error refers to 12 common factors that can lead to human
mistakes, particularly in safety-critical industries such as aviation, healthcare, and
manufacturing. These factors were initially identified by Gordon Dupont in the context of
aviation maintenance. Understanding these elements can help mitigate errors by addressing
the root causes. Here are the Dirty Dozen:
1. Lack of Communication: Poor communication between team members can lead to
misunderstandings and errors, accidents particularly in environments where clear instructions
or data exchange is critical. Example: Incomplete handovers between shifts,
miscommunication about tasks or safety protocols.
2. Complacency: Overconfidence can cause individuals to ignore signs of trouble or skip
important steps, assuming everything will work as expected. Examples: Skipping steps in a
checklist because they’ve never encountered a problem before, assuming a system is
functioning properly without verifying.
3. Lack of Knowledge: When individuals don’t have the necessary skills, knowledge, or
experience to perform a task properly, errors are more likely to occur. Examples: staff being
unfamiliar with equipment, inadequate training on updated systems or procedures.
4. Distraction: A distraction can cause a worker to lose focus on the task at hand, increasing
the likelihood of making an error. Examples: Phone calls, interruptions from colleagues,
external environmental noise.
5. Lack of Teamwork: When team members don’t collaborate effectively, crucial
information may be missed, or errors may go uncorrected because no one feels responsible.
Examples: One person assuming someone else will handle an issue, lack of communication
between departments.
6. Fatigue: Physical or mental exhaustion affects performance, slows reaction time, reduces
attention, and impairs judgment. Examples: Workers pulling long shifts without adequate
breaks, or insufficient rest between work periods.
7. Lack of Resources: When people don’t have the right tools, parts, information, or
personnel to do their job, they may try to make do, leading to mistakes. Examples: Using
improper tools or equipment because the right ones are unavailable, working short-staffed.
8. Pressure: Time constraints or high demands from management can push individuals to cut
corners, ignore procedures, or rush through tasks. Examples: Rushing a pre-flight check
because the flight is behind schedule, ignoring a safety protocol to meet a deadline.
9. Lack of Assertiveness: People may hesitate to speak up when they notice a problem,
especially if they are dealing with authority figures or senior colleagues. Examples: A junior
worker noticing an error but not informing a supervisor out of fear of reprisal or being wrong.
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10. Stress: Excessive personal or professional stress can cloud judgment and decrease focus,
leading to higher rates of error. Examples: Workers dealing with personal issues or stressful
working environments (tight deadlines, conflicts with colleagues).
11. Lack of Awareness: Faliure to be aware of the situation , surroundings, or critical details
can lead to errors or overlook potential hazards. Examples: Missing warning signs, failing to
notice an abnormality in a process because of tunnel vision on specific tasks.
12. Norms: Unwritten rules or informal practices that deviate from standard procedures,
often because they seem to be easier or more efficient. These "norms" may lead to errors.
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