By Richard Cook, David D. Woods, Sidney Dekker, Leila Johannesen, Nadine Sarter
Human blunders is pointed out persistently as a explanation for incidents and injuries. the result's a common conception of a 'human mistakes problem,' and ideas are notion to lie in altering the folk or their function within the method. for instance, we must always decrease the human function with extra automation, or regiment human habit by means of stricter tracking, ideas or approaches. yet in perform, issues have proved to not be this straightforward. The label 'human error' is prejudicial and unspecific, and any critical exam of the human contribution to safeguard and to procedure failure exhibits that the tale of human blunders is markedly complicated. This booklet takes you at the back of the human mistakes label. Divided into 5 components, it starts off by way of summarising the main major learn effects. half 2 explores how a altering realizing of injuries and an embracing of structures considering has greatly impacted rules approximately human blunders. half three explains the function of standard cognitive approach components (knowledge, approach, and pursuits) in working effectively on the sharp finish. half four experiences how the clumsy use of machine know-how can raise the opportunity of inaccurate activities and exams in all types of fields of perform. And half five tells how the hindsight bias constantly enters into attributions of blunders, and that human errors is an insignificant label, the results of a social and mental judgment strategy instead of an issue of target indisputable fact that we will be able to count number, tabulate, punish or dispose of. when you imagine you will have a human mistakes challenge, realize that the label itself isn't any rationalization and no consultant to countermeasures. the potential of positive swap, for growth on protection, lies at the back of the human mistakes label.
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Extra info for Behind Human Error (2nd edition)
Instead they continued to invest in anticipating the changing potential for failure because of the deeply held understanding that their knowledge base was fragile in the face of the hazards inherent in their work and the changes omnipresent in their environment. Safety for these organizations was not a commodity, but a value that required continuing reinforcement and investment. The learning activities at the heart of this process depended on open flow of information about the changing face of the potential for failure.
As the abnormal influences produced by a fault persist or grow over time, the capacity of automatic systems to counterbalance or compensate becomes exhausted. At some point they fail to counteract and the system collapses or decompensates. The result is a two-phase signature. In phase 1 there is a gradual falling off from desired states over a period of time. Eventually, if the practitioner does not intervene in appropriate and timely ways, phase 2 occurs – a relatively rapid collapse when the capacity of the automatic systems is exceeded or exhausted.
Peoples’ behavior is consistent with Simon’s (1969) principle of bounded rationality – that is, people use their knowledge to pursue their goals. What people do makes sense given their goals, their knowledge and their focus of attention at the time. Human (and machine) problem-solvers possess finite capabilities. There are bounds to the data that they pick up or search out, limits to the knowledge that they possess, bounds to the knowledge that they activate in a particular context, and conflicts among the multiple the problem with “human error” 17 goals they must achieve.