By Erik Hollnagel
Twist of fate research and probability evaluation have for many years excited by the human issue, quite 'human error'. numerous books and papers were written approximately the way to determine, classify, get rid of, hinder and atone for it. This bias in the direction of the examine of functionality disasters, results in a overlook of ordinary or 'error-free' functionality and the belief that as mess ups and successes have diversified origins there's little to be received from learning them jointly. Erik Hollnagel believes this assumption is fake and that security can't be attained merely by way of taking out dangers and screw ups. The ETTO precept seems on the universal trait of individuals at paintings to regulate what they do to compare the stipulations - to what has occurred, to what occurs, and to what could take place. It proposes that this efficiency-thoroughness trade-off (ETTO) - frequently sacrificing thoroughness for potency - is common. whereas sometimes the changes could lead on to opposed results, those are as a result exact same strategies that produce successes, instead of to blunders and malfunctions. The ETTO precept eliminates the necessity for specialized theories and types of failure and 'human blunders' and gives a manageable foundation for powerful and simply methods to either reactive and proactive security administration.
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B. ) The example of the circular-saw operator is found on page 94 of H. W. Heinrich (1931), Industrial Accident Prevention (New York: McGraw-Hill). This book pioneered the practical study of industrial safety, and introduced a number of models and methods, several of which are still in use. Mr Heinrich was an Assistant Superintendent of the Engineering and Inspection Division of Travelers Insurance Company in Hartford, CT, and the book was based on his extensive practical experience in accident investigation.
There is therefore always some uncertainty, and because of the uncertainty there is also risk. If something is going to happen with certainty 舑 or not going to happen with certainty, which amounts to the same thing 舑 then there is no risk. ) But wherever there is risk, there is also a need to understand the risk. Although people and societies have tried to protect themselves against hazards and risks at least as far back as The Code of Hammurabi, the consequences of the rampant technological developments that we have seen since the middle of the 20th century 舑 according to the Western way of counting, of course 舑 have made this more necessary than ever.
This does not mean that the 舖incorrect舗 actions that can explain an accident are right, but rather that the way in which these actions were made 舑 and therefore also the principles by which they must be understood 舑 was the same regardless of whether the outcome was a success or a failure. It is just the momentary variability or juxtaposition of conditions that led to the wrong or unwanted result. This book is about understanding those principles. And paradoxically, as shall be shown at the end, understanding those principles can to some extent free us from them.
