By Sidney Dekker
While confronted with a human mistakes challenge, you'll be tempted to invite 'Why didn't they be careful greater? How might they now not have noticed?'. you think that you could resolve your human blunders challenge via telling humans to be extra cautious, through reprimanding the miscreants, via issuing a brand new rule or approach. those are all expressions of 'The undesirable Apple Theory', the place you think your method is essentially secure if it weren't for these few unreliable humans in it. This previous view of human errors is more and more superseded and should lead you nowhere.The new view, against this, is aware human errors challenge is absolutely an organizational challenge. discovering a 'human error' by means of the other identify, or through the other human, is just the start of your trip, now not a handy end. the recent view acknowledges that structures are inherent trade-offs among safeguard and different pressures (for instance: production). humans have to create protection via perform, in any respect degrees of a company. Breaking new floor past its profitable predecessor, the sector consultant to knowing Human mistakes publications you thru the traps and misconceptions of the outdated view. It explains tips on how to keep away from the hindsight bias, to zoom out from the folk closest in time and position to the mishap, and withstand the temptation of counterfactual reasoning and judgmental language. however it additionally is helping you glance ahead. It indicates find out how to observe the hot view in construction your protection division, dealing with questions on responsibility, and developing significant countermeasures. It even is helping you in getting your company to undertake the recent view and increase its studying from failure.So while you are confronted by means of a human errors challenge, abandon the fallacy of a short repair. learn this booklet
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Additional resources for The Field Guide to Understanding Human Error
The effect of knowing an outcome of a sequence of events is huge. It has an enormous impact on your ability to objectively look back on a piece of performance. Actually, you no longer can. Consider the Greek mythological figure of Oedipus. He went about merrily, getting invited to make love to a woman named Jocasta. Which he did. What do you think the difference is between Oedipus’ memory of the brief affair —before and after he got the message? Knowing the outcome, he would no longer have been able to 24 The Field Guide to Understanding Human Error look back objectively on his behavior.
Explaining Failure by Seeking Failure The effect of wandering backwards through a sequence of events is profound. You begin with the outcome failure. And to explain that failure, your first reflex is often to seek other failures. Where did people go wrong? What did they miss? 1 Counterfactuals: Going back through a sequence, you wonder why people missed opportunities to direct events away from the eventual outcome. This, however, does not explain failure. for incorrect actions, flawed analyses, inaccurate perceptions.
For this, you can use all the tools and methods that the Field Guide provides. Notes 1 International Herald Tribune, June 13, 2000. 2 Lee, T. and Harrison, K. (2000). Assessing safety culture in nuclear power stations. Safety Science, 34, 61–97. 3 FLIGHT International, June 6–12, 2000. 4 International Herald Tribune, December 22, 2000 (p. 21). 5 International Herald Tribune, June 19, 2000. 6 International Herald Tribune, June 20, 2000. 2 The New View of Human Error In the New View of human error: • Human error is not a cause of failure.