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Human error is cited over and over as a cause of incidents and
accidents. The result is a widespread perception of a 'human error
problem', and solutions are thought to lie in changing the people
or their role in the system. For example, we should reduce the
human role with more automation, or regiment human behavior by
stricter monitoring, rules or procedures. But in practice, things
have proved not to be this simple. The label 'human error' is
prejudicial and hides much more than it reveals about how a system
functions or malfunctions. This book takes you behind the human
error label. Divided into five parts, it begins by summarising the
most significant research results. Part 2 explores how systems
thinking has radically changed our understanding of how accidents
occur. Part 3 explains the role of cognitive system factors -
bringing knowledge to bear, changing mindset as situations and
priorities change, and managing goal conflicts - in operating
safely at the sharp end of systems. Part 4 studies how the clumsy
use of computer technology can increase the potential for erroneous
actions and assessments in many different fields of practice. And
Part 5 tells how the hindsight bias always enters into attributions
of error, so that what we label human error actually is the result
of a social and psychological judgment process by stakeholders in
the system in question to focus on only a facet of a set of
interacting contributors. If you think you have a human error
problem, recognize that the label itself is no explanation and no
guide to countermeasures. The potential for constructive change,
for progress on safety, lies behind the human error label.
Human error is cited over and over as a cause of incidents and
accidents. The result is a widespread perception of a 'human error
problem', and solutions are thought to lie in changing the people
or their role in the system. For example, we should reduce the
human role with more automation, or regiment human behavior by
stricter monitoring, rules or procedures. But in practice, things
have proved not to be this simple. The label 'human error' is
prejudicial and hides much more than it reveals about how a system
functions or malfunctions. This book takes you behind the human
error label. Divided into five parts, it begins by summarising the
most significant research results. Part 2 explores how systems
thinking has radically changed our understanding of how accidents
occur. Part 3 explains the role of cognitive system factors -
bringing knowledge to bear, changing mindset as situations and
priorities change, and managing goal conflicts - in operating
safely at the sharp end of systems. Part 4 studies how the clumsy
use of computer technology can increase the potential for erroneous
actions and assessments in many different fields of practice. And
Part 5 tells how the hindsight bias always enters into attributions
of error, so that what we label human error actually is the result
of a social and psychological judgment process by stakeholders in
the system in question to focus on only a facet of a set of
interacting contributors. If you think you have a human error
problem, recognize that the label itself is no explanation and no
guide to countermeasures. The potential for constructive change,
for progress on safety, lies behind the human error label.
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