14ERROR AS INFORMATION

One of the themes reverberating throughout this book is that human error represents a symptom rather than a cause. In this view error is, in part, a form of information about the functioning of the system in which those people are embedded (Rasmussen, 1986). We can use the idea of error-as-information to go behind the label human error and learn about how to improve human-machine, socio-technical systems. Lanir (1986) has developed a framework that captures how organizations can react to disaster.

A FUNDAMENTAL SURPRISE

On March 28, 1979, the U.S. nuclear industry and technologists were rocked by the Three Mile Island accident (TMI). The consternation that resulted was due to more than the fact that it was the worst nuclear ...

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