3

Doing a ‘Human Error’ Investigation

What if you are asked to do a human factors investigation for something that happened—for example, in your organization? This chapter takes you through steps that will lead to useful and verifiable results:

•  getting human factors data;

•  building a timeline;

•  putting data in context;

•  leaving a trace;

•  constructing causes;

•  making recommendations.

These steps will allow you to conduct an investigation that takes ‘human error’ out of the realm of soft data and mystery. You can gather hard data and build a set of traces that leave visible conclusions and useful recommendations.

Getting Human Factors Data

‘Human error’ is not just about humans. It is about how features of people’s tools and tasks ...

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