4

Explaining the Patterns of Breakdown

So, what went wrong? What patterns can you identify in your data? This chapter introduces some human performance issues that could guide you:

•  cognitive fixation;

•  plan continuation;

•  fatigue;

•  buggy or inert knowledge;

•  new technology and computerization;

•  procedural adaptations;

It then discusses the currently popular use of “loss of situation awareness” and “complacency” as supposed explanations for ‘human error.’ The advice of the field guide is very simple: don’t use these things. It will explain why.

Of course, the results of a ‘human error’ analysis may remain infinitely negotiable and never become entirely certain. In a ‘human error’ analysis, the data we have available about what people ...

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