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;
• 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 ...