The Field Guide to Understanding Human Error, 2nd Edition

2 The New View of Human Error

In the New View of human error:

• Human error is not a cause of failure. Human error is the effect, or symptom, of deeper trouble.
• Human error is not random. It is systematically connected to features of people’s tools, tasks and operating environment.
• Human error is not the conclusion of an investigation. It is the starting point.

History is rife with investigations where the label “Human Error” was the conclusion. Paul Fitts, marking the start of aviation human factors in 1947, began to turn this around. Digging through 460 cases of “pilot error” that had been presented to him, he found that a large part consisted of pilots confusing the flap and gear handles. Typically, a pilot would land and then raise ...