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The Field Guide to Understanding Human Error, 2nd Edition by Sidney Dekker

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7 Sharp or Blunt End?

Reactions to failure focus firstly and predominantly on those people who were closest to producing or potentially avoiding the mishap. It is easy to see these people as the engine of action. If it were not for them, the trouble would not have occurred.

Someone called me on the phone from London, wanting to know how it was possible that train drivers ran red lights. Britain had just suffered one of its worst rail disasters—this time at Ladbroke Grove near Paddington station in London. A commuter train had run head-on into a high-speed intercity coming from the other direction. Many travelers were killed in the crash and ensuing fire. The investigation returned a verdict of “human error”. The driver of the commuter train ...

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