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

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9 Cause is Something You Construct

What is the cause of the mishap? In the aftermath of failure, no question seems more acute. There can be significant pressure from all kinds of directions to pinpoint a cause:

  • Not knowing what made a system fail is really scary;
  • People want to start investing in countermeasures;
  • People want to know how to adjust their behavior to avoid the same kind of trouble;
  • People may simply seek retribution, punishment, justice.

Two persistent myths drive our search for the cause of failure:

  • We think we can make a distinction between human error and mechanical failure, and that a mishap has to be caused by either one or the other. This is an oversimplification. Once you acknowledge the complexity of failure, you will ...

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