14 So What Went Wrong?

So, what went wrong? This chapter introduces a few typical mechanisms by which human performance can get into trouble. They can apply to all kinds of settings where people perform safety-critical work. Here they are:

  • Cognitive fixation
  • Plan continuation
  • Stress
  • Fatigue
  • Buggy or inert knowledge
  • New technology and computerization
  • Automation surprises
  • Procedural adaptations.

This chapter can offer you no more than a selection and a flavor of these mechanisms. The research literature underneath most of these phenomena is huge. Remember, you want to avoid the folk modeling that is so common in efforts to understand human error. This chapter asks and allows you to leave a trace, to show how you get to your conclusion from your ...

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