The Field Guide to Understanding Human Error, 2nd Edition

Preface

So you are faced with a human error problem.

What do you do?

How do you make sense of other people’s puzzling assessments and actions? How can you get people in your organization to stop making errors? How can you get your operations to become safer?

You basically have two options, and your choice determines the focus, questions, answers and ultimately the success of your efforts, as well as the potential for progress on safety in your organization:

• You can see human error as the cause of a mishap. In this case “human error”, under whatever label—loss of situation awareness, procedural violation, regulatory shortcomings, managerial deficiencies—is the conclusion of your efforts to understand error.
• You can see human error as the symptom ...