lu.se

Leonardo

Faculty of Engineering, LTH

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The Field Guide to Understanding Human Error

2006

Ashgate Publishing Co.
www.ashgate.com 

When faced with a human error problem, you may be tempted to ask "Why didn't they watch out better? How could they not have noticed?". You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. These are all expressions of "The Bad Apple Theory" where you believe your system is basically safe if it were not for those few unreliable people in it. This old view of human error is increasingly outdated and will lead you nowhere.

The new view, in contrast, understands that a human error problem is actually an organizational problem. Finding a "human error", by any other name, or by any other human, is only the beginning of your journey, not a convenient conclusion. The new view recognizes that systems are inherent trade-offs between safety and other pressures (for example: production).
People need to create safety through practice, at all levels of an organization.

Building on its successful predecessor, The Field Guide to Understanding Human Error guides you through the traps and misconceptions of the old view.
It tells you how to avoid the bias of hindsight, the temptation of counterfactual reasoning and judgmental language, and how to go beyond the people who were closest in time and place to the mishap. It then explains how you can apply the new view of human error to the analysis of safety problems and the construction of meaningful countermeasures. It even helps those who want to help their organizations adopt the new view and improve their learning from failure.

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