The Field Guide To Understanding Human Error

The Field Guide To Understanding Human Error

When faced with a human error problem, you may be tempted to ask "Why didn't theywatch out better? How could they not have noticed?". You think you can solve yourhuman error problem by telling people to be more careful, by reprimanding themiscreants, by issuing a new rule or procedure. This is a form of "The Bad Apple Theory" where you believe systems are 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 This old view of human error is increasingly outdated and will lead you nowhere.The new view, in contrast, understands that a human error problem is actually anorganizational problem. Finding a "human error", by any other name, or by any otherhuman, is only the beginning of your journey, not a convenient conclusion. The new viewrecognizes that systems are inherent trade-offs between safety and other pressures (forexample: production). People need to create safety through practice, at all levels of anorganization.Building on its phenomenally successful predecessor, The Field Guide to UnderstandingHuman Error first 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.So if you are faced by a human error problem, abandon the fallacy of a quick fix. Readthis book.