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> All too often, it's used to excuse systemic failings and avoid investigating the deeper causes of safety incidents. Completely agree. But I don't think avoid
by mjb 7y ago
> All too often, it's used to excuse systemic failings and avoid investigating the deeper causes of safety incidents.
Completely agree. But I don't think avoiding the term "operator error" (or human error, pilot error, medical error, whatever) is the solution to that way of thinking.
Instead, I think we need to keep repeating that humans, no matter how experienced, careful, knowledgable or well-meaning, are going to make mistakes. The job of system designers is to find ways to make systems robust in the face of those mistakes, and to help make it easier for humans to do the right thing.
Checklists are one powerful tool there, for example. Another one is making systems that behave like people's mental models predict. I wrote about that idea here: http://brooker.co.za/blog/2019/08/12/kind-wicked.html http://brooker.co.za/blog/2019/08/12/kind-wicked.html
- ethbro 7y agoSomeone recommended Human Error by James Reason on HN: https://www.amazon.com/Human-Error-James-Reason/dp/0521314194/ https://www.amazon.com/Human-Error-James-Reason/dp/052131419... I'm not sure how comprehensive / modern it is (not my subfield), but I enjoyed it. And it provided at least one framework to think about error. Specifically, that most errors can and should be categorized by the states necessary for their happening. Because the unique characteristics of each state (of which there are many) all suggest very different approaches to resolving or eliminating them. To bring it back to the example in question here, remediating the procedure to eliminate a lack of knowledge of failure cases or risk would not have prevented either of these accidents (both were well-informed). However, technical solutions to physically prevent unacceptably risky "bypass" procedures would have.