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"No Human Error" is a bad approach for most real world context. It could be useful in an academic or simulation approach. As other commentors have pointed out,
by csours 4y ago
"No Human Error" is a bad approach for most real world context. It could be useful in an academic or simulation approach.
As other commentors have pointed out, Sidney Dekker has written some very good books on this topic. I'll point out two approaches or mental tools that he teaches.
1: "Slip" vs "Mistake". A slip is an non-intentional error: hitting the wrong switch accidentally, forgetting to click a button, etc. In general you could help prevent these with simple UI tweaks. A mistake is an error in or with intention. You meant to do something, and you had in mind what you wanted to do, but you made a miscalculation or had a misunderstanding of the situation. Changing workflows and adding context can help with these. This is a gross oversimplification, listen to his talks online and buy the book if you're interested.
2: Understand hindsight bias and blame. Hindsight bias is absolutely pervasive in human thinking after an incident. After an incident you have much more time and information to process than the operators involved. If you really want to prevent future incidents you must understand the information, tools, and mental context of the operator at the time of the incident.
Blame is a box to hide complexity in. People are afraid of the tiger in the forest. Complexity is hard to talk about. After an incident you want to feel safe and OK. If you can put the blame somewhere, you have hunted down the tiger and you can feel safe. But, if you are simply blaming a person, then another person may make the exact same mistake. This is very hard to talk about because in many cases there are legal and moral implications. When you take a systemic approach to safety and preventing human error, leave your morals at the door, and do not mix legal and engineering discussions during the investigation. You can pick up your morals when you go home for the day and be disgusted on your own time. Having an overly legalistic and punitive system can delay system improvements. Again, this is super oversimplified, there is a universe of nuance in this subject.