Behind Human Error

Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a "human error problem," and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label "human error" is prejudicial and unspecific, and any serious examination of the human contribution to safety and to system failure shows that the story of human error is markedly complex. This book takes you behind the human error label. Divided into five parts, it begins by summarising the most significant research results. Part 2 explores how a changing understanding of accidents and an embracing of systems thinking has radically impacted ideas about human error. Part 3 explains the role of normal cognitive system factors (knowledge, mindset, and goals) in operating safely at the sharp end. Part 4 studies how the clumsy use of computer technology can increase the potential for erroneous actions and assessments in all kinds of fields of practice. And Part 5 tells how the hindsight bias always enters into attributions of error, and that human error is a mere label, the result of a social and psychological judgment process rather than a matter of objective fact that we can count, tabulate, punish or eliminate. If you think you have a human error problem, recognize that the label itself is no explanation and no guide to countermeasures. The potential for constructive change, for progress on safety, lies behind the human error label.

David D. Woods, Ph.D. is Professor at Ohio State University in the Institute for Ergonomics and Past-President of the Human Factors and Ergonomics Society. Sidney Dekker, Ph.D. is Professor of human factors and system safety at Lund University, Sweden. Richard Cook, M.D. is an active physician, Associate Professor in the Department of Anesthesia and Critical Care, and also Director of the Cognitive Technologies Laboratory at the University of Chicago. Leila Johannesen, Ph.D. works as a human factors engineer on the user technology team at the IBM Silicon Valley lab in San Jose, CA. Nadine Sarter, Ph.D. is Associate Professor in the Department of Industrial and Operations Engineering and the Center for Ergonomics at the University of Michigan.