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The Field Guide to Human Error Investigations: Difference between revisions
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The Field Guide to Human Error Investigations (view source)
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*'''Resource constraints''': the wish for a simple [[narrative]] leading to a quick and inexpensive means of remediation | *'''Resource constraints''': the wish for a simple [[narrative]] leading to a quick and inexpensive means of remediation | ||
*'''Failure reaction''': an instinctive reaction that since an accident has happened there must have been a failure | *'''Failure reaction''': an instinctive reaction that since an accident has happened there must have been a failure | ||
*'''Hindsight bias''': the benefit of hindsight in that (i) the accident has happened (ii) the causal chain is now clear (thanks to the simple [[narrative]]) (iii) there has been a failure | *'''Hindsight bias''': the benefit of hindsight in that (i) the accident has happened (ii) the causal chain is now clear (thanks to the simple [[narrative]]) (iii) there has been a failure. | ||
*'''Personal responsibility''': In an ironic self-hack those who are paid to be safety practitioners assume great responsibility, with some pride, notwithstanding that they don’t have the power or authority (what Daniel Pink would call “mastery” and “autonomy”) to effectively ''discharge'' that responsibility. But if they too are motivated to fall on their sword, as a matter of pride, it is an easy conclusion for an accident investigator to draw. | |||
*'''Political imperative''': the “best” outcome for the organisation — and its management — is that there is no deep, systemic root cause requiring extensive recalibration of the system's fundamental architecture (much less criticism of management for its design or supervision), and that superficial action (rooting out/remediating “bad apples”) is all that is needed. | *'''Political imperative''': the “best” outcome for the organisation — and its management — is that there is no deep, systemic root cause requiring extensive recalibration of the system's fundamental architecture (much less criticism of management for its design or supervision), and that superficial action (rooting out/remediating “bad apples”) is all that is needed. | ||