The Field Guide to Human Error Investigations: Difference between revisions

But blaming the [[meatware]] is to ignore history and be condemned yourself to repeat it. Changing the make-up of your operational workforce won’t make much difference if you leave the basic conditions under which they were obliged to operate unaddressed. Just adding more, increasingly detailed, policies — “codified over-reactions to situations that are unlikely to happen again” in {{author|Jason Fried}}’s elegant words<ref>{{author|Jason Fried}}, {{br|ReWork: Change the Way You Work Forever}}</ref> — will only make the gap between theory and practice wider.

Reactions to accidents tend to be:

*'''Retrospective''': made with the benefit of hindsight and full knowledge of inputs and outputs, and with ample time to construct a narrative that neatly links events into a causal chain — a causal chain that was not apparent to the actors at the time, and maybe an impressive, but all the same imaginary, feat of imagination from a [[middle manager]] not normally known for their creative skills.

*'''Proximal''': Focussing on people at the sharp end — the operators, traders, negotiators — the [[meatware]] closest to the accident, and not so much on the blunt end — the organisation, its goals, target end-states and its strategic management of the manufacturing process (in particular how it balances risk and reward) the provided tools and equipment, rules and [[policy|policies]] promulgated and the constraints and pressures imposed on those [[subject matter expert]]s to get the job done.

*'''Counterfactuals''': constructing alternative sequences of events — where operators “zigged”, but could have “zagged” — which might have avoided the incident. “''Forks in the road stand out so clearly to you, looking back. But when inside the tunnel, when looking forward and being pushed ahead by unfolding events, these forks were shrouded in the uncertainty and [[complexity]] of many possible options and demands; they were surrounded by time constraints and other pressures.”

*'''Judgmental''': To explain failure we seek failure: incorrect analyses, mistaken perceptions, misjudged actions. Again, hindsight is king. In each case, if you presented the operator with the facts as they were available to the investigator, in the same unpressurised environment, you might expect the “correct” outcome.