The Field Guide to Human Error Investigations: Difference between revisions

*'''It’s the [[meatware]]''': [[Complex]] (and [[complicated]]) systems would be fine ''were it not for the [[meatware]] screwing things up''. Human error is the main contributor to most system accidents, introduce unexpected  failures into an essentially robust mechanism.  Here, system design and management direction and oversight are otherwise effective strategies that are let down by unreliable human operators.

*'''It’s the system''': Accidents are an inevitable by-product of operators doing the best they can within [[complex]] systems that contain unpredictable vulnerabilities, where risks shift and change over time and priorities are unclear, conflicting and variable. Here, human operators are let down by shortcomings in system design and conflicting management pressure.

Those investigating accidents are motivated in ways which will favour the “[[meatware]]” theory:

*'''Resource constraints''': the wish for a simple [[narrative]] leading to a quick and inexpensive means of remediation

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.

{{Sa}}