The Field Guide to Human Error Investigations: Difference between revisions

The Field Guide to Human Error Investigations (view source)

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 *'''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.
-===Common canards====
+====Common canards====
 *'''Cause-consequence equivalence''': The assumption that a bad outcome must have had equally ''bad'' causes and, seeing as management-mandated and properly governed processes are unlikely to have been the process of really bad governance —we bureaucratised the shit out of that, after all — therefore the malignant cause ''must'' be the fault of a bad apple somewhere.
-But bad outcomes are ''not'' necessarily caused by equally bad inputs: the [[Three Mile Island]] disaster was a concatenation of seemingly insignificant and benign, but unusual, events.
+:But bad outcomes are ''not'' necessarily caused by equally bad inputs: the [[Three Mile Island]] disaster was a concatenation of seemingly insignificant and benign, but unusual, events. Indeed, that is the conclusions of [[normal accidents]] theory: You ''can’t'' prevent unexpected non-linear interactions, and these can often quickly spiral out of control.
+===The [[root cause]]===
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