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The Field Guide to Human Error Investigations: Difference between revisions
The Field Guide to Human Error Investigations (view source)
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{{A|book review|}} | {{A|book review|{{image|field guide|jpg|}}}}{{br|The Field Guide to Human Error Investigations}}<br>{{author|Sidney Dekker}}{{c|Systems theory}} | ||
Of a piece with {{author|Charles Perrow}}’s {{br|Normal Accidents}}, {{author|Sidney Dekker}}’s book is compelling in rooting the cause of accidents in poor system design and unnecessary complexity, overlaying safety features and compliance measures which only make the problem worse — that is, at the door of management and not poor benighted [[subject matter expert]]s who are expected to make sense of the | ===More on systems accidents=== | ||
Of a piece with {{author|Charles Perrow}}’s {{br|Normal Accidents}}, {{author|Sidney Dekker}}’s book is compelling in rooting the cause of accidents in poor system design and unnecessary complexity, overlaying safety features and compliance measures which only make the problem worse — that is, at the door of management and not poor benighted [[subject matter expert]]s who are expected to make sense of the [[Rube Goldberg machine]] that management expect them to operate. | |||
There are two ways of looking at system accidents: | There are two ways of looking at system accidents: | ||
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But blaming the [[meatware]] is to ignore history and condemn yourself to repeat it. Changing the make-up of your workforce won’t help if the basic conditions under which they are obliged to operate aren’t fixed. Simply 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. | But blaming the [[meatware]] is to ignore history and condemn yourself to repeat it. Changing the make-up of your workforce won’t help if the basic conditions under which they are obliged to operate aren’t fixed. Simply 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. | ||
===The work to rule as falsification of policy=== | |||
{{Work to rule capsule}} | {{Work to rule capsule}} | ||