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10 questions about human error 10 câu hỏi về lỗi của CON NGƯỜI
[...]... taken by human factors and system safety are no longer useful, but their usefulness can only really be appreci ated when we see their limits This book is but one installment in a larger transformation that has begun to identify both deep-rooted constraints and new leverage points in our views of human factors and system safety The 10 questions about human error are not just questions about human error. .. at all (and if human error is some thing in and of itself in the first place) They are actually questions about human factors and system safety as disciplines, and where they stand to day In asking these questions about error, and in sketching the answers to them, this book attempts to show where our current thinking is limited; where our vocabulary, our models, and our ideas are constraining prog... to fix—it could happen again tomorrow, or today The second defining characteristic is dualism Dualism means that there is a distinct separation between material and human cause—between hu man error or mechanical failure In order to be a good dualist, you of course have to deconstruct: You have to disconnect human contributions from mechanical contributions The rules of the International Civil Avia... These aspects of technology, and of operating it, raise questions about the appropriateness of the dualist, deconstructed, struc turalist model that dominates human factors and system safety In its place we may seek a true systems view, which not only maps the structural defi MECHANICAL FAILURE OR HUMAN ERROR? 5 ciencies behind individual human errors (if indeed it does that at all), but that appreciates... situation, but it did not happen Human errors had been found The investigation was concluded "Human error" is our default when we find no mechanical failures It is a forced, inevitable choice that fits nicely into an equation, where human er ror is the inverse of the amount of mechanical failure Equation 1 shows how we determine the ratio of causal responsibility: human error =f(1 - mechanical failure)... surrounding the operator Human errors are systematically connected to features of people's tools and tasks It may be difficult to predict when or how often errors will occur (though human reliability techniques have cer tainly tried) With a critical examination of the system in which people work, IX X PREFACE however, it is not that difficult to anticipate where errors will occur Human factors has worked... all crews consisting of two captains fail to arm the spoilers before landing Hu man error, in other words, is suspended, unstably, somewhere between the human and the engineered interfaces The error is neither fully human, nor fully engineered At the same time, mechanical "failures" (providing identical switches located next to one another) get to express themselves in human action So if a confusion... retained as a kind of comforting positivist, dualist, decon structive practice In the fitness-for-duty paradigm, sources of human error must be sought in the hours, days or years before the accident, when the human component was already bent and weakened and ready to break Find the part of the human that was missing or deficient, the "unfit part," and the human part will carry the interpretative load of... in need of a testbed for new ideas about the interface between people and complex systems This book, while focusing on human error, offers a systems approach that is particularly welcome in transportation human factors A major goal xvii Xviii SERIES FOREWORD of this book series is to link theory and practice of human factors The au thor is to be commended for asking questions that not only link theory... interests are human er ror, accident investigations, field studies, representation design, and auto mation He has some experience as a pilot, type trained on the DC-9 and Airbus A340 His previous books include The Field Guide to Human Error In vestigations (2002) xix This page intentionally left blank Chapter 1 Was It Mechanical Failure or Human Error? These are exciting and challenging times for human . Cataloging-in-Publication Data Ten Questions About Human Error: A New View of Human Factors and System Safety, by Sidney W.A. Dekker. ISBN 0-8 05 8-4 74 4-8 (cloth : . both deep-rooted constraints and new leverage points in our views of human factors and system safety. The 10 questions about human error are