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The Field Guide to Understanding 'Human Error'

Notes taken on Amazon

The Field Guide to Understanding ’Human Error’ will help you understand a new way of dealing with a perceived ‘human error’ problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system.

  • ‘Human Error’, is a label that we put on accidents.
  • To call something ‘Human Error’, you need show that they could have done the right thing, and you need to make sure the they knew what the right thing was.
  • There is an old view, and a new view
    • The old view is bad apples, humans are the cause of most accidents
    • New views human are apart of a larger system
      • The goals is to understand that system, and the context of the accident
  • In general people want to do a good job, so if there was an accident do we really think that most of them were caused by people who want to do a bad job?
  • Hindsight is powerful, you can see things that those involved could not see during the event.
  • Some kinds of work are going to involve more accidents
    • Driving around downtown new york is different then downtown bozeman Montana
    • Just because both involve cars and driving doesn't mean you can assume them to have the same amount of accidents
  • Accountability is important, people often will be quick to find themselves accountable. What the system needs to do is make sure that people who have the accountability also have enough control over their situation to make sure things work.
  • Accountability can be as simple as letting people give their account of things
  • How to start creating a “just culture”
    • Don't ask who is responsible, ask what is responsible.
    • Link knowledge of the messy details with the creation of justice
    • Explore the potential for restorative justice
    • Go from backward to forward-looking accountability
    • Put second victim support in place
  • Understand your reactions to failure to understand failure
    • Retrospective
      • Don't try to simplify, learn as much as you can
        • go outward not inward
      • Understand the context
    • Counterfactual - “The should have…”
      • Don't try and layout what didn't happen
      • Stop, and try and learn what did happen
      • They are the product of hindsight
    • Judgemental - Contempt prior to investigation
      • You can't judge, if you are trying to understand what happened
      • “Take the view from inside the tunnel”
    • Proximal - only looking at what is close
      • We like to think that things are cause by things that are close to the problem
      • Humans are really bad at seeing huge interconnected systems
      • We can't just look at things that are proximal to the event in question
      • You can't just look at the sharp end of the stick
  • It has lots of stuff about how to do investigations
  • Explaining how things breakdown
    • Cognitive fixation - taking action forces you to build an explanation where that action make sense
      • It can transform into a assumption that is take for granted
    • Plan continuation - Why stick with plan as situation deteriorates
      • In complex situations when you make a decision, your don't remake it. You constantly re-asses your ability to continue with your existing decision.
      • Thus you keep pushing the line a little bit
      • Even airlines have trouble with this stuff
    • Fatigue
      • We let people work fatigued, even when we don't know it.
    • Buggy an Inert Knowledge
      • To use knowledge you must:
        • Process the knowledge
        • have that knowledge organized in a way that makes it usable for the situation at hand
        • activate the relevant knowledge in context
      • Just because knowledge exists in the company, and is accessible to its people still does not mean people will utilize it.
      • If you suspect inert knowledge, look for differences between how people learn, and how they apply knowledge
        • Are they learning in a classroom, but asked to apply on a battlefield?
    • As technology assumes more responsibility, humans are not being relived, they are being asked to do more
      • “The Gulf Ware showed that there is a natural synergy between tactics, technology, and human factors: effective leaders will exploit every new advance to the limit.”
    • Compliance with norms that have shifted over time without being documented
    • Don't use loss of situational awareness
    • Don't use complacency
      • To prove complacency, you first need to show what optimal is
      • Pointing to things that people missed, because they were complacent, means you aren't taking the view of in the tunnel