As human beings, we may think that we know what is good or bad in terms of human characteristics. However, common sense does not allow us to answer questions such as:
➡ For how long can an operator remain vigilant in front of a screen where not much is happening? ➡ How can we design screen layouts that make it easier to detect when a reading is deviating from the norm? ➡ Why do operators on a dangerous site “deliberately” take risks? ➡ How can the entire team have made a poor diagnosis?
Here is a list of questions investigators may ask to determine whether line management deficiencies affected the accident. These questions are based on the seven…
An organizational event-causal story developed by James Reason starts with the organizational factors: Strategic decisions, Generic organizational processes – forecasting, budgeting, allocating resources, planning, scheduling,…
