15 human error thoughts we need to consider during our next incident investigation and causal analysis:
“Human error” is an attribution after the fact. Erroneous assessments and actions are heterogeneous. Erroneous assessments and actions should be taken as the starting point for an investigation, not an ending. Erroneous actions and assessments are a symptom, not a cause. There is a loose coupling between process and outcome. Knowledge of outcome (hindsight) biases judgments about the process. Incidents evolve through the conjunction of several failures/factors. Some of the contributing factors to incidents are always in the system. The same factors govern the expression of expertise and error. Lawful factors govern the types of erroneous actions or assessments to be expected. Erroneous actions and assessments are context-conditioned. Enhancing error tolerance, detection, and recovery together produce safety. Systems fail. Failures involve multiple groups, computers, and people, even at the sharp end. The design of artifacts affects the potential for erroneous actions and paths toward disaster.Source: Behind Human Error, 2nd Edition, David D. Woods, Sidney Dekker, Richard Cook, Leila Johannesen & Nadine Sarter, 2010
