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Steven Shorrock @StevenShorrock
, 3 tweets, 1 min read Read on Twitter
An engineer does not detect an alarm. This is classed as the ‘cause’. But no one assessed the risk of this or did an HF/ergonomics assessment of the task with reference to human performance. Two omissions/counterfactuals. Only the sharp end one is really considered ‘human error’.
The blunt end one is not considered ‘human error’ is not considered ‘causal’ and is not actually considered at all. We only consider human error to be sharp end behaviours. Everything else disappears into ‘context’ and so is not much considered (or remembered).
So human-error-as-cause prevails in the way that we think about unwanted events. We consider the events closest to the event more ‘causal’ and more erroneous, and hold those responsible for outcomes.
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