Field Guide to Human Error Investigations

<p>This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other componant, needs to be put back together in a mishap investigation.</p> 1: The Old View of Human Error: Human error is a cause of accidents; 1: The Bad Apple Theory; 2: Reacting to Failure; 3: What is the Cause?; 4: Human Error by any Other Name; 5: Human Error—in the Head or in the World?; 6: Put Data in Context; 2: The New View of Human Error: Human error is a symptom of trouble deeper inside a system; 7: Human Error—the New View; 8: Human Factors Data; 9: Reconstruct the Unfolding Mindset; 10: Patterns of Failure; 11: Writing Recommendations; 12: Learning from Failure; 13: Rules for in the Rubble