Behind Human Error, 2nd Edition

PART IICOMPLEX SYSTEMS FAILURE

In the study of accidents, it is important to understand the dynamics and evolution of the conditions that give rise to system breakdowns. Various stakeholders often imagine that the typical path to disaster is a single and major failure of a system component – very often the human. Hence, “human error” often is seen as a cause, or important contributor, to accidents. Studies of the anatomy of disasters in highly technological systems, however, show a different pattern. That which we label “human error” after the fact is never the cause of an accident. Rather, it is the cumulative effect of multiple cognitive, collaborative, and organizational factors. This, indeed, is the whole point of the second story: go behind ...