Behind Human Error, 2nd Edition

PART IIIOPERATING AT THE SHARP END

Accidents inevitably lead to close examination of operator actions as post-accident reviewers seek to understand how the accident occurred and how it might have been prevented, especially in high risk settings (e.g., aviation, anesthesia). Practitioner cognition is the source of practitioner actions and so adequate investigation requires teasing apart the interwoven threads of the activation of knowledge relevant to the situation at hand, the flow attention across the multiple issues that arise, and the structure of decisions in the moments leading up to the accident. Accordingly, models of cognition are the tools used to decompose the performance of practitioners into meaningful parts that begin to reveal ...