The New Look
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| The Usual Perceptions: | The New Look: | ||||||||||
"...some simple blunder in an otherwise safe system caused the accident..." |
Complex systems fail because of the combination of multiple small failures, each individually insufficient to cause and accident. Improving safety depends on understanding the details of technical work, how success is usually achieved, and how failure sometimes occurs. Effective change follows | ||||||||||
Concepts employed in the The New Look
1Reason J (1990) Human Error New York, Cambridge University Press [ISBN 0-521-31419-4]
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