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PEXiS - performance experts in safety - behind human error

The New Look

 

The Usual Perceptions: The New Look:

complex.jpg (15013 bytes)

"...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
Swiss Cheese1 Effect aa4.jpg (6799 bytes)
Sharp End-Blunt End aa3.jpg (4381 bytes)
Hindsight Bias hindisight.jpg (8768 bytes)
Competing Demands compete.jpg (9324 bytes)
People Make Safety aa1.jpg (11055 bytes)

1Reason J (1990) Human Error New York, Cambridge University Press [ISBN 0-521-31419-4]

 

 

 















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