Errors: An Inherent Part of Human-System Performance - Foundations for Designing User-Centered Systems - page 297

• The way technology is deployed shapes human performance, creating the
potential for new forms of error and failure.
Errors will happen. You may be able to get some idea of the sorts of errors that
may occur with your system by looking at archive data, where it exists. Alter-
natively, you may be able to collect data by running experiments using your
system or an appropriate simulator.
You can take appropriate account of potential errors by carefully considering
the type of system that you are designing, the people who will use it, and the
context in which they will operate it. There are several methods that will help you
analyze your system for potential errors, including Event Trees, Fault Trees, the
CREAM, and THEA, even at design time.
10.7 Other Resources
It is worth looking at Sidney Dekker's topics to get a fuller understanding of the
new (some would say more enlightened) view of human error. Ten Questions
About Human Error (Dekker 2005 ) is an easy and entertaining read, whilst also
being thought provoking. In it he addresses the issue of human error by posing the
following questions, and then going on to explain and to answer them at length:
1. Was it mechanical failure or human error?
2. Why do safe systems fail?
3. Why are doctors more dangerous than gun owners?
4. Don't errors exist?
5. If you lose situation awareness, what replaces it?
6. Why do operators become complacent?
7. Why don't they follow procedures?
8. Can we automate error out of the system?
9. Will the system be safe?
10. Should we hold people accountable for their mistakes?
You should be able to start to answer at least some of these questions for
yourself at this point.
The problems of dealing with blame, and how to establish a just (i.e., fair) culture,
form the content of Dekker's book, Just Culture (Dekker 2007 ). In it he gives
several examples of the sorts of problems that can occur when trying to make sure
that justice (in the widest sense of the word, rather than just the legalistic view) is
served. The main focus of the topic is on trying to balance safety and accountability
so that people who make honest mistakes are not necessarily held to be culpable. He
dispels the simplistic idea about needing to punish those that cross the line, by
showing that who gets to draw the line, and where they get to draw it, are major
determinants in deciding whether someone will be regarded as culpable or not.