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Analyses of the major accidents during recent decades have concluded that human errors on the part of operators, designers, or managers have played a major role. There are, however, several basic problems in the analysis of accidents and the identification of human error. This chapter addresses the nature of causal explanations and the ambiguity of the rules applied for the identification of the events to be included in the analysis and for the termination of the search for ‘causes’. In addition, the concept of human error is analysed and its intimate relation with human adaptation and learning is discussed. It is concluded that the identification of errors as a separate class of behaviour is becoming increasingly difficult in modern work environments. The influence of this change on the control of the safety of large-scale industrial systems is discussed.

Despite terrorist bombs and structural failures, human error on the flight deck continues to account for the majority of aircraft accidents. The Royal Air Force (RAF) Institute of Aviation Medicine (IAM) has investigated the psychology of such error since the early 1970s, and to this end has used two principal techniques. The first has involved assisting in the official inquiries into both RAF and civil flying accidents, and the second has involved setting up a reporting system that permits any commercial pilot to report his own everyday errors, in complete confidence, to the RAF IAM. The latter system possesses the clear benefit of gathering error data untainted by considerations of culpability, and sometimes permits system rectification before the occurrence of accidents. This chapter examines selected examples of errors associated with the design of equipment and with the social psychology of crews, and suggests that some consideration of the psychology of organizations may be necessary to ensure that the problems of human error are given the degree of consideration they require.

This chapter presents a personal narrative which explores experiences in an error study. It explains that the study started with a quite narrow and strictly cognitive focus and later included an adequate theory of human skill that accounted for coherent action sequences that deviate from current intentions. In the mid-1980s, the distinction was made between unintended errors and intentional deviations from standard procedures, and by the late 1980s and 1990s, the study focused on organizational accidents and the so-called Swiss cheese model was developed.

As automation increasingly takes its place in industry, especially in high risk industry, it is often blamed for causing harm and increasing the chance of human error when failures do occur. This chapter proposes that the problem is not the presence of automation, but rather its inappropriate design. The problem is that the operations under normal operating conditions are performed appropriately, but there is inadequate feedback and interaction with the humans who must control the overall conduct of the task. When the situations exceed the capabilities of the automatic equipment, the inadequate feedback leads to difficulties for the human controllers.

this chapter examines the Cartesian theodicy that could refute arguments in previous Meditations—namely, the human capacity for error and the nature of the divine. Descartes explains that if confronted with two choices—one better than the other—then that person would always choose the better of the two. However, a person's judgment can be compromised by simply having an unclear or indistinct perception of the choices presented. Alternately, a person may simply choose to forgo the better option in order to exercise the free will inherent in all human beings. However, even these arguments stand on weak ground, but the reader is left to decide whether or not an additional argument can add plausibility to the idea.

This chapter examines the safety consequences of fatigue-related constructs. Fatigue is conceptualized as both characteristics of previous night's sleep and sleepiness during the day. The chapter also covers job-related (e.g., long working hours, shift work, task characteristics) and individual factors (e.g., age, gender, lifestyle factors) that contribute to fatigue. Human error is proposed to be one of the mechanism by which fatigue influences workplace safety. Strategies for counteracting fatigue, both individual (e.g., stimulants, naps) and organizational (e.g., policy and legislation, shift work scheduling), are presented. The chapter concludes with a discussion on limitations and future directions for research in fatigue and occupational safety.

In this chapter, we consider the challenges that arise in accurately identifying the occurrence of disease, or more broadly, health outcomes. There are multiple pathways by which this occurs, including a poorly chosen entity for the purposes of studying etiology, underdiagnosis through lack of medical attention, misdiagnosis, and many other reasons why the assigned status does not reflect the true health status. Such errors can be independent of exposure or be differential in relation to exposure status, with important implications for the amount and type of bias that results. Methods for the evaluation of the impact of disease misclassification are considered, including obtaining accurate information on a subset of individuals, considering alternate methods of disease grouping, creating subgroups in which assignment is accurate, or restricting focus to disease subtypes that are accurately identified. Some amount of error in outcome assessment is inevitable, with the extent of such error dependent on the nature of the outcome of interest, the ability to apply definitive (sometimes invasive) tests to all participants, and human and instrument error associated with gathering and interpreting the information needed to assess health outcomes.

Approaches to failure in organizations are reviewed. The organizational intelligence, culture, normal accident, high-reliability, human error, and expertise approaches are reviewed. The review reveals both the contributions and limitations to these approaches. This review is framed by considering the limitations and contribution of Irving Janis and his reference to groupthink. The influence and wide acceptance of the concept of groupthink to both the theory and the practice of organizational decision making provides an important benchmark for the possibilities of understanding organizational failure from a single perspective. The chapter concludes by suggesting a need to better understand the role of learning and learning from experience in organizational breakdown.

The risk of error in an identification is shaped by all of the factors reviewed in Chapter 4. This chapter considers further ones: the various aspects of the identification procedure itself, and also steps that can occur immediately after the identification. These are factors typically under the control of law enforcement (and so they are system variables, not estimator variables). As a result, these factors create an opportunity for improving the identification process, allowing us to move toward procedures that will increase identification accuracy—aiding the prosecution of the actually guilty, and helping to protect the innocent.

This concluding chapter sums up theory of mind by focusing on our human love of stories. All stories involve narratives, and all narratives involve situations and actions linked together by minds. Characters in fiction chart complicated paths and spin myriad thoughts. Yet people understand and identify with them easily. Theory of mind allows this to happen. Without the underpinning of mind, authors could not write fiction and readers could not understand it. Authors create credible fictional characters by fabricating for them wants, thoughts, feelings, plans, hopes, preferences, and actions that satisfy or thwart their intentions—all characteristics within the framework of ordinary theory of mind. This is why stories cannot be completely fictional. They must be based on an everyday psychology that a reader can understand or else there is nothing they can relate to.

Healthcare changed dramatically during the 20th century; industrialization lead to contention for control over medical work and there was a shift from autonomous, professional control to managerial, hierarchical control, which included a strong belief in technical rationality. The rise of scientific-bureaucratic medicine combined ideas from Taylorism (i.e., the “one best way.” separation of planning from activity, and the rise of a managerial class) and a rationalizing turn in medicine (e.g., evidence-based medicine) to produce a hybrid group of clinician-managers, who can retain control of healthcare in health professionals’ hands. The quality improvement effort preceded the safety movement in health care by about a decade.

Most people think that tsunamis happen in the sea, but huge events generated by landslides into lakes, rivers, and dams indicate otherwise. For example, during the 563 event in Lake Geneva, a massive fort and numerous towns and villages along its shores were destroyed. There were earlier tsunamis and there will doubtless be more in the future. Indeed, man-made lakes—reservoirs—also represent spectacular dam-building failures. The Vajont Dam in Italy is a story of human folly, a disregard for Nature’s warnings that led to the death of thousands of people downstream. Landslides fall into rivers and can also produce massive waves. New Zealand’s largest historical tsunami was caused by just such a scenario, and although no people died, it offers an ominous sign of what can happen around any water body, fresh or otherwise, in the world.