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[email protected] Reason: I attest to the accuracy and integrity of this document Date: 2005.06.12 17:05:33 +08'00' TEN QUESTIONS ABOUT HUMAN ERROR A New View of Human Factors and System Safety Human Factors in Transportation A Series of Volumes Edited by Barry A. Kantowitz Barfield/Dingus • Human Factors in Intelligent Transportation Systems Billings • Aviation Automation: The Search for a Human-Centered Approach Dekker • Ten Questions About Human Error: A New View of Human Factors and System Safety Garland/Wise/Hopkin • Handbook of Aviation Human Factors Hancock/Desmond • Stress, Workload, and Fatigue Noy • Ergonomics and Safety of Intelligent Driver Interfaces O'Neil/Andrews • Aircrew Training and Assessment Parasuraman/Mouloua • Automation and Human Performance: Theory and Application \Vise/Hopkin • Human Factors in Certification TEN QUESTIONS ABOUT HUMAN ERROR A New View of Human Factors and System Safety Sidney W. A. Dekker Lund University 2005 LAWRENCE ERLBAUM ASSOCIATES, PUBLISHERS Mahwah, New Jersey London Copyright © 2005 by Lawrence Erlbaum Associates, Inc. All rights reserved. No part of this book may be reproduced in any form, by photostat, microform, retrieval system, or any other means, without the prior written permission of the publisher. Lawrence Erlbaum Associates, Inc., Publishers 10 Industrial Avenue Mahwah, New Jersey 07430 Cover design by Sean Trane Sciarrone Library of Congress Cataloging-in-Publication Data Ten Questions About Human Error: A New View of Human Factors and System Safety, by Sidney W.A. Dekker. ISBN 0-8058-4744-8 (cloth : alk. paper). ISBN: 0-8058-4745-6 (pbk: alk paper). Includes bibliographical references and index. Copyright information for this volume can be obtained by contacting the Library of Congress. Books published by Lawrence Erlbaum Associates are printed on acid-free paper, and their bindings are chosen for strength and durability. Printed in the United States of America 10 9 8 7 6 5 4 3 2 1 Contents Acknowledgments vii Preface ix Series Foreword xvii Author Note xix 1 Was It Mechanical Failure or Human Error? 1 2 Why Do Safe Systems Fail? 17 3 Why Are Doctors More Dangerous Than Gun Owners? 46 4 Don't Errors Exist? 65 5 If You Lose Situation Awareness, What Replaces It? 90 6 Why Do Operators Become Complacent? 123 7 Why Don't They Follow the Procedures? 132 8 Can We Automate Human Error Out of the System? 151 9 Will the System Be Safe? 171 vi 10 CONTENTS Should We Hold People Accountable for Their Mistakes? 193 References 205 Author Index 211 Subject Index 215 Acknowledgments Just like errors, ideas come from somewhere. The ideas in this book were developed over a period of years in which discussions with the following people were particularly constructive: David Woods, Erik Hollnagel, Nancy Leveson, James Nyce, John Flach, Gary Klein, Diane Vaughan, and Charles Billings. Jens Rasmussen has always been ahead of the game in certain ways: Some of the questions about human error were already ta