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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