Customer Reviews

The Field Guide to Human Error Investigations

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Over the past several years I have been going through a revolution in thought on incidents, accidents, and human error, thanks to Nancy Leveson of MIT, David Woods of Ohio State, and Sidney Dekker of Lund University in Sweden and others. Sidney Dekker's book, "The Field Guide to Human Error Investigations" continues the revolution.

The book is divided into two parts:

Part 1 of the book discusses the old views of human error and why they are flawed. For example, knowledge of the outcome of an accident can lead investigators to what is known as hindsight bias: the belief that the outcome was more predictable and recognizable, and critical cues missed by the participants were more apparent. Dekker also discusses how undefined, scientific-sounding words and phrases make for investigation and reports with little content. These, and many other discussions in Part 1 are part of the "bad apple" theme which states that if we just got rid of the "bad apples" in our organizations then our systems and organizations will be safe (until the next incident or accident happens!).

Part 2 of the book examines investigating human error from the perspective that people at work generally make rational and safe decisions based on their understanding of their environment and generally do not consiously perform a known unsafe act. Often safety is one of a number of competing goals that people balance. Sometimes safety is reduced over time in a series of decisions that are reasonable at the time but in aggregate significantly increases coupling, complexity or safety margins. When an incident or accident occurs it is critical to understand the conditions and situation as the participants viewed it then, and to understand why the decisions and actions appeared correct and made sense to them, at that time. Only in this way will one get beyond the label of human error, gain insight on what led the people to take the action they did and what can be done.

For those who subscribe to a "identify-blame-punish" approach to investigations this book will be unsatisfying. For those who want to go beyond the paradigm this book is well worrth the read.

Far better is the book that is effectively the second edition: Dekkers' The Field Guide to Understanding Human Error. This refines the authors work into a far more effective book.