12 of 13 people found the following review helpful:
4.0 out of 5 stars
Complex systems don't yield simple answers, September 22, 2005
This book does pose 10 thought provoking questions, providing ample material to cast doubt on the solidity and trustworthiness of many of the accepted ideas and practices concerning accident investigation. An enduring theme throughout the book is that the answers you find depend on the questions you ask and they, in turn, depend on your beliefs about accidents. While there has been a growing chorus of discontent over the commonly used causal model accidents, there is limited consensus over what should replace it. The purpose of this book is not to propose an accident investigation model, but to question beliefs about human error, which is done so effectively that the reader is lead to doubt that there is such a thing and that all accidents could be subject to so much doubt that no conclusions about there causes and possible remedies could ever be found.
This book does a thorough job of examining human interaction with systems and, towards the end, provides some clues about how systems could be designed so that they are less error prone, safer and more resilient.
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5.0 out of 5 stars
Superb book on Philosophy, April 29, 2011
This review is from: Ten Questions About Human Error: A New View of Human Factors and System Safety (Human Factors in Transportation) (Hardcover)
This book is about philosophy. It examines how we go about examining failure, and what's wrong with our current understanding of why systems fail.
We think of a system as being like a clock, with various gears inside that interact with one another and together they make the clock work. If the clock fails, we investigate the internal parts to determine which one is defective, and fix or replace that part.
We do the same thing with systems of people. If an airplane crashes, we examine the people involved, determine whom to blame ("You're defective!"), and repair or replace that person ("Better training! Stop screwing up!")
We've reached the limit of what we can achieve using this paradigm. The accidents we are seeing today no longer fit the "someone screwed up" model of failure. Instead we're seeing normal people doing normal work in normal organizations, everyone doing what to them appears to be the right thing to do, and yet we still have these occasional enormous failures.
We then retroactively look for the defective part, and we tend to find what we are looking for. If only this person had done something different back then, this whole disaster wouldn't have happened.
People do not make errors. People do what seems like the right thing to do at the time, with no prior knowledge of what the outcome will be. People do not wear out like gears, and the system isn't static like a clock. People grow and adapt, and the system itself grows and adapts.
The problem isn't that people fail to follow our ideal model of how the system should work, the problem is our ideal model fails to model how the real world actually works.
The problem is our ideal model is static, with static gears that can't improve themselves, they can only degenerate. People aren't static. People are constantly in a state of flux, growing, adapting, making decisions, changing their environment, and in turn being changed by their environment. Our static models can't handle this reality.
We need a new philosophy. We need a new way of understanding. This book is about philosophy, how our philosophy is itself limited, where our philosophy fails, why we resist changing our philosophical understanding of how the world works, and what a new philosophy might look like.
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