-
Errors relate to individual performance, systems
in which individuals work (including technology), and how people,
technologies and systems interact.
-
Human/system interaction both “creates safety”
and “causes errors”
-
Human errors indicate a deeper problem in the system
itself.
- To “explain” an error, you must analyze what occurred in the context in which it occurred
- People don’t try to make mistakes
- At the time, the actions taken made sense/were
logical to those taking the actions (even though, in retrospect,
they were wrong)
- Must change that context if future errors
are to be prevented
