Perspectives on Human Error: Hindsight Biases and Local Rationality

This earlier (1999/2000) handbook from Woods and Cook gives a really good 101 in cognitive This earlier (1999/2000) handbook from Woods and Cook gives a good high-level 101 in cognitive systems and systems thinking. It’s titled “Local rationality, hindsight bias and outcome bias”.

It has a wide scope (38 pages):

· They cover some accidents that were attributed to “human error”, but upon further investigation had the hallmarks of systems accidents

· They provide some perspectives on the concept/label of error, and perspectives of “erratic people or systems issues”

Based on the events analysed “the “errors” were not random events, rather they resulted from understandable, regular, and predictable aspects of the design of the tools practitioners used”

· They argue that “When the mental model that practitioners hold of such systems is inaccurate or incomplete, their actions may well be inappropriate. These mental models are sometimes described as “buggy.”

· They discuss the interactions between knowledge in context, inert knowledge and how to activate knowledge in context

· “Going behind the label “human error” involves investigating how knowledge was or could have been brought to bear in the evolving incident”

· Challenges to “loss of situational awareness” and challenges of rule following, where the “cognitive work associated with managing multiple threads of activity goes beyond the activities needed to merely follow the rules”

· Challenges with revising situation assessments after things have changed, what they term fixation or cognitive lockup

· Goal conflicts, coupling/interactive complexity and more