Hollnagel on “Human error”: error as cause, process or outcome

Not much to say – some extracts from a 2007 chapter from Erik Hollnagel, unpacking whether we really need “human error”?

I knocked the summary up last night and will probably post in the next couple of weeks. Oh man, I need to give up on chapters…what a slog.

He argues:

·        Human error “is not a meaningful term at all”, or at least, is too ambiguous

·        HE can be used as a cause of something – “failure was due to human error”. This puts the focus on error as the cause

·        HE as the action or process itself, like error in forgetting to check the water level; this doesn’t consider the consequences

·        HE as the undesired outcome – like leaving the keys in the lock. He notes “the focus is solely on the outcome, although the linguistic description is of the action”

One contrasting definition comes from Woods et al.”

“The label “human error” is a judgment made in hindsight. After the outcome is clear, any attribution of error is a social and psychological judgment process, not a narrow, purely technical, or objective analysis”

Finally, and something I found interesting, is that the “growing interest in “human error” as a phenomenon in its own right did not come from psychology but from practitioners facing the problems of humans working in complex industrial systems”.

Hollnagel also challenges whether it’s really the case that psychology has, broadly speaking, ignored “human error”, or whether the other practice-driven fields (which he calls engineering, human factors, operational safety etc.) have just overemphasised it.

And in concluding, argues:

“there is no need of a theory of “human error” because the observed discrepancies in performance should be explained by a theory of normal performance rather than specific “error mechanisms”

Summary soon.

Ref: Hollnagel, E. (2007). Human error: Trick or treat. Handbook of applied cognition, 219-238.

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