What happens when operators misunderstand the design and designers misunderstand the operators? Couple of partial extracts from Busby & Hibberd’s 2002 article which explored accident report sources to construct mismatches between operator and designer assumptions. PS. Check out my YouTube and recent Critical Control / barrier vid: https://youtube.com/@safe_as_pod?si=iUaDPJynPemQRZhY Shout a coffee: https://buymeacoffee.com/benhutchinson Extracts: · Designers may… Continue reading What happens when operators misunderstand the design and designers misunderstand the operators?
Tag: complex system
The contribution of latent human failures to the breakdown of complex systems
What is the role of frontline people within complex system failures? For James Reason, it was often just providing the local triggers to “manifest systemic weaknesses created by fallible decisions made earlier”. This 1990 paper goes through his thinking of human performance in complex failure. It was meant to be a small post, but couldn’t… Continue reading The contribution of latent human failures to the breakdown of complex systems
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