Overview:
- Disasters will repeat as underlying causes not being tackled
- Complex socio-technical systems require focus on te human contribution
- Short term focus:
- Acknowledge the problem
- Structure, process, practice, discipline
- Longer term:
- No quick fixes, research the hman aspects, understand our problems in our domain
Vulnerable System Sundrome
- Blame
- Enemy of understanding
- Destroys trust vital to reporting
-Denial
- IT couldn't happen here
- We have an excellent safety culture
- Wrong Focus
- Single minded, blinkered focus
- Cost, on-timing running
Characteristics of Risk Denial
- Can't happen here
- Normalising the evidence
- Confirmation bias, expect to see what you see
- Ad-hoc criteria
- Downgrading of intermittent warnings
- Onus of proof
- Group-think
....
View the entire Presentation:
Accidents Incidents and the Human Factor
John Thorogood