In order to understand error, you have to examine the larger system in which these people worked. You can divide an operational system into a sharp end and a blunt end: • At the sharp end (for example the train cab, the cockpit, the surgical operating table), people are in direct contact with the safety-critical process. • The blunt end is the organization or set of organizations that both supports and constrains activities at the sharp end (for example, the airline or hospital; equipment vendors and regulators).
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