Gijs Limonard

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What to think of when investigating ‘human error’        • As far as the people involved were concerned, the outcome was not going to happen. If they knew it was going to, they would have done something else.        • Nobody comes to work to do a bad job. This is the local rationality principle. People do what makes sense to them at the time given their focus of attention, their knowledge and their goals (which may well be the organization’s goals, stated or unstated).        • Human error is not the cause of failure, but the effect. So ‘human error,’ under whatever label (“loss of situation ...more
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The Field Guide to Understanding 'Human Error'
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