ABSTRACT

Research on human error is as old as the field of human factors (Fitts and Jones, 1947). Despite this long record of investigation into the factors that lead to erroneous actions and assessments, the belief remains commonplace that the verdict “human error” is a meaningful statement of the cause of failures. The belief that human errors are random acts constituting a basic category of human performance blocks our ability to understand and therefore control the factors that lie behind failures of complex systems. Human factors has always probed for the systematic factors behind the label “human error” in the nature of the problems people face, in the design of the artifacts that people use, and in the organization that

provides resources and sets goals. In other words, the label human error is not a conclusion, but rather a starting point for investigation (Woods et al., 1994).