ABSTRACT

Success and failure are emergent properties of essentially any work system. As such, they may be viewed as opposite sides of the same system-related performance coin, separated sometimes by a much narrower rim or margin than we might first think. In order to begin to understand work system failure (as often evidenced by a catastrophic accident or a costly quality problem), it is imperative that we better understand the role that human performance and human error play in failure. Successfully achieving this better understanding is critical if we are to prevent or at least negate the almost always costly and sometimes tragic consequences of failure.