ABSTRACT
There has been an increasing awareness in recent years, through the occurrence of major accidents and complacency about modern day living, of the need to improve safety and to protect the environment. The application of remedial measures to the tangible or observable causes of error has been shown by experience to be less effective in minimising overall errors, than by the application of remedial measures to root causes. Analysis and root cause determination systems can most effectively exist as part of a comprehensive data collection, storage retrieval and experience feedback system. In deciding to develop an expert system for the root cause determination of human error, many of the foregoing factors were taken into consideration. Reporting and analysis systems with human factors content are continuing to be developed to facilitate experience feedback. Management response has been less enthusiastic, possibly by perceiving the expert system as a threat to conventional management choice.
