ABSTRACT
The new view examines not only the engineered hardware that people work with for systemic reasons behind failure, but features of people’s operations and organizations as well—features that push people’s trade-offs one way or another. The new view of human error centers around a number of insights. In the New View, investigations are driven by one unifying principle: human errors are symptoms of deeper trouble. The New View of human error does not claim that people are perfect. But if something had happened to the aircraft as a result of icing, the investigation would probably have returned the finding of “human error”, saying that the pilot knowingly continued into severe icing conditions. Trade-offs between safety and other goals enter, recognizably or not, into thousands of little and larger decisions and considerations that practitioners make every day.
