An Alternative View of Human Error

Traditional decision-making research views decisions as discrete processes that can be separated from the context in which the decisions are made and studied as an isolated phenomenon. This view is starting to be challenged. Instead of thinking of operations as predefined sequences of actions, human interaction with a system is increasingly being considered to be a continuous control task in which separate decisions or errors are difficult to identify. 

Not only are individual unsafe actions difficult to identify in this nontraditional control model of human decision making, but the study of decision making cannot be separated from a simultaneous study of the social context, the value system in which it takes place, and the dynamic work process it is intended to control [166]. This view is the foundation of some modern trends in decision-making research, such as dynamic decision making [25], the new field of naturalistic decision making [217,102], and the approach to safety described in this book. 

Once again, future progress in accident reduction requires tossing out the old assumption and substituting a new one  

New Assumption 4 Operator behavior is a product of the environment in which it occurs To reduce operator error we must change the environment in which the operator works. 

Human behavior is always influenced by the environment in which it takes place. Changing that environment will be much more effective in changing operator error than the usual behaviorist approach of using reward and punishment. Without changing the environment, human error cannot be reduced for long. We design systems in which operator error is inevitable, and then blame the operator and not the system design. 

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