Summary of James Reason's Human Error

By IRB Media

Please note: This is a companion version & not the original book. Book Preview:

#1 The past decade has seen a rapid increase in what might loosely be called studies of errors for their own sake. The most obvious impetus for this renewed interest has been a growing public concern over the terrible cost of human error.

#2 The two sides of the same coin are automaticity, which makes slips or actions not planned inevitable, and resource limitations, which contribute to informational overload and data loss.

#3 The search for human error is not as abundant or as varied as it might seem. While errors are much rarer than correct actions, they typically take a limited number of forms.

#4 The two targets in Figure 1. 1 show a pattern of ten shots, one fired by rifleman A, the other by rifleman B. A’s shots were around the bull’s eye, but the grouping was poor. B’s shots fell into a tight cluster, but at a distance from the bull’s eye.

• Language: English
• Publisher: IRB Media
• Release date: May 21, 2022
• ISBN: 9781669394082

IRB Media

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Insights on James Reason's Human Error

Contents

Insights from Chapter 1

Insights from Chapter 2

Insights from Chapter 3

Insights from Chapter 4

Insights from Chapter 5

Insights from Chapter 6

Insights from Chapter 7

Insights from Chapter 8

Insights from Chapter 9

Insights from Chapter 10

Insights from Chapter 1

#1

The past decade has seen a rapid increase in what might loosely be called studies of errors for their own sake. The most obvious impetus for this renewed interest has been a growing public concern over the terrible cost of human error.

#2

The two sides of the same coin are automaticity, which makes slips or actions not planned inevitable, and resource limitations, which contribute to informational overload and data loss.

#3

The search for human error is not as abundant or as varied as it might seem. While errors are much rarer than correct actions, they typically take a limited number of forms.

#4

The two targets in Figure 1. 1 show a pattern of ten shots, one fired by rifleman A, the other by rifleman B. A’s shots were around the bull’s eye, but the grouping was poor. B’s shots fell into a tight cluster, but at a distance from the bull’s eye.

#5

The more common type of prediction is illustrated by the following example. It can be predicted with near certainty that during next January, the banks will return a large number of cheques with this year’s date on them. We cannot predict the exact number of the misdated cheques, nor can we say precisely who will make this error. But we do know that such habit intrusions are among the most common errors.

#6

The notion of intention is two-fold: an expression of the end-state to be attained, and an indication of the means by which it is to be achieved. The more routine the activity, the fewer the number of low-level control statements required to specify it.

#7

The distinction between spontaneous and subsidiary actions is an example of the distinction between intentional and non-intentional actions. Someone might hit another on the spur of the moment without forming any prior intention. In this case, the intention resides only in the action itself.

#8

The defense of automatism is based on the idea that some actions are performed without any intention whatsoever. To prove criminal liability, it must be shown not only that the consequences of the criminal act were intended, but also that the act itself was committed voluntarily.

#9

The distinction between actions that achieve their intended goal and those that do not is important. The former are rare, but the latter are common. We become aware of our actions having strayed from their intended path when we perform some largely automatic task in familiar surroundings and a marked degree of attention is taken away from the task at hand.

#10

The distinction between mistakes and slips is made clear by the three-question algorithm. Mistakes involve a mismatch between the prior intention and the intended consequences, while slips and lapses involve a discrepancy between the intended actions and those that were actually executed.

#11

Working definitions of error are useful rather than ideal. They attempt to embody the essential psychological characteristics of the phenomena without struggling too hard to mark out their exact semantic boundaries.

#12

Mistakes are more subtle than slips, and they are typically more complex. They are also more difficult to detect, and they can remain unnoticed for long periods of time.

#13

There is no universal agreement on how to classify human errors. The literature is full of taxonomies, which range from the highly task specific to broad statements of underlying error tendencies.

#14

There are a limited number of formal ways in which a sequence of words or actions can deviate from intention. Therefore, it is not surprising that there is high agreement between judges in their allocation of slips to these limited behavioral categories.

#15

The level of classification above the trigger point is the one that addresses the complex relationship between error type and the situation or task