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HUMAN ERROR & INCLUSIVE LANGUAGE


Andrew Hatch


LLS SRE

Main takeaways

Human Error is not a blameless term

It has a history, not all good

Humans will always be the adaptable parts of your complex system. Learning from incidents doesn't stop here

Inclusive Language

has invested a lot in this

It is important and matters to everyone

"Human Error" is neither an Inclusive term nor Accurate - with respect to Cognitive Sciences

Human Error as a theory

...errors and issues with the system should not happen at all, the issue is with a few rogue or stupid people that cause the problems

Sidney Dekker - 2002

...blaming incidents on "Human Error" can be a convenient and cheap label to use so as to control sunk costs, and avoid having to upset elite interests

Charles Perrow - 1984

Human Error Origins

Frederick Winslow Taylor

The Principles of Scientific Management (1911)

=

"unpredictable"

"inefficient"

"untrustworthy"

Human as a failure mode

=

"Human error" is not the conclusion of an investigation. It is the starting point.

Sidney Dekker - 2002

Evolution of Incident Learning

Man Made Disaster
Swiss Cheese Model
5 Whys and Root Cause

Chain of events

1:1 Cause and Effect

Linear Thinking

Linear Thinking

Cognitive Sciences, Cybernetics, Sociology, Psychology,
Human Factors, Complex Systems Science and Philosophy,
Safety Science, Socio-Technical Systems

Old habits die hard

How can we be better

Stop using the term, in Slack, Email and Incidents

Look deeper, what are all the contributing factors

Learn through understanding, not just knowledge

Interested?

The NO view of human error - Erik Hollnagel (Ph.D)

Behind Human Error - David Woods Ph.D, et al

The Field Guide to Understanding Human Error - Sidney Dekker Ph.D

Drift into Failure - Sidney Dekker Ph.D

Thank you

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