The Field Guide to Understanding 'Human Error'¶
Dekker, S. (2011). The Field Guide to Understanding 'Human Error'.
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Primes¶
- Thick Description
- Incident post-mortems and safety reviews — a strong post-mortem records not only the failure steps but the operator's mental model, fatigue state, on-call context, and prior incident class; a bare-fact write-up cannot support learning.
This sourceArticulates the "new view" of human error, replacing thin records of procedural deviation with thick reconstruction of the operator's context, tooling, and mental model so that the action's local rationality is recoverable.
- Incident post-mortems and safety reviews — a strong post-mortem records not only the failure steps but the operator's mental model, fatigue state, on-call context, and prior incident class; a bare-fact write-up cannot support learning.
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