Explaining the Patterns of Breakdown

Abstract

So, what went wrong? What patterns can you identify in your data? This chapter introduces some human performance issues that could guide you:

• cognitive fixation; • plan continuation; • fatigue; • buggy or inert knowledge; • new technology and computerization; • procedural adaptations;

It then discusses the currently popular use of “loss of situation awareness” and “complacency” as supposed explanations for ‘human error.’ The advice of the field guide is very simple: don’t use these things. It will explain why.