Number of words – 590 The design of the keyboard has a long and peculiar history. Early typewriters experimented with a wide variety of layouts, using three basic themes. One was circular, with the letters laid out alphabetically; the operator would find the proper spot and depress a lever, lift a rod, or do whatever … Read more
Number of words – 404 When automation fails, it often does so without warning. This is a situation I have documented very thoroughly in my other books and many of my papers, as have many other people in the field of safety and automation. When the failure occurs, the human is “out of the loop.” … Read more
Number of words – 151 Resilience engineering is a paradigm for safety management that focuses on how to help people cope with complexity under pressure to achieve success. It strongly contrasts with what is typical today—a paradigm of tabulating error as if it were a thing, followed by interventions to reduce this count. A resilient … Read more
Number of words – 268 Accidents usually have multiple causes, whereby had any single one of those causes not happened, the accident would not have occurred. The British accident researcher James Reason describes this through the metaphor of slices of Swiss cheese: unless the holes all line up perfectly, there will be no accident. This … Read more
Number of words – 534 Multitasking, whereby we deliberately do several tasks simultaneously, erroneously appears to be an efficient way of getting a lot done. It is much beloved by teenagers and busy workers, but in fact, all the evidence points to severe degradation of performance, increased errors, and a general lack of both quality … Read more
Number of words – 545 Checklists are powerful tools, proven to increase the accuracy of behavior and to reduce error, particularly slips and memory lapses. They are especially important in situations with multiple, complex requirements, and even more so where there are interruptions. With multiple people involved in a task, it is essential that the … Read more
Number of words – 397 In commercial installations, the pressure to keep systems running is immense. Considerable money might be lost if an expensive system is shut down. Operators are often under pressure not to do this. The result has at times been tragic. Nuclear power plants are kept running longer than is safe. Airplanes … Read more
Number of words – 366 Some rules come from experience; others are formal procedures in manuals or rulebooks, or even less formal guides, such as cookbooks for food preparation. In either case, all we must do is identify the situation, select the proper rule, and then follow it. When driving, behavior follows well-learned rules. Is … Read more
Number of words – 240 An accident with an Airbus airplane illustrates the problem. The flight control equipment (often referred to as the automatic pilot) had two modes, one for controlling vertical speed, the other for controlling the flight path’s angle of descent. In one case, when the pilots were attempting to land, the pilots … Read more
Number of words – 192 The immediate cause of most memory-lapse failures is interruptions, events that intervene between the time an action is decided upon and the time it is completed. Quite often the interference comes from the machines we are using: the many steps required between the start and finish of the operations can … Read more
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