What is the difference between a decision, judgement, perception and failure?

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  • How might an investigator know when he is getting it wrong… when he/she is “missing the real story behind failure”?
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    Dekker introduces the concept of “local rationality” what Edward de Bono calls the logic bubble.

 

SKU: Repo789890

Dekker shows us two approaches to human error; the old view of human error (human error is a cause of accidents) and the new view of human error (human error as a symptom of trouble deeper inside a system), characterise these two approaches and consider their manifestations in the popular press and political statements.

Write down the six topics of Part I… “The old view of human error”.

 

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Part I  –  The old view of human error;

Chapter 1.     The bad apple theory

 

Dekker’s chapters will each take about an hour to read and summarise.  Try and do one chapter in its entirety at a time.  The “bad apple theory” has a fine (and well entrenched) position, summarise its three basic principles and suggest an example from an M & M meeting or work experience.

 

Dekker describes the “ultimate goal of investigation” as being to learn from failure.  Do you think that this would be the opinion of radio “shock jocks”?  What about politicians or bureaucrats?

 

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Dekker believes that investigators usually set out with the best of intensions to follow the “new view” but can be tricked back into the bad apple theory.  He identifies five reasons for this and it is worth noting them.

 

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Page 6

Describe two dangers of the bad apple theory.

 

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Page 7

Be wary of policy and procedures and the paradox of the apparent technological fix.

 

Page 9- 10

The bad apple theory persists, why?

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Page 11

How might an investigator know when he is getting it wrong… when he/she is “missing the real story behind failure”?

 

Page 12

Dekker introduces the concept of “local rationality” what Edward de Bono calls the logic bubble.

 

What is local rationality?

 

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List some of the concerns other than safety that systems deal with.

 

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Why were you chosen for your profession?  Are you required to meet demands other than safety?

 

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Chapter 2.     Reacting to Failure

 

“The more we react the less we understand”.  What does Dekker mean when he says that our reactions to failure share the following features.

 

Retrospective 

 

Proximal 

 

Counter factual 

 

Judgemental 

 

Dekker introduces one of the most important principles of his work with his description of “hindsight bias”.

 

Cross out the incorrect word to make this sentence correct.

 

“One of the safest bets you can make as an investigator or outside observer is that you know (less/more) about the incident or accident than the people who are caught up in it”.

 

Hindsight bias means that you now know what was important then.

 

Page 19

Dekker makes an important statement about mixing realities… try and paraphrase it here.

 

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Page 20

Draw a blunt end/sharp end diagram or cartoon.

 

Why do people focus on the proximal?

 

Page 23

Is this statement true or false?  “Challenges to existing views are usually welcomed by all of those involved”

 

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Dekker illustrates his points with true stories or “narrative” the story of the pilot who committed suicide is a chilling reminder of the power of the concepts under discussion in this course.  Would you be able to “illustrate” this book with your own stories?

 

Page 25

What is a “counter factual”…  Why do they occur?

 

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Page 27

Judgemental

What is the difference between a decision/judgement/perception and a “failure”?

 

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Page 28

Dekker’s first medical example is worth noting.

 

Page 29

What is “cause consequence equivalence”?

 

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James Reason has a mental antidote to “cause-consequence equivalence” in his thought provoking statement “the best people can make the worst mistakes”.

 

Page 30

Dekker describes, “the most profound… and most frightening lesson you and your organisation can learn from a mishap”…  What is that lesson?

 

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Chapter 3.  What is the cause?

 

Dekker challenges what he calls “two persistent myths”.
Write down each myth… and each challenge.

 

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Read through to the end of the first paragraph of page 33…  Cause is not something you find.  Cause is something you construct…

Incident analysis is important and certainly better than nothing at all but Dekker’s post modern insight is an important warning.

On the first paragraph of page 34, Dekker defines a “root cause” perhaps a little controversially… what is his definition?

 

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Consider Dekker’s question.  What is the cause of “not having an accident”.

 

Dekker makes the point that for a mishap to occur in a complex and well-protected system many things do need to have gone wrong.  This means that there are many potential causes that can be identified.

 

Dekker explains the connect between human and mechanical error as often due to the interaction between the two.

 

In the last paragraph Dekker explains why he thinks there is a “70% human contribution to failure”… (page 39) can you paraphrase this?

 

 

Chapter 4.  Human Errors by any other Name.

 

What is CRM?  (page 41)

 

Dekker is cynical about what he calls “Folk Science”.  Why?

 

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Chapter 5.  Human Error – in the Head or in the World.

 

Where can you look for human error?  (page 47)

 

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Where should “the reconstruction of mind set” begin?  (page 50)

 

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Chapter 6.  Put data in context.

 

Outline the shortfalls of comparing people’s performance to procedure standards.

 

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Jot down Barbara Tuchman’s quote.  (page 57)

 

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