On Finding Root Causes
Mathias Lafeldt
432

Good article Mathias. ‘Human error as cause’ is an efficiency-thoroughness trade-off in itself, and also an sharp-end-blunt-end trade-off, as Richard implies below. Many of us in human factors (including me) have struggled with this (especially prior to getting our heads fully around Hollnagel’s, Woods’, Cook’s, and Dekker’s writings), and we have used the term obsessively but not implying human error as cause, but as symptom. Even that is problematic. Here’s a handy patient information sheet for those afflicted: https://humanisticsystems.com/2014/11/13/occupational-overuse-syndrome-human-error-variant-oos-hev/

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