| Abstract: | Official enquiries into large scale system failures may be used to interpret events according to the various types of human error which were committed. For example there are errors in operation of the system, in maintenance practices etc. Twelve well documented disasters are analysed and the conclusion emerges that operator error predominates. This fact is not suprising, reflecting as it does the short time span in which operators have to make decisions, compared to the other players such as designers, maintenance men etc. This conclusion has implications for the other human disciplines involved. For example designers should conceive systems which will be less prone to operator error, while management should support operators in whatever way possible to increase their effectiveness. |
