[DOCUMENT]:
HUMAN ERROR José Luis Garc í a-Chico (jgarciac@email.sjsu.edu) San Jose State University ISE 105 Spring 2006 April 24, 2006 “ To err is human...” (Cicero, I century BC) “... to understand the reasons why humans err is science” (Hollnagel, 1993) What is important to know about human error? Human error is in our nature
How can we prevent accidents caused by human error? This presentation deals with typical examples of severe accidents related to human errors, and shows methods to prevent them.
The document lists several SharePoint and technology conferences happening in 2012-2013, including the SharePoint Conference in November 2012, SharePoint Saturday events in the UK and elsewhere from July to December 2012, the European SharePoint Conference in Copenhagen from February 4-7 2013, Microsoft Techdays in February 2013, and the 2013 MVP Global Summit from February to March 2013.
Advanced PostMortem Fu and Human Error 101 (Velocity 2011)John Allspaw
The document discusses various approaches to analyzing failures and incidents, including:
- Sequence-of-events analysis, which provides a simple explanation but can ignore context and validate hindsight bias.
- Epidemiological models adapted from Reason which view failures as resulting from the alignment of latent conditions and active failures. This helps uncover multiple contributors but does not fully explain interactions.
- Taking a systemic view of failures as emergent from interactions across an organization and technical system, rather than from individual components. Context factors well beyond the immediate technical systems are relevant to understanding failures.
[DOCUMENT]:
HUMAN ERROR José Luis Garc í a-Chico (jgarciac@email.sjsu.edu) San Jose State University ISE 105 Spring 2006 April 24, 2006 “ To err is human...” (Cicero, I century BC) “... to understand the reasons why humans err is science” (Hollnagel, 1993) What is important to know about human error? Human error is in our nature
How can we prevent accidents caused by human error? This presentation deals with typical examples of severe accidents related to human errors, and shows methods to prevent them.
The document lists several SharePoint and technology conferences happening in 2012-2013, including the SharePoint Conference in November 2012, SharePoint Saturday events in the UK and elsewhere from July to December 2012, the European SharePoint Conference in Copenhagen from February 4-7 2013, Microsoft Techdays in February 2013, and the 2013 MVP Global Summit from February to March 2013.
Advanced PostMortem Fu and Human Error 101 (Velocity 2011)John Allspaw
The document discusses various approaches to analyzing failures and incidents, including:
- Sequence-of-events analysis, which provides a simple explanation but can ignore context and validate hindsight bias.
- Epidemiological models adapted from Reason which view failures as resulting from the alignment of latent conditions and active failures. This helps uncover multiple contributors but does not fully explain interactions.
- Taking a systemic view of failures as emergent from interactions across an organization and technical system, rather than from individual components. Context factors well beyond the immediate technical systems are relevant to understanding failures.
1. IL T’A ÉTÉ DIT DE NE PAS RENDRE L’ERREUR RÉELLE, ET LA FAÇON DE
LE FAIRE EST TRÈS SIMPLE.
SI TU VEUX CROIRE EN L’ERREUR, TU DOIS LA RENDRE RÉELLE PARCE
QU’ELLE N’EST PAS VRAIE.
MAIS LA VÉRITÉ EST RÉELLE EN ELLE-MÊME, ET POUR CROIRE EN LA
VÉRITÉ TU N’AS RIEN À FAIRE.
COMPRENDS BIEN QUE TU NE RÉPONDS PAS DIRECTEMENT À QUOI
QUE CE SOIT, MAIS À L’INTERPRÉTATION QUE TU EN DONNES.
AINSI, TON INTERPRÉTATION DEVIENT LA JUSTIFICATION DE TA
RÉPONSE.
C’EST POURQUOI IL EST HASARDEUX POUR TOI D’ANALYSER LES
MOTIFS D’AUTRUI.
SI TU DÉCIDES QUE QUELQU’UN ESSAIE RÉELLEMENT DE T’ATTAQUER,
DE TE DÉSERTER OU DE T’ASSERVIR, TU RÉPONDRAS COMME S’IL
L’AVAIT RÉELLEMENT FAIT, AYANT RENDU SON ERREUR RÉELLE POUR
TOI.
EN INTERPRÉTANT L’ERREUR, TU LUI DONNES UN POUVOIR; ET AYANT
FAIT CELA, TU PASSERAS SUR LA VÉRITÉ.