Health and Safety
Executive / Commission
Research reports
A set of about 60 offshore incident reports was obtained and
combined with a small set of reports of
inquiries into full scale offshore accidents and then developed
into cause-effect analyses. In each case the task was to identify
how people's problem solving had been distributed, how this
distribution had failed, and the assumptions that they had been
making, by implication. It was these implied but flawed assumptions
that were then carried over into the development of the workbooks.
A further step was then taken to identify general design principles
that would help make systems less vulnerable to each assumption
type.
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