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HSE RR203

Distributed Cognition Models for Human Factors Failures in Operating and Design Processes

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SUMMARY

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.

This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the author(s) alone and do not necessarily reflect HSE policy

Publisher: HSE
Published in: 2004

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