Human Error

"I admit I chose this book out of a slight sense of obligation. I’m mainly interested in wrongness as a cultural idea – in how we think about being wrong, and how we feel about it – whereas Reason approaches error very much as a technical problem to be solved. But he’s one of the foremost thinkers in what you might call error studies, and his ideas are crucial to some of the advancements made in error prevention in domains where it really matters, such as aviation and engineering. One thing he does is taxonomise error: he divides wrongness into slips, lapses and mistakes, and then into all these subdivisions – errors of omission versus errors of commission and so on and so forth. This, too, is part of the intellectual history of this area – a big part, in fact, since one of the main reasons we as a culture think about mistakes is to try to prevent or eradicate them. Reason is a part of that tradition, and specifically he tries to understand the psychology of error in order to figure out what sorts of practices could lead to safer outcomes in high-risk fields. He’s heavily influenced by Daniel Kahneman and Amos Tversky, the Nobel Prize-winning economists, who were the first to really develop this study of heuristics – of the cognitive short cuts and rules of thumb we use to navigate the daily world. That’s right. The important thing about these assumptions is that they mostly serve us very well, but every once in a while they lead to big mistakes. That’s because they’re just extrapolations from experience, not logical necessities: it’s perfectly possible that one day, the lights behind that car might turn out to be midgets holding torches. So what Reason says is, ‘If our minds fail in predictable ways, we can develop systematic tools to prevent those errors.’ It’s not a gripping read if you’re not an insider, but it represents such an important part of the study of wrongness that it seemed inappropriate not to nod to it. Also, how wonderful that a man named Reason wrote a book on error. I’m a champion of error. Error is part of the richness of life. Of course, there are errors that are tragic and unacceptable and that we should seek to avoid, but even there, we’re not well served by an attitude that is horrified and humiliated by mistakes. We need to study and understand them and accept them as realities, and Reason’s book does exactly that."