File attachment:
| Title | Summary of issues emerging in coordination breakdown from secondary sources (in particular inquires and similar) |
| Publication Type | Report |
| Year of Publication | 2011 |
| Authors | Brooks, B |
| Abstract | The secondary sources analysis is being conducted using the Human Factors Analysis and Classification System (HFACS) as a framework (Wiegmann & Shappell, 2003). This classification system draws off Reason’s “Latent error” model of understanding organisational error as a combination of active and latent failures. While the Reason model has strengths in acknowledging that errors occur due to a range of organisational factors or failures of other organisational defenses, Reason’s model is necessarily descriptive. The Human Factors Analysis and Classification System (HFACS) provides an explanatory framework to better understand the trajectory of an error. |
