Na passada sexta-feira, durante o meu jogging, ouvi no noticiário das 19h uma reportagem sobre os "erros humanos" na base das mortes de bombeiros nos incêndios do passado Verão, segundo um relatório. Torci logo o nariz à mensagem... erro humano?
"O relatório da Administração Interna sobre a morte de bombeiros durante o combate aos incêndios deste verão fala em "erro humano". O polémico documento ainda não chegou à Assembleia da República." (fonte)
Há anos registei aqui no blogue algumas reflexões retiradas de um livro intitulado "O erro em medicina":
- Erro humano (Julho de 2006) - ler pelo menos esta referência
- Eliminar o pivot - Esse é o objectivo!
- O erro humano não existe!
- Não há, nunca há "erro humano"
- Recordar: Não há erro humano!!!
"The ‘human error’ explanation does not seem to serve safety, so what does it serve? Perhaps it partly serves society’s need for simple explanations and someone to blame, while absolving society itself for its demands.
The driver’s recorded phone call indicated that he knew this and had foretold such an accident in a warning to the company’s safety specialists: “I already told those guys at safety that it was very dangerous. We are human and this can happen to us. This curve is inhuman.”. The judge is now reportedly expanding the preliminary charges to include numerous top officials of the state railway infrastructure company, Adif, including rail safety senior officials, for alleged negligence.
Indeed, the popularisation of the term ‘human error’ has provided perhaps the biggest spur to the development of human factors in safety-related industries – with a downside. When something goes wrong, complexity is reduced to this simple, pernicious, term. ‘Human error’ has become a shapeshifting persona that can morph into an explanation of almost any unwanted event.
‘Human error’ points to individuals in a complex system. In complex systems, system behaviour is driven fundamentally by the goals of the system and the system structure. People provide the flexibility to make it work."