How distribution in human problem solving imperils systems

The distribution of people’s problem solving is an important source of failure in complex, hazardous production systems. An analysis was made of about 60 offshore accidents and incidents in an attempt to work out how people distribute their problem solving and how this fails. Inferences were made about the assumptions that were ef fectively being made in this distribution, and how the system could have been made less vulnerable to such assumptions in the design process. A prompting tool has been developed to help introduce this analysis into risk identif ication exercises in both design and operations.