ACCOUNTABILITY OF WORK ACTIVITY IN HIGH-CONSEQUENCE WORK SYSTEMS - HUMAN ERROR IN CONTEXT

Organizational context is now accepted as a central concept in attempt s to understand error in human-machine systems. However, accounts whic h emphasize the processes of everyday organizing, such as accountabili ty and work activity, are needed in order to establish organizational requirements for design. In this article, we provide a framework for t he consideration of organizational contexts of human error in high-con sequence work systems, with a view to integrating empirical insights a nd supporting practical design work. We draw on computer-supported coo perative work conceptualizations of the process of everyday organizing , particularly the notion of ''accountability for work activity'' whic h is pivotal to our organizational account of error. The conceptual fr amework is characterized here as a set of dimensions which are express ive concerning the relationship between accountability and work activi ty in different contexts: (1) explicit-implicit; (2) global-local; (3) stable-transient and (4) dependent-independent. The framework is demo nstrated with respect to everyday work practices in a radiology depart ment and its analytical utility validated with respect to two document ed aviation system failures. Applying the framework has enabled us to identify and define, in terms of the dimensions, a number of contexts for vulnerability in high-consequence systems: contexts for collusion, violation, deference, loss of control, buck passing and complacency. These are discussed in terms of requirements for error-tolerant design . In the final section of the article, links between the various conte xts for vulnerability and the design process are explored. (C) 1997 Ac ademic Press Limited.