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Abstract:
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Introduction: Errors (“performances which deviate from ideal”)1 are a part of our everyday existence.2 The majority of these errors are usually trivial, of no significance, recurring and preventable. Accidents are errors “with sad consequences”3 and occur in a system which is “tightly coupled”3 and so not forgiving. Research in aviation, the nuclear power industry and maritime transport accidents has shown that accidents are rarely produced by a single cause but usually by a host of interacting ones. Accidents are, therefore, the consequence of a group of errors, or a collection of interacting negative incidents. |