[Cognitive traps: the case of omission in the genesis of work-related accidents].
This article discusses omissions in work-related accidents. The authors present James Reason's concepts on task characteristics which can increase the chance of operator omission. These ideas were applied to three accidents in which worker omission was given as the "cause" and "proof" of victim's guilt. Analysis of these accidents as a stepwise sequence of activities shows at least four of Reason's omissions characteristics. The expression "cognitive trap" is used to describe their simultaneous presence, and these omissions are highlighted as an organizational aspect requiring consideration in accident-prevention strategies.
Almeida
Ldeberto Muniz de
LM
Departamento de Saúde Pública, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, Brazil. ialmeida@fmb.unesp.br
Binder
Maria Cecília Pereira
MC
D000062:Accidents, Occupational; D003073:Cognitive Dissonance; D006801:Humans; D008297:Male; D012307:Risk Factors