??? ????

???? ??? ????? ?????? ???????? ????? ??????? ?? ?????? ??????? ?? ????? ??????? ???????? ?? ???????? ???????? ??? ?????? ??????? (??? ???? ??????? ???? ????? ??? ???? ) ??? ???? ??????? (???? ??? ??????) ??? ??????? ?????? (??? ???? ??????? ???? ???? ?????? ??????? ????? ???? ?????? ????????) ??? ???? ???? (???? ????? ?????).

??????? [ ??? ]

????? ????? ???????? (Erik Hollnagel): ^[1] ???? ????? ????? ?????? ??? ?????? ?????? (?????? ???????? ??????? ?????? ?? ???? ??????) ?? ???? ??????? ???? ???? ???? ???? ?? ??????. ^[2]

????? ??????? ?????? [ ??? ]

????? ??????? ?????? ??? ????? ????? ?????: ??? ?? ????? ≪????? ??????≫ ?? ????? ??? ????? ≪?????? ??????≫? ??? ?? ???? ?????? ???? ??? ??≪?????≫ ???? ???? ??? ??? ?????? ??? ??????: ^[3]^[4] ???? ??? ????????? ???? ???? ????? ???? ??? ????? ≪????? ??????≫ ?? ?? ?????? ??? ?? ?????? ?????? ?????? ??????. ??? ??? ??? ????? ???? ????? ?? ?????? ??????? ???? ??????? ???????? ?????? ???? ??????? ?? ??????. ??? ??? ????? ????? ?????? ???? ?? ???????? ????????? ??????? ?? ??????? ?????? ???????? ??? ?????? ??? ?? ???? ?? ??? ?? ???????? ??????? ??? ??????? ??????. ^[5]

???? ????? ?????? [ ??? ]

???? ?????? ?? ????? ?????? ????? ??????. ^[6]^[7]

?????? ??????? ????? ?????? ??????? (??? ???? ??????? ?????? ???????? ????? ?????? ???????? ?????) ^[8]
????? ?????? ????? ????????? ??????? ^[9] ??????????? ??? ????? ??
- ??????? ???????? ??????? ??????? (???? ????? ????? ??? ???????)
- ??????? ???????? ?????? ??????? (???? ????? ?? ???????? )
- ??????? ???????? ?????? ?????? ????? ^[10] (??? ???? ??????: ???? ?? ????? ??????? ????? ????? ?? ????? ????? ^[3]^[11])
?? ???? ????? ???????? ??? ???? ??????? ??????? ????? (??? ???? ??????? ?????? ?????? ) ????? ??????? ????? ???????? ????? ???????? .

????? ??????? ??????? [ ??? ]

??? ??????? ???????? ????? ?????? ??? ???????? ??????? ?????? ??????? ??? ?? ??? ??????? ??????? ????? ??????? ????????? ???????????? ????? ?????? ??? ?????? ???????? ??????? ?????? ?? ???????? ????????. ???? ??? ??????? ????????? ????????? ?? ????????????? ???? ???? ????? ?????? ?? ???? ?? ???????? ??? ???? ?? ???? ??? ??????? ???????? ?????.

???? ??? ????? ????? ??? ????? ?????? ????? ?? ??????? ?????? ?? ????? ????????? ??? ??? ???????? ?????? ???????? ????? ??????.

???? ?????? ???????? ????????? ????? ?? ???????? ??????? ??? ?????? ??????? ??????. ????? ????? ???? ??????? ???????? ?? ???? ????? ??????? ???????? (MORT). ^[12]^[13]

?????????? [ ??? ]

????? ??? ???????? ??? ?? ?????? ???????? ??????? ??? ≪????≫ ?? ≪??? ????≫ ?? ????? ??? ?? ????? ??????? ???????. ^[14]^[15] ?? ??????? ??? ???? ?????? ?????? ???????? ???? ???? ?? ?????? ???????? ???????? (?????????) ????? ??? ?????? ???? ???? ??????? ???? ?????. ???? ???? ???????? ??????? ??? ??????? ?????? ???????? ?????? ????? ??? ??????? ????????? ???? ???? ?? ???? ??? ????? ?? ??????? ???????. ?? ??????? ??????? ????? ??? ???????? (??????? ???? ???? ?? ??????? ??????) ?????????? (??????? ???? ???? ?? ??????? ?????) ??? ?? ????? ??? ??????? ??? ??? ???? ?????? ??????. ?????? ??????? ?????? ???? ?? ???? ????? ????? ??????? (???? ETTO)? ^[16] ???? ???? ?? ???? ??? ???? ??????? ?????? ??????? ?? ??????? ?????????.

??????? [ ??? ]

^ [1] , Erik Hollnagel home page
^ [2] , Hollnagel: Why "Human Error" is a Meaningless Concept ^{[
???? ??????
]} ???? ?????? 2012-04-06 ?? Wayback Machine
^ ^? ^? Reason, 1991
^ Woods, 1990
^ Hollnagel, E., Woods, D. D. & Leveson, N. G. (2006). Resilience engineering: Concepts and precepts. Aldershot, UK: Ashgate
^ Jones, 1999
^ Wallace and Ross, 2006
^ Senders and Moray, 1991
^ Roth et al., 1994
^ Sage, 1992
^ Norman, 1988
^ (Kirwan and Ainsworth, 1992;
^ search for MORT on the FAA Human Factors Workbench ???? ?????? 2017-01-21 ?? Wayback Machine
^ Hollnagel, E. (1983). Human error. (Position Paper for NATO Conference on Human Error, August 1983, Bellagio, Italy)
^ Hollnagel, E. and Amalberti, R. (2001). The Emperor’s New Clothes, or whatever happened to “human error”? Invited keynote presentation at 4th International Workshop on Human Error, Safety and System Development.. Linkoping, June 11?12, 2001.
^ Hollnagel, E. (2009). The ETTO Principle - Efficiency-Thoroughness Trade-Off. Why things that go right sometimes go wrong. Ashgate

????? ?????

?? ????? ??? ?????? ??: ??? ????

[1] [1] , Erik Hollnagel home page

[2] [2] , Hollnagel: Why "Human Error" is a Meaningless Concept ^{[
???? ??????
]} ???? ?????? 2012-04-06 ?? Wayback Machine

[Reason,_1991-3] ? ^? Reason, 1991

[4] Woods, 1990

[5] Hollnagel, E., Woods, D. D. & Leveson, N. G. (2006). Resilience engineering: Concepts and precepts. Aldershot, UK: Ashgate

[6] Jones, 1999

[7] Wallace and Ross, 2006

[8] Senders and Moray, 1991

[9] Roth et al., 1994

[10] Sage, 1992

[11] Norman, 1988

[12] (Kirwan and Ainsworth, 1992;

[13] search for MORT on the FAA Human Factors Workbench ???? ?????? 2017-01-21 ?? Wayback Machine

[14] Hollnagel, E. (1983). Human error. (Position Paper for NATO Conference on Human Error, August 1983, Bellagio, Italy)

[15] Hollnagel, E. and Amalberti, R. (2001). The Emperor’s New Clothes, or whatever happened to “human error”? Invited keynote presentation at 4th International Workshop on Human Error, Safety and System Development.. Linkoping, June 11?12, 2001.

[16] Hollnagel, E. (2009). The ETTO Principle - Efficiency-Thoroughness Trade-Off. Why things that go right sometimes go wrong. Ashgate

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