Erik Hollnagel of the Cognitive Systems Engineering Lab at the U of LinkÃ¶ping works in the area of human performance and accident analysis / prevention and has a number of topic overview pieces at his Research Topics listing. The one on The principle of Efficiency-Thoroughness Trade-Off (ETTO) was particularly interesting to me.
The conclusion is that both normal performance and failures are emergent phenomena, hence that neither can be attributed to or explained by specific components or parts. For the humans in the system this means in particular that the reason why they sometimes fail, in the sense that the outcome of their actions differ from what was intended or required, is due to the variability of the context and conditions rather than to the failures of actions. The adaptability and flexibility of human work is the reason for its efficiency. At the same time it is also the reason for the failures that occur, although it is never the cause of the failures. Herein lies the paradox of optimal performance at the individual level. If anything is unreasonable, it is the requirement to be both efficient and thorough at the same time – or rather to be thorough when with hindsight it was wrong to be efficient.
[found via a discussion on the Critical Chain mailing list]
One of the frequent findings of failure analyses is that it's the fault of people not behaving as they "should have done." What I read Hollnagel as saying is that people act based on a trade-off between being thorough and being efficient. Human behavior is part of a larger system that is constantly adjusting to its environment. And it is this system that has to be diagnosed to understand why the particular "short cut" failed when it normally worked just fine.
Update: fixed title spelling.