Abstract
An important causal factor in many failures of complex engineered systems and the subsequent accident sequences is a mismatch between the intentions of the system designers and operators. A study was conducted of the misconceptions that designers appeared to have about operators' intentions and the operating environment, and the misconceptions that operators had about the system's design or the designers' intentions. Inferences about these mutual misconceptions were made from a set of accident investigations in the marine, offshore and onshore process industries. The result was a taxonomy of misconceptions that suggested a variety of systematically flawed assumptions in the decision making of both designers and operators. A prompting tool was developed to help both designers and operators structure the examination of their assumptions. This tool was assessed in conjunction with 20 firms operating or designing hazardous installations in a range of industries.
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