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Field Guide to Understanding Human Error
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Field Guide to Understanding Human Error

4.25  ·  Rating details ·  413 ratings  ·  46 reviews
When faced with a human error problem, you may be tempted to ask 'Why didn't they watch out better? How could they not have noticed?'. You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. These are all expressions of 'The Bad Apple Theory', where you believe your system is ...more
Paperback, 252 pages
Published June 28th 2006 by CRC Press (first published January 1st 2002)
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Ali Sattari
A concise book with to the point argument and examples and with a pretty good narrative. Most if not all of arguments can be made for incident management and firefighting in IT and Software industry as well.
Mike Pearce
Mar 15, 2017 rated it it was amazing
Shelves: non-fiction
This book is an absolute must read for anyone "in charge of" or responsible for people. Superb view on "human error". ...more
Sep 28, 2019 rated it really liked it
Must read for everyone in a leading position.
Great read for everyone else cause it probably will make you less of a dick at the workplace. ;)
Not super exciting read, but an important one.
Matthew Horvat
Aug 29, 2009 rated it really liked it
Have a safety incident that you are pissed about? Ever kick someone off the job for not wearing their safety glasses? I happen to be following the safety officer when he asked the drywall guy to send his plaster home for the day. This was the second confirmed occurrence of the violation. Later I happen to be in a planning meeting when the plaster foremen informed the group that they were late delivering what was needed because of the safety officer.

Nobody ever asked the guy why he removed his g
Mark McGranaghan
Jan 12, 2014 rated it it was amazing
This book examines "human error" as the natural outcome of systems where "people were doing reasonable things given the complexities, dilemmas, trade-offs and uncertainty that surrounded them."

It argues that that systems "are not basically safe" but that "safety needs to be created through practice, by people", especially when there is a lot of technology and automation involved.

It argues for confronting the tradeoff between production and safety, and examining how organizational and management
Jul 19, 2019 rated it liked it
This book should be required reading for anybody responsible for anything. Written as a field guide for aviation accident investigators and contains a lot of very specific tips and tricks and details. While these might be less relevant for people from other industries the basic idea on how to approach and understand human error remains 100% valid.
Nathan Powell
Nov 04, 2012 rated it it was amazing
Excellent book in my opinion. If you want to think about error and mistakes and how to prevent them systemically this is the book for you. It is written from the perspective of accidents and safety, however all professionals that want to prevent errors will get something from this book.
Chris Weatherburn
Feb 13, 2021 rated it really liked it  ·  review of another edition
This review has been hidden because it contains spoilers. To view it, click here.
Tõnu Vahtra
Sep 25, 2018 rated it really liked it
“Underneath every simple, obvious story about ‘human error,’ there is a deeper, more complex story about the organization.” I expected more substance from this book but since it was relatively short then you cannot really go too much into details, also the first version of the book (first written in 2002) thus the examples were from aerospace and mining industries, it's about time to cover this topic in more detail in the context of IT organization. I would not consider the "old approach to safe ...more
Apr 25, 2013 rated it liked it  ·  review of another edition
Definitive book on an important subject, but it felt repetitive, like the entire book could have been one quarter the length. Still, a must read for anyone who deals with complex systems and, well, humans.
Dekker works in the field of disaster recovery/study. Trying to learn from plane crashes what happened and what were the factors that lead to the accident. He gives several examples of reports and points out that in order to learn from these reports and be more safe in the future, companies can't just point to "Bad Apples" and add another safety check. Learning how the system works and it's pressures helps insiders understand it's weaknesses and know where outside or inside safety procedures cou ...more
Joel Bastos
Sep 02, 2019 rated it it was amazing
An excellent crash course on gaining perspective when trying to understand "Human Error". In a nutshell, you should never blame human error when trying to understand the real causes of a failure, as it will hinder ineffective the analysis, preventing the required visibility from understanding the causes.

In highly complex systems, it's much easier to blame "Human Error" rather than unravel the web of complexity, the lack/bad processes in-place, the never-ending interdependencies and the perspecti
Jan D
Apr 19, 2018 rated it really liked it
A systemic view on human errors. The title is actually a bit misleading, since the book states that “human error” is caused by an interplay of incentives, culture, authority/responsibility and co-existing pressures, and rarely by single people who behave wrong.


Dekkers argument is that "should not have done" makes sense only in hindsight, with the information an outsider has after the error has happened. Most people want to do their job right, and thus they usually do what makes sense in
Miguel Palhas
The first half of this book is highly insightful, explaining how to reason abou human errors, and frame them in a productive way, in order to learn and improve, rather than just blame whoever was at the center of it
It's a nice follow up to some of my previous readings on systems thinking, a topic I'm really getting into.

Towards the second half, the book goes into details about how organizations work, and , and some other details that are not as relevant to me in particular. It also felt a bit re
William "Spig"
Nov 27, 2020 rated it it was amazing
Coming into the book I thought this was set up to be an analytical book on how to do an effective safety investigation. How to root out and deal with fringe behavior. This is a leadership book. I’ve talked much about being accountable foe leadership decision for everything under your umbrella but this book helped me go deeper and see the culture of doing business on an aircraft carrier is my responsibility. Fatigue and professionalism are battles but good solid leadership that owns first rather ...more
4.5 stars. This is relevant to all private and public organizations who deal with human error as a safety issue (although perhaps equally applicable to quality assurance in general). Extremely insightful and practical in its explanations on why things can go wrong, how we tend to focus on the irrelevant and induce greater error over time, and much more. It’s recommendations should be widely implemented in leader and manager education. I would highly recommend it to military leaders in particular ...more
Nick Armstrong
Sep 26, 2018 rated it really liked it
Shelves: business
Good; can be summarized as: nobody tries to do a bad/dangerous job, mistakes are made as folks do their best with limited information in the situation as they perceive it. So the best bet to figuring out errors is to put yourself in the mind of the person making the error and asking yourself what did they know at the time things started going south - and what would have to be true (to them) for them to make the same decisions?
Mar 13, 2019 rated it really liked it
Could be a bit shorter, and contains logical fallacies: for instance, the author is constantly using examples from aviation, and concludes that "nobody comes to work aiming to do a bad job". That is certainly true for an aircraft pilot who has every intent and incentive to "not do a bad job". The same argument does not hold for many other industries, where consequences of doing a bad job are not nearly as fatal. ...more
Dec 25, 2020 rated it really liked it
Read this a while ago - a few things I think now that I attribute to the book:

* systems work most of the time, and it's because people generally can figure out how to do the right thing
* sometimes systems fail, because people did not figure out how to do the right thing
* when a tense situation is unfolding, the people involved are making choices that make sense to them in that context. If the choice turns out to be wrong, that is regrettable, but also, "it was the right idea at the time."
Miguel Silva
Feb 01, 2021 rated it liked it
Dont get me wrong, the topic that this book addresses is very important and is very well explained with real examples, in my opinion, this book should be read by all, we need, once and for all, to stop blaming each other and search the real root cause that originated what went wrong.
My grade is not 4 or 5, because i dont think is a topic for a book with that many pages, you could full-fill the same purpose in half the book, there is too much repetition.
Kyla Squires
Dec 26, 2018 rated it liked it
Shelves: sciences, non-fiction
Easy and informative if repetitive read on disaster post-mortems and how human error is probably a direct result of a poorly designed system rather than poor performing humans.

You will never feel safe again.
victoria  Bishop
Sep 21, 2019 rated it it was amazing
Wonderfully written book about human factors. Very aviation focused so not good to read before flying anywhere if you are a nervous flyer. Sidney Dekker also does some interesting you tube lectures on this topic.
Nov 11, 2017 rated it really liked it  ·  review of another edition
This is a great book about understanding and dealing with human error. It feels repetitive especially in the beginning, but overall it is a good and insightful read.
Joel Péclard
Nov 13, 2019 rated it it was amazing
The best book on accident investigation and new view safety philosophy. When I recommend friends and colleagues to read Dekker I always recommend this book first.
Joel Tone
Started off strong, but then seemed to just get discouraged
Jul 29, 2020 rated it liked it  ·  review of another edition
Good, but very repetitive. It could have been half as long.
Kieran Gutteridge
Aug 09, 2020 rated it really liked it
Great insights and very relevant to IT resilience
Ryan Frantz
May 16, 2019 rated it it was amazing  ·  review of another edition
I read the 2nd edition 4-5 years ago. Not only did it transform my way of thinking about incidents and how we understand the systems we build and operate, it set me on a path to learn even more about safety, human factors, and resilience. I read this edition as part of a book club I started at work to help spread this ideas. Even years later, I've dog-eared the majority of the pages because there is so much useful content to pull out. ...more
Apr 05, 2018 rated it it was ok  ·  review of another edition
Shelves: safety-nf
Don't get me wrong, there are some good snippets of ideas buried inside this book, but it is poorly written and hard to follow.

The text reads like that sort of cheap, quickly written US high school textbook where nothing is really explained and you're supposed to pick up everything by osmosis. And far from adding anything to the text, the stick diagrams are mindlessly incomprehensible. My main gripe is with the examples: they're in italics but merge together narrative and his sarky gibes at oth
Matthew Horvat
Sep 07, 2009 rated it really liked it  ·  review of another edition
Recommends it for: Safety professionals and all construction field foremen, project managers and supers
More important than the bulleted rules of engagement for a human error investigation, and more important than the pitfalls to avoid, are Sidney Dekker's signs of not learning from failure. The safety department of today, as with our standards, don't include a possibility of real safety transformation.

This is an early book in Dekker's literature about human error. He provides a self-generating solution to human failure - learning.

I find this work to be incredibly relevant to increasing performan
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Sidney W. A. Dekker (born 1969, "near Amsterdam"),is a Professor at Griffith University in Brisbane, Australia, where he founded the Safety Science Innovation Lab. He is also Honorary Professor of Psychology at the University of Queensland.

Previously, Dekker was Professor of human factors and system safety at Lund University in Sweden,where he founded the Leonardo da Vinci Laboratory for Complexit

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“Underneath every simple, obvious story about ‘human error,’ there is a deeper, more complex story about the organization.” 2 likes
“There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact.”1” 1 likes
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