Behind Human Error

by David D. Woods

“Human error” was not an explanation in terms of a psychological category of human deficiencies. It marked a beginning of the search for systemic explanations. The label really was placeholder that said, “I don’t really know what went wrong here, we need to look deeper.”

There is an almost irresistible notion that we are custodians of already safe systems that need protection from unreliable, erratic human beings (who get tired, irritable, distracted, do not communicate well, have all kinds of problems with perception, information processing, memory, recall, and much, much more). This notion is unsupported by empirical evidence when one examines how complex systems work.