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Kindle Notes & Highlights
People do not come to work to do a bad job. Safety in complex systems is not a result of getting rid of people, of reducing their degrees of freedom. Safety in complex systems is created by people through practice—at all levels of an organization.
“Human error” is not an explanation for trouble. It demands an explanation.
If you want to understand human error, you have to assume that people were doing reasonable things given the complexities, dilemmas, trade-offs and uncertainty that surrounded them. Just finding and highlighting people’s mistakes explains nothing. Saying what people did not do, or what they should have done, does not explain why they did what they did.
What (you think) should’ve happened cannot explain people’s behavior
It is never surprising to find human errors at the heart of system failure because people are at the heart of making these systems work in the first place.
