The Field Guide to Understanding 'Human Error'

by Sidney Dekker

Life at the thin edge of the wedge Many industries have become considerably safer over the past century. For sure, there are activities that lie at or near the unsafe system definition (certain forms of surgery, for example, or recreational activities such as base jumping). But many organizations are now ultra-safe or near-zero. They live at the thin edge of the wedge. Creating even more progress on safety there is quite difficult. It is easy to see, however, that doing more of the same does not lead to something different: it will maintain the status quo. In other words, emphasizing standardization and compliance, and investing in incident reporting, will help the organization maintain its safety level. It will do little, however, to improve safety even further. Let’s focus on ultra-safe or near-zero organizations for the moment. This is important because: • Safety improvements over the last decades, including technologies, regulation, training, reporting systems, social awareness and more, have brought many industries into or toward the ultra-safe band. Parts of your industry may be close to, or in it, as well. • Making an ultra-safe or near-zero organization even safer is one of the most difficult challenges. There is little theory to guide you. Safety progress in such organizations has gone asymptotic: that is, the curve of progress is plateauing. • At the same time, ultra-safe or near-zero organizations still suffer surprisingly big accidents from...