The Field Guide to Understanding 'Human Error'

by Sidney Dekker

Your organization and ‘human error’ • Your organization is not basically or inherently safe. People have to create safety by putting tools and technologies to use while negotiating multiple system goals at all levels of your organization. • The priorities and preferences that people express through their practice may be a logical reproduction of what the entire organization finds important. • Human error is the inevitable by-product of the pursuit of success in an imperfect, unstable, resource-constrained world. The occasional human contribution to failure occurs because complex systems need an overwhelming human contribution for their safety. • So ‘human error’ is never at the root of your safety problems. ‘Human error’ is the effect of trouble deeper inside your system. • It also means that ‘human error’ is not random. ‘Human error’ is systematically connected to features of people’s tools, tasks and operating environment.