“We are supermen: we can solve any problem, repair the most complex outage. We do not make errors.” It is not possible to eliminate human error if it is thought of as a personal failure rather than as a sign of poor design of procedures or equipment. My report to the company executives was received politely. I was even thanked. Several years later I contacted a friend at the company and asked what changes they had made. “No changes,” he said. “And we are still injuring people.”
