The Field Guide to Understanding 'Human Error'

by Sidney Dekker

A most colorful characterization of this comes from James Reason: “Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking.”

“There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact.”

Let us, above all, remember that nobody came to work to do a bad job, and that the ultimate aim of this activity is to learn and improve. Anything that gets in the way of doing that will further harm the organization, and the people in it.

Success narrows perceptions, changes attitudes, reinforces a single way of doing business, breeds overconfidence in the adequacy of current practices, and reduces the acceptance of opposing points of view.