The Field Guide to Understanding Human Error

1. Human error is a symptom, not the cause of safety issues

'Human error' is never at the root of your safety problems. 'Human error' is the effect of trouble deeper inside your system.

Systems perspective. Human error should be seen as a consequence of systemic issues within an organization, not as the primary cause of accidents or safety breaches. This view shifts the focus from blaming individuals to examining the complex interplay of factors that contribute to errors.

Contributing factors. These may include:

• Poorly designed equipment or processes
• Inadequate training or resources
• Misaligned incentives or conflicting goals
• Communication breakdowns
• Organizational culture issues

By treating human error as a starting point for investigation rather than a conclusion, organizations can uncover and address the root causes that create conditions for errors to occur.

2. Abandon the "Old View" of blaming individuals for errors

Reprimanding "Bad Apples" is like peeing in your pants. You did something about the problem and feel relieved. But then it gets cold and uncomfortable. And you look like a fool.

Counterproductive approach. The "Old View" of safety, which focuses on finding and punishing individuals responsible for errors, is not only ineffective but can be harmful to an organization's safety culture. This approach:

• Discourages open reporting of incidents
• Fails to address systemic issues
• Creates a culture of fear and blame
• Misses opportunities for learning and improvement

Shift to a "New View". Instead, adopt a perspective that:

• Seeks to understand why actions made sense to people at the time
• Focuses on improving systems and processes
• Encourages open communication about safety concerns
• Treats incidents as learning opportunities
• Recognizes that people generally come to work intending to do a good job

3. Understand the context and perspective of those involved

To understand what went on in somebody's mind, you have to reconstruct the situation in which that mind found itself.

Contextual understanding. To truly grasp why errors occur, it's crucial to put yourself in the shoes of those involved. This means:

• Reconstructing the sequence of events as they unfolded
• Identifying the information available to individuals at each point
• Considering the goals, pressures, and constraints they were operating under
• Recognizing the complexity and uncertainty of the situation

Avoid hindsight bias. It's easy to judge decisions in retrospect, knowing the outcome. However, this fails to capture the reality of decision-making in the moment. Instead, focus on understanding how the situation appeared to those involved, given their knowledge and perspective at the time.

4. Investigate incidents without hindsight bias

Hindsight causes you to oversimplify history, compared to how people understood events at the time they were happening.

Beware of simplification. Hindsight bias leads to:

• Overestimating the predictability of past events
• Underestimating the complexity and uncertainty faced by those involved
• Creating a false sense of inevitability about the outcome

Investigative approach. To combat hindsight bias:

• Focus on gathering facts about the sequence of events
• Avoid using outcome knowledge to judge earlier decisions
• Resist the temptation to identify a single "root cause"
• Examine multiple contributing factors and their interactions
• Use a systems approach to understand how various elements combined to create the conditions for the incident

By avoiding hindsight bias, investigations can yield more accurate insights and lead to more effective preventive measures.

5. Safety culture is complex and cannot be imposed from the top

Culture is complex and emerges from interactions between people.

Emergent phenomenon. Safety culture is not something that can be simply mandated or installed by management. It arises from:

• Daily interactions and practices of workers at all levels
• Shared values, beliefs, and attitudes about safety
• Informal norms and expectations
• Leadership behaviors and priorities

Influencing culture. While culture can't be directly controlled, it can be influenced:

• Lead by example, demonstrating commitment to safety
• Encourage open communication about safety concerns
• Recognize and reward safe behaviors and practices
• Invest in training and resources that support safety
• Align incentives and performance measures with safety goals
• Involve workers in safety decision-making and improvement efforts

Remember that changing culture is a long-term process that requires consistent effort and reinforcement at all levels of the organization.

6. Recognize that safety improves differently at various levels

The safer you become, the more difficult it is to achieve safety improvements.

Safety spectrum. Organizations exist on a spectrum of safety levels, from unsafe to ultra-safe. Improvement strategies must be tailored to an organization's current safety level:

• Unsafe systems: Focus on basic safety measures and standardization
• Safer systems: Implement safety management systems and incident reporting
• Safe systems: Develop a strong safety culture and proactive risk management
• Ultra-safe systems: Address subtle drift into failure and maintain vigilance

Diminishing returns. As systems become safer, traditional approaches to improvement yield less benefit. Ultra-safe organizations must:

• Look beyond obvious risks to identify potential sources of failure
• Maintain a sense of vulnerability and avoid complacency
• Focus on understanding and enhancing system resilience
• Continuously challenge assumptions about safety

7. Move beyond compliance to create resilient systems

Safety is not the absence of negative events, but the presence of positive capacities.

Limitations of compliance. While rules and procedures are important, they cannot anticipate every situation. Overreliance on compliance can lead to:

• Rigidity in the face of unexpected situations
• Missed opportunities for improvement
• A false sense of security

Building resilience. Resilient systems are able to:

• Anticipate potential problems before they occur
• Respond effectively to unexpected events
• Adapt to changing conditions and new challenges
• Learn from experience and near-misses

To foster resilience:

• Encourage critical thinking and problem-solving skills
• Empower workers to make decisions in uncertain situations
• Create flexible procedures that guide rather than constrain
• Develop robust feedback mechanisms to capture and share learning
• Invest in training that emphasizes principles over rigid rules

8. Empower workers and value their expertise in safety

Whoever is expert and knows the work, gets to say.

Frontline expertise. Workers who perform safety-critical tasks daily often have the deepest understanding of:

• Potential hazards and risks
• Practical challenges in implementing safety procedures
• Informal workarounds and adaptations used to get work done
• Early warning signs of potential problems

Empowerment strategies:

• Involve workers in safety planning and decision-making
• Create channels for bottom-up communication of safety concerns
• Provide resources and authority for workers to address safety issues
• Recognize and reward worker contributions to safety improvement
• Foster a culture where questioning and speaking up is encouraged

By tapping into frontline expertise, organizations can develop more effective and practical safety measures while also increasing worker engagement and ownership of safety.

9. Beware of focusing solely on reducing negative events

Defining safety as the absence of negatives is expressed most obviously by "zero visions."

Limitations of negative metrics. While reducing accidents and incidents is important, focusing solely on these measures can be misleading:

• It may encourage underreporting of problems
• It doesn't capture "near misses" or potential risks
• It fails to recognize positive safety behaviors and practices

Balanced approach. Instead, consider:

• Tracking leading indicators of safety performance
• Measuring and rewarding proactive safety behaviors
• Assessing the health of safety systems and processes
• Evaluating the organization's capacity to learn and improve
• Monitoring the quality of safety-related communication and decision-making

By broadening the definition of safety beyond just the absence of negative events, organizations can develop a more comprehensive and proactive approach to managing risks.

10. Implement hard fixes that address systemic issues

Hard fixes change something fundamental about, or in, the organization. This makes them hard. But it also makes them real fixes.

Beyond quick fixes. Avoid the temptation to implement superficial solutions that don't address underlying issues:

• Retraining individuals involved in an incident
• Adding more procedures or checklists
• Implementing minor technical fixes

Systemic solutions. Instead, focus on fundamental changes that address root causes:

• Redesigning systems or processes to eliminate error-prone steps
• Aligning incentives and performance measures with safety goals
• Improving communication and decision-making structures
• Addressing cultural issues that contribute to safety problems
• Investing in technology that enhances safety capabilities

While these solutions may be more challenging to implement, they offer the potential for lasting improvement in safety performance. They demonstrate a serious commitment to learning from failures and creating a safer organization.

Last updated: March 29, 2025