(Dekker; ISBN 978-1-4724-3905-5)

Preface

"In the Old View, 'human errors' are the cause of most of your trouble. People, in this view, are a problem to control. People's behavior is something to control, something that you have to modify. You might believe you have to start with people's attitudes, because those influence their behavior. So you try to shape those attitudes with posters and campaigns and sanctions, which you hope will impact their behavior and reduce their errors. You might even elect to sanction some people under your 'just culture' policy (even though there is generally no evidence that any of this works).

"In the New View, the behavior which we call 'human error' is not a cause of trouble. It is the consequence, the effect, the symptom of trouble deeper inside your organization. The New View assumes that people do not come to work to do a bad job. So when there are bad outcomes, you must look beyond those people, at the conditions in which they worked at the time. You and your organization may well have helped create those conditions. Leave those conditions in place, and the same bad outcome may happen again--no matter how many sanctions you impose, posters you put up, or safety attitude campaigns you launch."

"... promise yourself this:

"Discipline yourself to think critically about your 'human error' problem. Make sure you ask all the questions that need asking. And then ask some more.
"Do not celebrate closure on your 'human error' probem too early. Don't take the easy answers to be the correct ones.
"Make sure you ask "is that so?" whenever you, or other people, seem to have reached a conclusion about 'human error'. Do so relentlessly. Never stop questioning.
"Use the contrast between the Old and New View to look at problems in your own setting and environment anew. Use it to map where other people might be in their thinking about 'human error'.
Use the contrast to contribute actively to a more productive dialogue about 'human error'--not one where you necessarily want to be right all the time, but one that gets other people to stop, question, and think."

A focus on 'human error' makes you do all the wrong things.

If the HR department is involved in safety in your organization, then an incident investigation can quickly degenerate from learning opportunity into performance review.

Some believe that they need to keep beating the "human" until the 'human error' goes away.

Chapter 1: Two Views of 'Human Error'

First view (Old View) aka Bad Apple Theory:

Complex systems would be fine, were it not for the erratic behavior of some unreliable people (Bad Apples) in it.
'Human error' cause accidents: more than two-thirds of them.
Failures come as unpleasant surprises. They are unexpected and do not belong in the system. Failures are introduced to the system through the inherent unreliability of people.

Or, in other words:

Human frailties lie behind the majority of accidents. 'Human errors' are the dominant cause of trouble.
Safety rules, prescriptive procedures and management treatises are supposed to control erratic human behavior.
But this control is undercut by unreliable, unpredictable people who still don't do what they are supposed to do.
Some Bad Apples have negative attitudes toward safety, which adversely affects their behavior. So not attending to safety is a personal problem, a motivational one, an issue of individual choice.
The basically safe system, of multiple defenses carefully constructed by the organization, is undermined by erratic or unreliable people.

In order to not have safety problems, people should do as they aer told. They should be compliant with what managers and planners have figured out for them. Smart managers are others above them have put in place those rules; all the dumb operators or practitioners need to do is follow them! The reason they don't is clear: operators' negative attitudes, which adversely affect their behaviors. So more work on their attitudes should do the trick.

Bad People in Safe Systems, or Well-Intentioned People in Imperfect Systems?

Stories of error seem so simple:

somebody did not pay enough attention
if only somebody had recognized the significance of this indication, or of that piece of data, then nothing would have happened;
somebody should have put in more effort;
somebody thought that taking a shortcut was no big deal.

Most errors seem so preventable

get rid of Bad Apples;
put in more rules, procedures, and compliance demands;
tell people to be more vigilant (posters, memos, slogans);
get technology to replace unreliable people.

These don't help in the long run; in fact, they are counterproductive:

Getting rid of Bad Apples tends to send a signal to other people to be more careful with what they do, say, report, or disclose. It does not make 'human error' go away, but it does tend to make the evidence of them go away, evidence that might otherwise have been available to you and your org to use to learn and improve
Putting in more rules runs into the problem that there is always a gap between how work is imagined and how it is done. Pretending that this gap does not exist is sticking your head in the sand.
Telling people to be more vigilant does nothing to remove the problem, but instead puts your ignorance about the problem on full display. If all you are seen to be able to do is to tell people to "try harder", then it's obvious you have made up your mind about what the source of the problem is, which does not help your credibility or standing among your people.
Getting technology to replace people is an attractive idea, but introduces new problems as well as new capacities. Rather than replacing human work, it changes human work.

It's important to note:

Safety is never the only goal; orgs exist to provide goods/services (and make money from it)
People do their best to reconcile different goals simultaneously.
A system isn't automatically safe: people actually have to create safety through practice at all levels of the org.
The tools or technology that people work with create error opportunities and pathways to failure.

Underneath every simple, obvious story about 'human error', there is a deeper, more complex story about the organization.

Old View	New View
Asks who is responsible for the outcome	Asks what is responsible for the outcome
Sees 'human error' as the cause of trouble	Sees 'human error' as the symptom of deeper trouble
'Human error' is random, unreliable behavior	'Human error' is systematically connected to features of people's tools, tasks, and operating environment
'Human error' is an acceptible conclusion of an investigation	'Human error' is only the starting point for further investigation
Says what people failed to do	Tries to understand why people did what they did
Says what people should have done to prevent the outcome	Asks why it made sense for people to do what they did

People Do Not Come to Work to Do a Bad Job

The psych basis for the New View is the "local rationality principle": People do what makes sense to them at the time--given their goals, attentional focus, and knowledge--otherwise they wouldn't be doing it. If people did things that seem at first to be inexplicable, it is not beause they were doing inexplicable things. We are not positioning ourselves to understand why it made sense for them to do what they did. That burden is on us--we need to put ourselves in their shoes, see the world through their eyes.

If it made sense for people to do what they did, then it may make sense for others as well.

New View investigations have the following characteristics:

They are not about individual practitioners;
They open a window on problems that all practitioners may be facing. Their "errors", after all, are symptoms of systemic problems that all practitioners may be exposed to;
They are not a performance review;
They are not about discipline or blame;
They are a learning opportunity. They see failures as markers in the system's everyday behavior, and thus an opportunity to learn about organizational, technological, and operational features that create error potential.

The New View does not claim that people are perfect. It keeps you from judging and blaming people for not being perfect.

But... What About the Idiots?

The New View seems overly charitable. "There needs to be some accountability"--by which we mean that we should be allowed to blame the truly blameworthy.

"Bad Apples clearly exist"

Pushback against the New View.

Examples:
* British Medical Journal study showed that a small number of doctors accounted for a very large number of complaints from patients: 3% of doctors generated 49% of complaints, and 1% of doctors accounted for 25% of all complaints.
* In 1913, Tolman and Kendall (pioneers of American safety movement) strongly recommended managers to be on the lookout for men who always hurt themselves, and take the hard decision to get rid of them.
* Around 1925, British and German psychologists suggested that there were particularly "accident-prone" workers, and that the inclination to "accident" was proportional to the number of accidents previously suffered.

But... pushback began against the percentage-based nature of the analysis. Are these apples-to-apples comparisons?

Practitioners are not all exposed to the same kind and level of accident risk. This makes it impossible to compare their accident rates and say that some, because of personal characteristics, are more accident-prone than others.

"Individual differences exist but accommmodating them is a system issue"

When you observe a consistent, repeated "Bad Apple" in your org, you may be looking at a mismatch between the task and the person. Where the responsibility for creating/resolving that mismatch lies:

Is that a matter of personal reponsibility for the individual involved? Is it up to them to not be mismatched to the work given to them?
Or is it a matter for the organization/profession to matchin people to work as closely as possible? The less discretionary space (their ability to adjust their styles, communication, input, or attention) people have in their work, the more responsibility would fall on the organization.

A "Bad Apple" problem, to the extent that you cna prove its existence, is a system problem and a system responsibility.

"There has to be accountability"

Holding people accountable means getting them to take responsibility for their work; such individual responsibility, and the expectation of being held accountable for outcomes, is vital to much safety-critical work, and often intricately connected to people's professional identity. The job would not be fun, meaningful, "worth it", if it weren't for that responsibility and accountability. This accountability forms the other side of professional autonomy and competence, to be seen to be good at what you do, and accepting the consequences when things do not go well. Such accountability gives people considerable pride, and it can even routine operational work deeply meaningful.

But people do wnat to be held accountable fairly. They want to be held accountable by those who really know the messy details of what it takes to get the job done--not by those who only think they know. It is also unfair to make people responsible for things over which they have no or little authority.

The authority-responsibility mismatch

You cannot fairly ask somebody to be responsible for something he/she had no control over--it is impossible to hold somebody accountable for something over which they had no authority.

The authority-responsibility mismatch brings us back to the basic goal conflicts that drive most safety-critical and time-critical work; such work consists of holding tother a tapestry of multiple competing goals, of reconciling them as best as possible in real-time practice: Efficiency-thoroughness trade-offs (ETTOs).

This lays down a good rule:

holding people accountable is fine;
but you need to be able to show that people had the authority to live up to the responsibility you are now asking of them;
if you can't do that, your calls for accountability have no merit, and you'd better start looking at yourself.

Accountability and the systems approach

A systems approach understands that each component or contributor in a system has specific responsibilities to help attain the system's overall goals. These responsibilities cannot just be put on other people or other parts of the system.

There is no evidence that a systems approach dilutes personal accountability. In fact, second victims show just how much responsibility practitioners take for things that go wrong.

Accountability doesn't have to be about blame. Accountability can mean letting people their account/story. If you hold somebody accountable, that does not have to mean exposing that person to liability or punishment. Storytelling is a powerful mechanism for others to learn vicariously from troube.

To report or not to report

Depending on the safety level of the activity, a confidental (not anonymous) reporting system is a key source of safety-related information. Anonymous: the reporter is known to nobody. Confidential: the reporter is known, but only for safety people (not people who could create career jeopardy).

Accountability os the "just culture"

Many orgs struggle with how to create a "just culture". They try buying it off the shelf and then it doesn't work.

The challenge is to create a culture of accountability that encourages learning. Every step toward accountability that your organization takes should serve that goal. Every step that doesn't serve that goal should be avoided.

People with more power in the org tend to see the culture as more "just"
Managers/supervisors can sometimes see a "just culture" program as a good way to get someone fired
There is little evidence that orgs which have implemented such schemes produce more learning. In fact, they sometimes encourage a climate of risk secrecy
There is also little evidence that practitioners avoid personal accountability, even when your org has embraced a systems view. (Recall research on second victims and how much responsibility they take for things that go wrong on their watch.)
Deciding whether behavior is an honest mistake or more culpable involves all kinds of value judgements--who will make those judgements, and how will they draw the lines between the categories ("honest mistakes"/"risk-taking behavior"/"intentional recklessness"). (This also requires knowing intentions/motivations, which is impossible.)

Instead, think about creating justice in your response to incidents by addressing the points below:

Don't ask who is responsible, ask what is responsible.
Link knowledge of the messy details with the creation of justice. Make sure you have people involved in the aftermath of an incident who know the messy details, and who have crddibility in the eyes of other practitioners.
Explore the potential for restorative justice. Retributive justice focuses on the errors or violations of individuals. It suggests that if the error/violation (potentially) hurt someone, then the response should hurt as well. Restorative justice suggests that if the error/violation (potentially) hurt, then the response should heal. It acknowledges the existence of multiple stories and points of view about how things could have gone wrong (and how they normally go right). Restorative justice fosters dialogue between the actor and the surrounding community, rather than a break in relationships through sanction and punishment.
Go from backward- to forward-looking accountability. Backward-looking accountability means blaming people for past events. Forward-looking accountability focuses on the work necessary for change and improvement, and connects organizational and community expectations for such work. What should we do about the problem, and who should be accountable for implementing those changes and assessing whether they work?
Put second-victim support in place.

The Field Guide to Understanding 'Human Error' (3rd Ed)

A new view of accidents caused by 'human error'.

Preface

Chapter 1: Two Views of 'Human Error'

Bad People in Safe Systems, or Well-Intentioned People in Imperfect Systems?

People Do Not Come to Work to Do a Bad Job

But... What About the Idiots?

"Bad Apples clearly exist"

"Individual differences exist but accommmodating them is a system issue"

"There has to be accountability"

The authority-responsibility mismatch

Accountability and the systems approach

To report or not to report

Accountability os the "just culture"

Chapter 2: Containing Your Reactions to Failure

Chapter 3: Doing a 'Human Error' Investigation

Chapter 4: Explaining the Patterns of Breakdown

Chapter 5: Understanding Your Accident Model

Chapter 6: Creating an Effective Safety Department

Chapter 7: Builing a Safety Culture

Chapter 8: Abandoning the Fallacy of a Quick Fix

Epilogue: Speaking for the Dead