The Field Guide to Understanding Human Error

When faced with a human error problem, you may be tempted to ask 'Why didn't they watch out better? How could they not have noticed?'. You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. These are all expressions of 'The Bad Apple Theory', where you believe your system is basically safe if it were not for those few unreliable people in it. This old view of human error is increasingly outdated and will lead you nowhere. The new view, in contrast, understands that a human error problem is actually an organizational problem. Finding a 'human error' by any other name, or by any other human, is only the beginning…