15BALANCING ACCOUNTABILITY AND LEARNING
THE PRESSURE TO HOLD PEOPLE ACCOUNTABLE
When organizations make progress on safety by going behind the label “human error”, it is mostly because they are able to do two things:
Take a systems perspective: accidents are not caused by failures of individuals, but emerge from the conflux or alignment of multiple contributory system factors, each necessary and only jointly sufficient. The source of accidents is the system, not its component parts.
Move beyond blame: blame focuses on the supposed defects of individual ...
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