The Field Guide to Understanding Human Error, 2nd Edition

18 What about People’s Own Responsibility?

Remember the tension from Chapter 1? There are always two ways to construct a story about human error:

• You can build a story about individuals, about sharp end operators. These people made errors. They did not follow the rules; they did not try hard enough. They should have done something else. But this first, obvious story, is always incomplete and probably wrong in many ways. It contains counterfactuals, and typically offers judgments instead of explanations.
• The second, deeper story, in contrast, is a story about the organization surrounding people at the time; about the system that accompanied and helped produce the behavior at the sharp end. When you relocate people’s behavior in this setting, ...