For most senior safety professionals, we have arrived at a place in our careers where we can understand the significance of what Dr. Reason said in 1997. Although most would agree, we started our careers in a very different place when it comes to how we derived the root causes of accidents throughout our careers. But when Dr. Reason stated this in 1997, it was not well received; especially at the time when Behavior Based Safety was taking hold in industrial workplaces. Still, to this day, we will see well-educated, certified, and seasoned safety pros struggle with this fact of “human error.” Some will retire, having never accepted this premise of human error management.
Here is an excerpt from Managing the risks of organizational accidents, Reason, 1997.
(emphasis by me)
In safety and elsewhere, human error is one of a long-established list of “causes” used by the press and accident investigators. But human error is a consequence, not a cause. Errors are shaped and provoked by upstream workplace and organizational factors. Identifying an error is merely the beginning of the search for causes, not the end. The error, just as much as the disaster that may follow it, is something that requires an explanation. Only by understanding the context that provoked the error can we hope to limit its recurrence.
So why are people so ready to accept human error as an explanation rather than as something that needs explaining? The answer is deeply rooted in human nature. Psychologists call it the fundamental attribution error. When we see or hear of someone performing badly, we attribute this to some enduring aspect of the individual’s personality. We say that he or she is careless, silly, stupid, incompetent, reckless or thoughtless. But if you were to ask the person in question why they are behaving in this fashion, they would almost certainly point to the local situation and say they had no choice-circumstances forced them to do it that way. The reality, of course, lies somewhere in between.