One of the MUST-read books for accident investigators and safety professionals trying to understand the acts/behaviors of workers (and management) is James Reason’s Human Error. In chapter 7, Dr. Reason makes a very profound statement regarding the significant role “latent organizational failures” play in the vast majority of accidents…
“In the past, reliability analyses and accident investigations have focused primarily upon active operator errors and equipment failures. While operators can, and frequently do, make errors in their attempts to recover from an out-of-tolerance system state, many of the root causes of the emergency were usually present within the system long before these active errors were committed. Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking.”
Source: Human Error, James Reason, Department of Psychology University of Manchester, 1990
