The Field Guide to Understanding Human Error by Sidney Dekker

Have a safety incident that you are pissed about? Ever kick someone off the job for not wearing their safety glasses? I happen to be following the safety officer when he asked the drywall guy to send his plaster home for the day. This was the second confirmed occurrence of the violation. Later I happen to be in a planning meeting when the plaster foremen informed the group that they were late delivering what was needed because of the safety officer. 

Nobody ever asked the guy why he removed his glasses. It made sense for him to do it even after he had been formally requested to use them again. I wonder what is going to happen tomorrow? He'll either be back fighting the same problem or someone else will be in his way.

Sidney Dekker outlines circumstantial evidence of what occurs during accidents. He discusses learning about the mindset of the participants when incidents occur and gives advice about getting angry or indignant at the accident and how doing so prevents learning.  In this field guide he continues to give practical recommendations about how to move forward with investigating human error and talks on why it is so frequently done with no learning results.

Accidents can no longer be tolerated to be viewed as individual accidents but rather should be viewed as systemic problems. Everyone is responsible, vulnerable and able to change the system. We can't just stop searching for the Bad Apple; we must broadly embrace the New View - the system view. "Problems are at least as complicate as the organizations that created them."

While reading the possibility of a New Safety Department opened. One where learning was at the forefront; people were interested in exposing real sources of operational vulnerability followed by building a better system… Nobody was retrained, reprimanded, proceduralized or tech'ed when an accident occurred. PDSA takes on a whole new meaning and a possibility for a construction site that is not imminently dangerous.