No theory forbids me to say "Ah!" or "Ugh!", but it forbids me the bogus theorization of my "Ah!" and "Ugh!" - the value judgments. - Theodor Julius Geiger (1960)

Beyond Human Error & Safety Culture

Beyond Giants and Windmills / Beyond 'Human Error' and 'Safety Culture'

In Miguel de Cervantes' 1605 'Don Quixote de la Mancha', the main character mistakes windmills for giants, causing a doomed confrontation. For today alone, I consider these windmills to be symbolic representations of a specific interpretation of both “human error” and “safety culture.”

“Human error” often serves as the perceived root cause of challenges. This idea revolves around the belief that individuals themselves pose a problem that requires control, making their behavior the primary target for change. Attitudes are seen as precursors to behavior, leading to efforts to shape these attitudes through campaigns, posters and punishments, in the hope of influencing behavior and reducing errors. However, the effectiveness of such measures remains largely unproven, even under the guise of a 'just culture' policy (Dekker, 2014).

As we strive to manage or mitigate the inherent risks associated with advanced technologies or procedures, our goal is to harness the power of innovation while minimizing unforeseen consequences or risks. Sociologist Susan Silbey drew a parallel with Greek mythology, comparing Prometheus' act of stealing fire from the gods to the transmission of knowledge and technological advancement. Yet this act also symbolizes potential dangers and unforeseen consequences that come with progress. 
The 'safety culture', which is often interpreted as an attempt to contain Prometheus, tends to overlook broader societal and structural factors at play. It appears to focus on remnants rather than the original purpose of learning – a residual aspect rather than a comprehensive exploration of the social fabric.

Efforts to manage safety often face intangible elements, leading proponents of safety culture to ambiguously attribute responsibility for complex technological outcomes within a cultural domain. This ambiguity often leads to convenient explanations, attributing errors to operator accidents when something goes wrong. In seventeenth-century England, assistants and craftsmen were blamed for scientific errors, shielding gentlemen scientists and apparatus from blame. Despite the current apparent scientific dominance, attention still tends to focus on the individual, failing to address the systemic problems of advanced technologies (Silbey, 2009, p. 363).

Ultimately, Don Quixote's misinterpretations lead to his downfall, reflecting the potential fate of organizations that misunderstand the complexity of reality. Cervantes' masterpiece reflects the battle against perceived giants such as 'human error' and 'safety culture'. Closer examination reveals complex adaptive systems that require an understanding beyond reductionist perspectives.

Ref.
Dekker, S. (2014), The Field Guide to understanding ‘human error’ - Third edition, Ashgate.
Silbey, S. (2009), Taming Prometheus, in: Annu. Rev. Sociol. 2009. 35: pp. 341–69.