Six stages to the New View of human error

This older (2007) paper with Sid Dekker as co-author may interest you. It’s a quick read (link in comments).

This paper studied four different organisations over 2 years in their efforts to learn from failure.

They distinguished six stages in an organisation’s “growth to embracing the ‘new view’ of human error and system safety’.

They argue that organisations can struggle with a “human error problem”. Instead, human performance variability, like error, is seen as a symptom of deeper problems inside the organisation.

Pushing their thinking is said to move stakeholders “away from the illusion of quick fixes”, like rooting out isolated causes, and “towards more systemic changes”.

[Note. I dislike the term ‘New View’, but that’s what they called it, so I’m using that]

The six stages were:

1. Crisis: paralysis of the “old view”: All organisations were said to have a kind of desperation, where incidents kept occurring and existing means of finding error, reprimands, tighter procedures didn’t appear to work.

2. Disassembling the old view interpretations: This stage resulted from recognition that a “human error problem is an organizational problem”.

When organisations saw error as intel about deeper problems, this guided them to the sources of those issues, like goal conflicts, resource constraints, priorities and how these factors “systematically and predictably produced outcomes”.

3. Freezing old view countermeasures: The first stages led to a type of profound unease and managerial discomfort, where people could not “turn to traditionally satisfying ways of dealing with failure”.

This stage meant freezing the existing countermeasures like blaming people, resisting immediate turn to more procedures “to solve the latest discovered gap in system operations”.

4. Understanding that people create safety through practice: This stage involves the recognition that “risk is not caused by people in otherwise safe systems” and that “Systems are not basically safe, they are made safe through people”.

Organisations came to see that “people’s practices has evolved to cope with many hazards, complexities, trade-offs and dilemma’s of their work”.

5. New view investments and countermeasures: This stage involved investments in the system and different countermeasures. As they said “Managers stopped fighting symptoms…[like by] helping people” instead of a new procedure.

6. Learning how you are learning from failure: This stage involved the shift away from first-order learning activities, like knee-jerk and superficial fixes, towards more sustained second-order activities.

Here the organisation monitors how it is learning.

It’s said that this shift “expose the underlying rifts, disagreements and mixed character of the organization itself. These conflicts, though unsettling, are crucial to learning about safety”.

Ref: Dekker, S., Siegenthaler, D., & Laursen, T. (2007). Six stages to the new view of human error. Safety Science Monitor, 11(1), 1-5.