To 'Errr...' is Human
Without exception, every organisation I have worked with purports to have a blame free culture. Despite this, investigation terms of reference remain all too often fixated on human error.
Accepting almost every investigation I have conducted involved some form of human error, it should also be accepted that any decision or action that contributed to the incident was well intentioned. Typically, to get the job done or when troubleshooting an equipment or plant failure to get things back up and running. Remember…in the mind of the individual that experienced or suffered a human error, he or she believed, at that time human error occurred, they were doing the right thing – only the benefit of hindsight suggests differently.
The likelihood and the consequences of human error are typically the symptom of a wider organisational issue…make this the starting point for your investigations, not the end, exploring the context of the error is critical!
Always investigate through the eyes and mind of the worker, not the sponsor of the investigation.
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