ABSTRACT
Human error is systematically connected to features of the tasks and tools that people work with, and to features of the environment in which they carry out their work. Typical of reactions to failure is that people start very low or downstream. Recommendations focus on those who committed the error, or on other operators like them. The ease of implementation and the effectiveness of an implemented recommendation generally work in opposite directions. Generally, recommendations for changes low on a causal chain are not very sweeping. The case for including or emphasizing high-end recommendations in a first investigation is strong. The ability to generate structural recommendations that aim high up in a causal chain is a reflection of the quality and depth of understanding of human error. Investigations are typically expensive. Organizations can end up allocating significant resources to probing an incident, regardless of whether they want to or have to because of regulations.
