ABSTRACT
Reactions to failure focus firstly and predominantly on those people who were closest to producing or potentially avoiding the mishap. It is easy to see these people as the engine of action. If it were not for them, the trouble would not have occurred. In order to understand error, people have to examine the larger system in which these people worked. One can divide an operational system into a sharp end and a blunt end. Looking for sources of failure far away from people at the sharp end is counterintuitive. Some people and organizations see surprise as an opportunity to learn. Failures offer them a window through which they can see the true internal workings of the system that produced the incident or accident. People and organizations often want the surprise in the failure to go away, and with it the challenge to their views and beliefs.
