ABSTRACT
A human error investigation should ultimately point to change that will truly remove the error potential from a system—something that places a high premium on meaningful recommendations. With a serious human error investigation, many of the kinds of conditions can probably be uncovered in any complex system. 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. It is easy to be put off as investigator before readers even begin writing any recommendations. The ability to generate structural recommendations that aim high up in a causal chain is a reflection of the quality and depth of their understanding of human error. Recommendations low in the causal chain aim for example at retraining individuals who proved to be deficient, or at demoting them or getting rid of them in some other way.
