ABSTRACT
The standard approach in most organisations following an accident is to blame the worker. This continued tendency means performance will never materially improve. Workers are generally doing their best to deliver the work requirements in spite of a range of pressures that they face day to day. The implicit assumption is that systems work if the worker follows them properly, but no system is perfectly designed to be flawless or capable of dealing with regular variability in the field. This disengages workers and undermines improved performance.
