Problem
Failures are misunderstood when people are judged without considering their situation.
Action
Examine the goals, information, and constraints that shaped decisions at the time.
Outcome
You uncover system factors that contributed to failure.
Chapter: Two Views of ‘Human Error’
Problem
Immediate judgments reduce learning from incidents.
Action
Gather facts and explore what happened before assigning responsibility.
Outcome
You develop a more accurate understanding of the event.
Chapter: Containing Your Reactions to Failure
Problem
Investigations often miss why actions made sense to the people involved.
Action
Trace the event through the experiences, decisions, and conditions faced by participants.
Outcome
You identify how the failure developed in practice.
Chapter: Doing a ‘Human Error’ Investigation
Problem
Similar failures continue when common influences remain hidden.
Action
Identify patterns of pressure, weakness, or constraint across multiple events.
Outcome
You can address sources of repeated failure.
Chapter: Explaining the Patterns of Breakdown
Problem
Incorrect accident models lead to ineffective safety actions.
Action
Review whether your explanations of accidents align with the realities of operational work.
Outcome
You choose improvements that more effectively reduce risk.
Chapter: Understanding Your Accident Model
Problem
Safety efforts become disconnected when they rely only on rules and procedures.
Action
Study how people adapt and succeed during normal daily operations.
Outcome
Safety measures become more practical and effective.
Chapter: Creating an Effective Safety Department
Problem
Important safety information stays hidden when people fear negative consequences.
Action
Create an environment where concerns, mistakes, and near misses can be discussed openly.
Outcome
Risks are identified earlier.
Chapter: Building a Safety Culture
Problem
Simple fixes often leave the underlying causes unchanged.
Action
Change the conditions and processes that increase the likelihood of failure.
Outcome
Improvements are more durable.
Chapter: Abandoning the Fallacy of a Quick Fix