Mr. Dekker's premise is how do you investigate accidents without blaming the employees. He asks, "Is human error the cause or a symptom of trouble?" To him, "human error" is the starting point not the end. This was intriguing to me because he does not believe that complex systems are inherently safe and everything would be fine if we could just get rid of those "bad apples" who mess it up. My brain immediately started jibbering "but, but, but...that's WRONG"! There are bad apples! If we just got rid of them, forced them to follow the rules, invented new rules, etc. life would be wonderful and we could live in our shiny, happy perfect world. Mr. Dekker has a strong background in aviation accident investigation. He also writes in a clear, easy to follow style that makes sense to me. He makes two statements that resonate with me and he makes them both in the first chapter.
- "You have to assume that nobody comes to work to do a bad job."
- "You have to understand why what people did made sense to them at the time."
The first statement got me thinking. Nobody goes to work and thinks I'm going to crash this car, or give wrong medication or electrocute myself. Most of us show up and try to get through the day.
"People are doing reasonable things given their point of view and focus of attention; their knowledge of the situation; their objectives and the objectives of the lager organization they work for. In normal work that goes on in normal organizations, safety is never the only concern, or even the primary concern. Systems do not exist to be safe, the exist to make money; to render a service; provide a product. Besides safety there are multiple other objectives: pressures to produce; to not cost an organization unnecessary money; to be on time; to get results; to keep customers happy. People's sensitivity to these objectives, and their ability to juggle them in parallel with demands for safety, is one reason they were chosen for the jobs, and why they are allowed to keep them."
The second statement is even more crucial to me. If it made sense to one person, odds are good it will make sense to someone else. Chapter three is called "The Hindsight Bias". You've heard that saying hindsight is 20/20? Well, not in Mr. Dekker's world. Hindsight is the wrong place to be. You need to follow the events from inside with the knowledge that was available at the time.
"Hindsight changes how we look at past decision making. It turns real convoluted complexity into a simple linear story; a binary decision to err or not to err."As he also states, to these people, in these situations, the outcome was not known or they would have done something different.
So what do you do? How do you change your thinking and patterns. Not easily. This book is full of so much information, but I found something in every chapter that translated to my work environment. He isn't saying that people do not bear any responsibility for their actions or don't make mistakes. I have to say this was one of the most compelling books I read this year. If non fiction is your thing, or understanding systems, I highly recommend this book.
