There’s a reason that “human error” is in quotation marks in the title of this book. “Human error” is only an error in hindsight; if you’re investigating an accident, you have the luxury of knowing the outcome and what the people involved did “wrong”. Talking about “human error” comes from an assumption that a system is inherently safe and that it’s pesky humans that make it unsafe with their not following procedures and losing situational awareness and becoming complacent (whatever THAT means). But this is not how reality works. People don’t show up at work intending to have an accident. They work in messy, complicated systems, sometimes with workarounds to get the job done.

So human error, blaming, and finding what went wrong is the “old view” of safety. In this book, Sidney Dekker explains the “new view” of safety, one that has as its basis the idea that people don’t come to work to do a bad job, that we need to see the accident scenario from the point of view of the participants (who did not know how their day was going to turn out), to figure out why they did what they did, and to examine the operating context in which they are working. Not only that, but also examining how resilient a system is: after all, things go right more often than they go wrong. What makes a system resilient, and can you use that information to prevent future accidents? Dekker explains these concepts clearly and with humour, and draws on actual accident investigation reports to illustrate his points.

The only reason this isn’t a full five stars is that I found some of the formatting weird (why were some passages made to look like block quotes if they weren’t direct quotes from another publication?). But the content is what really matters here, and it’s very well done. Endnotes at the end of each chapter, and the whole last chapter is a list of further reading, with explanations of why they are useful books to read—I love when authors do that with a “further reading” list.

Recommended if you are interested in accident investigation, safety, or why people do what they do. ( )

This book is an absolute must read for anyone "in charge of" or responsible for people. Superb view on "human error". ( )

Fascinating and very interesting! ( )