This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other componant, needs to be put back together in a mishap investigation.

A restorative just culture has become a core aspiration for many organizations in healthcare and elsewhere. Whereas 'just culture' is the topic of some residual conceptual debate (e.g. retributive policies organized around rules,violations and consequences are 'sold' as just culture), the evidence base on, and business case for, restorative practice has been growing and is generating increasing, global interest. In the wake of an incident, restorative practices ask who are impacted, what their needs are and whose obligation it is to meet those needs. Restorative practices aim to involve participants from the entire community in the resolution and repair of harms. This book offers organization leaders and stakeholders a practical guide to the experiences of implementing and evaluating restorative practices and creating a sustainable just, restorative culture. It contains the perspectives from leaders, theoreticians regulators, employees and patient representatives. To the best of our knowledge, there is no book on the market today that can function as a guide for the implementation and evaluation of a just and learning culture and restorative practices. This book is intended to fill this gap. This book will provide, among other topics, an overview of restorative just culture principles and practices; a balanced treatment of the various implementations and evaluations of just culture and restorative processes; a guide for leaders about what to stop, start, increase and decrease in their own organizations; and an attentive to philosophical and historical traditions and assumptions that underlie just culture and restorative approaches. The interest in 'just culture', not just in healthcare but also in other fields of safety-critical practice, has been steadily growing over the past decade. It is a trending area. In this, it has become clear that 20-year-old retributive models not only hinder the acceleration of performance and organizational improvement but have also in some cases become a blunt HR instrument, an expression of power over justice and a way to stifle honesty, reporting and learning. What is new in this, then, is the restorative angle on just culture, as it has been developed over the last few years and now is practised and applied to HR, suicide prevention, healthcareimprovement, regulatory innovations and other areas.

A restorative just culture has become a core aspiration for many organizations in healthcare and elsewhere. Whereas 'just culture' is the topic of some residual conceptual debate (e.g. retributive policies organized around rules,violations and consequences are 'sold' as just culture), the evidence base on, and business case for, restorative practice has been growing and is generating increasing, global interest. In the wake of an incident, restorative practices ask who are impacted, what their needs are and whose obligation it is to meet those needs. Restorative practices aim to involve participants from the entire community in the resolution and repair of harms. This book offers organization leaders and stakeholders a practical guide to the experiences of implementing and evaluating restorative practices and creating a sustainable just, restorative culture. It contains the perspectives from leaders, theoreticians regulators, employees and patient representatives. To the best of our knowledge, there is no book on the market today that can function as a guide for the implementation and evaluation of a just and learning culture and restorative practices. This book is intended to fill this gap. This book will provide, among other topics, an overview of restorative just culture principles and practices; a balanced treatment of the various implementations and evaluations of just culture and restorative processes; a guide for leaders about what to stop, start, increase and decrease in their own organizations; and an attentive to philosophical and historical traditions and assumptions that underlie just culture and restorative approaches. The interest in 'just culture', not just in healthcare but also in other fields of safety-critical practice, has been steadily growing over the past decade. It is a trending area. In this, it has become clear that 20-year-old retributive models not only hinder the acceleration of performance and organizational improvement but have also in some cases become a blunt HR instrument, an expression of power over justice and a way to stifle honesty, reporting and learning. What is new in this, then, is the restorative angle on just culture, as it has been developed over the last few years and now is practised and applied to HR, suicide prevention, healthcareimprovement, regulatory innovations and other areas.

- Sidney Dekker examines how decades of deregulation and privatization have only led to a greater burden of compliance, and why, with so many rules to ensure safety, things can still go spectacularly wrong. - Written for all those with a vested interest in understanding the actual nature of organizational safety and performance, and in doing so make tangible improvements. - The first in a unique trilogy, this book complements Dekker's many best-sellers while broadening his appeal way beyond safety-critical industries.

- Sidney Dekker examines how decades of deregulation and privatization have only led to a greater burden of compliance, and why, with so many rules to ensure safety, things can still go spectacularly wrong. - Written for all those with a vested interest in understanding the actual nature of organizational safety and performance, and in doing so make tangible improvements. - The first in a unique trilogy, this book complements Dekker's many best-sellers while broadening his appeal way beyond safety-critical industries.

Work has never been as safe as it seems today. Safety has also never been as bureaucratized as it is today. Over the past two decades, the number of safety rules and statutes has exploded, and organizations themselves are creating ever more internal compliance requirements. At the same time, progress on safety has slowed to a crawl. Many incident- and injury rates have flatlined. Worse, excellent safety performance on low-consequence events tends to increase the risk of fatalities and disasters. Bureaucracy and compliance now seem less about managing the safety of the workers we are responsible for, and more about managing the liability of the people they work for. We make workers do a lot that does nothing to improve their success locally. Paradoxically, such tightening of safety bureaucracy robs us of exactly the source of human insight, creativity and resilience that can tell us how success is actually created, and where the next accident may well happen. It is time for Safety Anarchists: people who trust people more than process, who rely on horizontally coordinating experiences and innovations, who push back against petty rules and coercive compliance, and who help recover the dignity and expertise of human work.

What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner's tailplane? Or the oil spill disaster in the Gulf of Mexico with the burn-up of Space Shuttle Columbia? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. We have trouble grasping the complexity and normality that gives rise to such large events. We hunt for broken parts, fixable properties, people we can hold accountable. Our analyses of complex system breakdowns remain depressingly linear, depressingly componential - imprisoned in the space of ideas once defined by Newton and Descartes. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. Our technologies have gotten ahead of our theories. We are able to build things - deep-sea oil rigs, jackscrews, collateralized debt obligations - whose properties we understand in isolation. But in competitive, regulated societies, their connections proliferate, their interactions and interdependencies multiply, their complexities mushroom. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure. It studies sensitive dependence on initial conditions, unruly technology, tipping points, diversity - and finds that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed success and that are supposed to protect organizations from disaster. It develops a vocabulary that allows us to harness complexity and find new ways of managing drift.

Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a 'human error problem', and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label 'human error' is prejudicial and hides much more than it reveals about how a system functions or malfunctions. This book takes you behind the human error label. Divided into five parts, it begins by summarising the most significant research results. Part 2 explores how systems thinking has radically changed our understanding of how accidents occur. Part 3 explains the role of cognitive system factors - bringing knowledge to bear, changing mindset as situations and priorities change, and managing goal conflicts - in operating safely at the sharp end of systems. Part 4 studies how the clumsy use of computer technology can increase the potential for erroneous actions and assessments in many different fields of practice. And Part 5 tells how the hindsight bias always enters into attributions of error, so that what we label human error actually is the result of a social and psychological judgment process by stakeholders in the system in question to focus on only a facet of a set of interacting contributors. If you think you have a human error problem, recognize that the label itself is no explanation and no guide to countermeasures. The potential for constructive change, for progress on safety, lies behind the human error label.

First published in 1999, this volume examined how increasing cockpit automation in commercial fleets across the world has had a profound impact on the cognitive work that is carried out on the flight deck. Pilots have largely been transformed into supervisory controllers, managing a suite of human and automated resources. Operational and training requirements have changed, and the potential for human error and system breakdown has shifted. This compelling book critically examines how airlines, regulators, educators and manufacturers cope with these and other consequences of advanced aircraft automation.

First published in 1999, this volume examined how increasing cockpit automation in commercial fleets across the world has had a profound impact on the cognitive work that is carried out on the flight deck. Pilots have largely been transformed into supervisory controllers, managing a suite of human and automated resources. Operational and training requirements have changed, and the potential for human error and system breakdown has shifted. This compelling book critically examines how airlines, regulators, educators and manufacturers cope with these and other consequences of advanced aircraft automation.

The second edition of a bestseller, Safety Differently: Human Factors for a New Era is a complete update of Ten Questions About Human Error: A New View of Human Factors and System Safety. Today, the unrelenting pace of technology change and growth of complexity calls for a different kind of safety thinking. Automation and new technologies have resulted in new roles, decisions, and vulnerabilities whilst practitioners are also faced with new levels of complexity, adaptation, and constraints. It is becoming increasingly apparent that conventional approaches to safety and human factors are not equipped to cope with these challenges and that a new era in safety is necessary. In addition to new material covering changes in the field during the past decade, the book takes a new approach to discussing safety. The previous edition looked critically at the answers human factors would typically provide and compared/contrasted them with current research and insights at that time. The edition explains how to turn safety from a bureaucratic accountability back into an ethical responsibility for those who do our dangerous work, and how to embrace the human factor not as a problem to control, but as a solution to harness. See What's in the New Edition: New approach reflects changes in the field Updated coverage of system safety and technology changes Latest human factors/ergonomics research applicable to safety Organizations, companies, and industries are faced with new demands and pressures resulting from the dynamics and nature of the modern marketplace and from the development and introduction of new technologies. This new era calls for a different kind of safety thinking, a thinking that sees people as the source of diversity, insight, creativity, and wisdom about safety, not as the source of risk that undermines an otherwise safe system. It calls fo

How do people cope with having "caused" a terrible accident? How do they cope when they survive and have to live with the consequences ever after? We tend to blame and forget professionals who cause incidents and accidents, but they are victims too. They are second victims whose experiences of an incident or adverse event can be as traumatic as that of the first victims. Yet information on second victimhood and its relationship to safety, about what is known and what organizations might need to do, is difficult to find. Thoroughly exploring an emerging topic with great relevance to safety culture, Second Victim: Error, Guilt, Trauma, and Resilience examines the lived experience of second victims. It goes through what we know about trauma, guilt, forgiveness, and injustice and how these might be felt by the second victim. The author discusses how to conduct investigations of incidents that do not alienate second victims or make them feel even worse. It explores the importance support and resilience and where the responsibilities for creating it may lie. Drawing on his unique background as psychologist, airline pilot, and safety specialist, and his own experiences with helping second victims from a variety of backgrounds, Sidney Dekker has written a powerful, moving account of the experience of the second victim. It forms compelling reading for practitioners, risk managers, human resources managers, safety experts, mental health workers, regulators, the judiciary, and many other professionals. Dekker provides a strong theoretical background to promote understanding of the situation of the second victim and solid practical advice about how to deal with trauma that continues after an event leading to preventable harm or even avoidable death of a patient, consumer, or colleague. Listen to Sidney Dekker speak about his book

In this unique book, Sidney Dekker tackles a largely unexplored dilemma. Our scientific age has equipped us ever better to explain why things go wrong. But this increasing sophistication actually makes it harder to explain why we suffer. Accidents and disasters have become technical problems without inherent purpose. When told of a disaster, we easily feel lost in the steely emptiness of technical languages of engineering or medicine. Or, in our drive to pinpoint the source of suffering, we succumb to the hunt for a scapegoat, possibly inflicting even greater suffering on others around us. How can we satisfactorily deal with suffering when the disaster that caused it is no more than the dispassionate sum of utterly mundane, imperfect human decisions and technical failures? Broad in its historical sweep and ambition, The End of Heaven is also Dekker's most personal book to date.

When faced with a 'human error' problem, you may be tempted to ask 'Why didn't these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it. Building on its successful predecessors, the third edition of The Field Guide to Understanding 'Human Error' will help you understand a new way of dealing with a perceived 'human error' problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a 'human error' problem, abandon the fallacy of a quick fix. Read this book.

This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other componant, needs to be put back together in a mishap investigation.

How are today's 'hearts and minds' programs linked to a late-19th century definition of human factors as people's moral and mental deficits? What do Heinrich's 'unsafe acts' from the 1930's have in common with the Swiss cheese model of the early 1990's? Why was the reinvention of human factors in the 1940's such an important event in the development of safety thinking? What makes many of our current systems so complex and impervious to Tayloristic safety interventions? 'Foundations of Safety Science' covers the origins of major schools of safety thinking, and traces the heritage and interlinkages of the ideas that make up safety science today. Features Offers a comprehensive overview of the theoretical foundations of safety science Provides balanced treatment of approaches since the early 20th century, showing interlinkages and cross-connections Includes an overview and key points at the beginning of each chapter and study questions at the end to support teaching use Uses an accessible style, using technical language where necessary Concentrates on the philosophical and historical traditions and assumptions that underlie all safety approaches

The second edition of a bestseller, Safety Differently: Human Factors for a New Era is a complete update of Ten Questions About Human Error: A New View of Human Factors and System Safety. Today, the unrelenting pace of technology change and growth of complexity calls for a different kind of safety thinking. Automation and new technologies have resulted in new roles, decisions, and vulnerabilities whilst practitioners are also faced with new levels of complexity, adaptation, and constraints. It is becoming increasingly apparent that conventional approaches to safety and human factors are not equipped to cope with these challenges and that a new era in safety is necessary. In addition to new material covering changes in the field during the past decade, the book takes a new approach to discussing safety. The previous edition looked critically at the answers human factors would typically provide and compared/contrasted them with current research and insights at that time. The edition explains how to turn safety from a bureaucratic accountability back into an ethical responsibility for those who do our dangerous work, and how to embrace the human factor not as a problem to control, but as a solution to harness. See What's in the New Edition: New approach reflects changes in the field Updated coverage of system safety and technology changes Latest human factors/ergonomics research applicable to safety Organizations, companies, and industries are faced with new demands and pressures resulting from the dynamics and nature of the modern marketplace and from the development and introduction of new technologies. This new era calls for a different kind of safety thinking, a thinking that sees people as the source of diversity, insight, creativity, and wisdom about safety, not as the source of risk that undermines an otherwise safe system. It calls for a kind of thinking that is quicker to trust people and mistrust bureaucracy, and that is more committed to actually preventing harm than to looking good. This book takes a forward-looking and assertively progressive view that prepares you to resolve current safety issues in any field.

What does the collapse of sub-prime lending have in common with a broken jackscrew in an airliner's tailplane? Or the oil spill disaster in the Gulf of Mexico with the burn-up of Space Shuttle Columbia? These were systems that drifted into failure. While pursuing success in a dynamic, complex environment with limited resources and multiple goal conflicts, a succession of small, everyday decisions eventually produced breakdowns on a massive scale. We have trouble grasping the complexity and normality that gives rise to such large events. We hunt for broken parts, fixable properties, people we can hold accountable. Our analyses of complex system breakdowns remain depressingly linear, depressingly componential - imprisoned in the space of ideas once defined by Newton and Descartes. The growth of complexity in society has outpaced our understanding of how complex systems work and fail. Our technologies have gotten ahead of our theories. We are able to build things - deep-sea oil rigs, jackscrews, collateralized debt obligations - whose properties we understand in isolation. But in competitive, regulated societies, their connections proliferate, their interactions and interdependencies multiply, their complexities mushroom. This book explores complexity theory and systems thinking to understand better how complex systems drift into failure. It studies sensitive dependence on initial conditions, unruly technology, tipping points, diversity - and finds that failure emerges opportunistically, non-randomly, from the very webs of relationships that breed success and that are supposed to protect organizations from disaster. It develops a vocabulary that allows us to harness complexity and find new ways of managing drift.

Work has never been as safe as it seems today. Safety has also never been as bureaucratized as it is today. Over the past two decades, the number of safety rules and statutes has exploded, and organizations themselves are creating ever more internal compliance requirements. At the same time, progress on safety has slowed to a crawl. Many incident- and injury rates have flatlined. Worse, excellent safety performance on low-consequence events tends to increase the risk of fatalities and disasters. Bureaucracy and compliance now seem less about managing the safety of the workers we are responsible for, and more about managing the liability of the people they work for. We make workers do a lot that does nothing to improve their success locally. Paradoxically, such tightening of safety bureaucracy robs us of exactly the source of human insight, creativity and resilience that can tell us how success is actually created, and where the next accident may well happen. It is time for Safety Anarchists: people who trust people more than process, who rely on horizontally coordinating experiences and innovations, who push back against petty rules and coercive compliance, and who help recover the dignity and expertise of human work.

In this unique book, Sidney Dekker tackles a largely unexplored dilemma. Our scientific age has equipped us ever better to explain why things go wrong. But this increasing sophistication actually makes it harder to explain why we suffer. Accidents and disasters have become technical problems without inherent purpose. When told of a disaster, we easily feel lost in the steely emptiness of technical languages of engineering or medicine. Or, in our drive to pinpoint the source of suffering, we succumb to the hunt for a scapegoat, possibly inflicting even greater suffering on others around us. How can we satisfactorily deal with suffering when the disaster that caused it is no more than the dispassionate sum of utterly mundane, imperfect human decisions and technical failures? Broad in its historical sweep and ambition, The End of Heaven is also Dekker's most personal book to date.

How are today's 'hearts and minds' programs linked to a late-19th century definition of human factors as people's moral and mental deficits? What do Heinrich's 'unsafe acts' from the 1930's have in common with the Swiss cheese model of the early 1990's? Why was the reinvention of human factors in the 1940's such an important event in the development of safety thinking? What makes many of our current systems so complex and impervious to Tayloristic safety interventions? 'Foundations of Safety Science' covers the origins of major schools of safety thinking, and traces the heritage and interlinkages of the ideas that make up safety science today. Features Offers a comprehensive overview of the theoretical foundations of safety science Provides balanced treatment of approaches since the early 20th century, showing interlinkages and cross-connections Includes an overview and key points at the beginning of each chapter and study questions at the end to support teaching use Uses an accessible style, using technical language where necessary Concentrates on the philosophical and historical traditions and assumptions that underlie all safety approaches

Increased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues. People often think, understandably, that safety lies mainly in the hands through which care ultimately flows to the patient-those who are closest to the patient, whose decisions can mean the difference between life and death, between health and morbidity. The human factors approach refuses to lay the responsibility for safety and risk solely at the feet of people at the sharp end. That is where we should intervene to make things safer, to tighten practice, to focus attention, to remind people to be careful, to impose rules and guidelines. The book defines an approach that looks relentlessly for sources of safety and risk everywhere in the system-the designs of devices; the teamwork and coordination between different practitioners; their communication across hierarchical and gender boundaries; the cognitive processes of individuals; the organization that surrounds, constrains, and empowers them; the economic and human resources offered; the technology available; the political landscape; and even the culture of the place. The breadth of the human factors approach is itself testimony to the realization that there are no easy answers or silver bullets for resolving the issues in patient safety. A user-friendly introduction to the approach, this book takes the complexity of health care seriously and doesn't over simplify the problem. It demonstrates what the approach does do, that is offer the substance and guidance to consider the issues in all their nuance and complexity.

When faced with a 'human error' problem, you may be tempted to ask 'Why didn't these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it. Building on its successful predecessors, the third edition of The Field Guide to Understanding 'Human Error' will help you understand a new way of dealing with a perceived 'human error' problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a 'human error' problem, abandon the fallacy of a quick fix. Read this book.

How do people cope with having "caused" a terrible accident? How do they cope when they survive and have to live with the consequences ever after? We tend to blame and forget professionals who cause incidents and accidents, but they are victims too. They are second victims whose experiences of an incident or adverse event can be as traumatic as that of the first victims'. Yet information on second victimhood and its relationship to safety, about what is known and what organizations might need to do, is difficult to find. Thoroughly exploring an emerging topic with great relevance to safety culture, Second Victim: Error, Guilt, Trauma, and Resilience examines the lived experience of second victims. It goes through what we know about trauma, guilt, forgiveness, and injustice and how these might be felt by the second victim. The author discusses how to conduct investigations of incidents that do not alienate second victims or make them feel even worse. It explores the importance support and resilience and where the responsibilities for creating it may lie. Drawing on his unique background as psychologist, airline pilot, and safety specialist, and his own experiences with helping second victims from a variety of backgrounds, Sidney Dekker has written a powerful, moving account of the experience of the second victim. It forms compelling reading for practitioners, risk managers, human resources managers, safety experts, mental health workers, regulators, the judiciary, and many other professionals. Dekker provides a strong theoretical background to promote understanding of the situation of the second victim and solid practical advice about how to deal with trauma that continues after an event leading to preventable harm or even avoidable death of a patient, consumer, or colleague. Listen to Sidney Dekker speak about his book

Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a 'human error problem', and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label 'human error' is prejudicial and hides much more than it reveals about how a system functions or malfunctions. This book takes you behind the human error label. Divided into five parts, it begins by summarising the most significant research results. Part 2 explores how systems thinking has radically changed our understanding of how accidents occur. Part 3 explains the role of cognitive system factors - bringing knowledge to bear, changing mindset as situations and priorities change, and managing goal conflicts - in operating safely at the sharp end of systems. Part 4 studies how the clumsy use of computer technology can increase the potential for erroneous actions and assessments in many different fields of practice. And Part 5 tells how the hindsight bias always enters into attributions of error, so that what we label human error actually is the result of a social and psychological judgment process by stakeholders in the system in question to focus on only a facet of a set of interacting contributors. If you think you have a human error problem, recognize that the label itself is no explanation and no guide to countermeasures. The potential for constructive change, for progress on safety, lies behind the human error label.