Deutsch: Schweizer Emmentaler AOC, Block (Photo credit: Wikipedia)
Human error does not exist in accident causation, all errors are systemic in nature.
The above summary comes from my reading of Reason’s (1990, 1997) work presenting what has come to be regarded as the Swiss Cheese model of accident prevention. The context is one of minimising the possibility of major incidents or catastrophe occurring while recognising that it is an almost impossible task to completely eradicate risk.
Much of the health and safety literature demonstrates that in many major accident inquiries the most common conclusion is to find an outcome of human error. In contrast, when deconstructed by human factors experts a shift transpires where the focus becomes one of systemic factors causing the incident to occur. This ordinarily takes place between what is regarded as the sharp-end (individual employee level) and the blunt-end (organisation & management level).
Here I would like to put forth the idea that this sharp-end, blunt-end distinction coupled with the attribution of error is potentially also applicable to the field of work out-with the health and safety consideration. In principle this means that for the majority of workplace errors of any manner, the cause is more likely to be systemic and somewhere between the blunt-end and the sharp end, but most likely not at the sharp-end itself.
What does this mean for HR, occupational psychology, business psychology, managers, supervisors and senior leadership? Simply put, it means that the policies and systems need to be in place within the organisation to ‘fully’ account for and attribute the cause of error rather than passing-the-buck or passing the error off to an employee at the sharp end. This also will require the setting up of policies, procedures and practices which consider possible risk and minimise it, furthermore it would provide a standardised attribution framework within the sphere of performance appraisal and assessment clarifying the accountability dynamic.
