(47b) Admitting Human Error in the Workplace - a Case Study in Maximizing Safe and Reliable Performance with Human Factors

Human error is inevitable and serves as a symptom of systemic failure. As with all symptoms, it becomes a signal spurring systemic change. The idea is to welcome error as an indication that leadership should investigate the dark, murky, uncomfortable cultural issues that made the error seem like a good idea at the time. Instead of blaming individuals for error, ask why the system responded the way it did. In this interactive session, participants will use an on-screen response system to experience a developing investigation as facilitators of a real-world example. We will study an organization’s emergent behavior through the actions of two operators. As a rule, these operators did not set out to cause failure; rather, they intended to contribute to the larger success of the organization. Nevertheless, as part of a multi-dimensional operating framework, they were shepherded by complex events into making decisions that instead caused an incident.