4Workers Don’t Cause Failure, Workers Trigger Failure
“Cause is not found in the rubble. Cause is created in the minds of the investigators…”
Sidney Dekker, The Field Guide to Understanding Human Error
Questions about Your Organization:
How long would it take to find a worker at my organization not following a procedure?
Does not following an organizational procedure always create an immediate failure?
Why is it when we have an event that we attribute that event to a failure by the worker to follow procedures?
Remember: Three Parts of a Failure
Every event you will have or have had in your organization is actually made up of three distinctly different parts:
The Context of the Failure: This is everything that led up to the actual event. ...
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