So how do you make a ‘human error’ problem go away? The answer isn’t as simple as the question. In the aftermath of failure, the pressure to come up with findings and recommendations quickly can be enormous—depending on the visibility of the industry or the accident. An intense concern for safety (or showing such concern) can translate into pressure to reach closure quickly, something that can lead to a superficial study of the mishap and Old View countermeasures. Here are some really obvious, but false, quick fixes:
• reprimanding the people involved;
• retraining the people involved in a mishap;
• writing a procedure;
• adding just a little bit more technology.
These quick fixes are false because: ...