The Field Guide to Understanding Human Error, 2nd Edition

15 Look into the Organization

A human error problem is an organizational problem. Not because it creates problems for the organization. It is organizational because a human error problem is created, in large part, by the organization in which people work. This means that understanding human error hinges on understanding the organizational context in which people work. There are many ways to parse this context, but this chapter looks at the following:

• Procedural drift and different images of work;
• Production pressure and goal conflicts;
• Safety culture.

Procedural Drift

There are two ways of looking at a mismatch between procedures and practice:

• As non-compliant behavior, or “violations”. People who violate the procedures put themselves above ...