This quote comes from the book The Field Guide to Understanding Human Error by Sidney Dekker. In it, Dekker explores the “bad apple theory”, whereby our operations and SOP’s are inherently safe except for those few unreliable people working within it.

Dekker questions the idea that concluding “human error” is the end of a safety investigation, arguing that it is only the beginning. If we are to be safety professionals, what happens when we assume the worker was attempting to do the right thing when the accident occurred? How does the environment, communication, and situation create error?

For those in the safety professions, I ask you this: How often does your report conclude when you decide that human error is the root cause? What would you do different in your safety investigations if you can’t choose the worker as the root cause?

If an investigation leads you to identify the human element as a root cause, it is not when your work stops. There is more you can do at this point.

Dekker has written a number of works, Safety Differently being his most prolific. He’s an interesting writer, but like every “Safety Book” out there, they are guides, not SOP’s to follow.